NEBOSH International Diploma in Occupational Health and Safety

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Element IB5 : Biological Agents.

Learning outcomes:
On completion of this element, candidates should be able to:
1. Explain the types and properties of biological agents found at work.
2. Explain the assessment and control of risk from exposure to biological agents at work.
Relevant Standards

International Labour Standards, List of Occupational Disease Recommendations, R194,

International Labour Organisation, Geneva, 2002

Article 1.3: Biological agents

International Labour Office, Ambient Factors in the Workplace, an ILO Code of Practice,
ILO, 2001. ISBN 922111628

Minimum hours of tuition: 7 hours.

1.0 Biological Agents - Identification & Evaluation.

In the last few study units, we have examined an important group of hazardous substances. We
now move on to a different category of occupational health hazard, biological agents.
These are, in the main, naturally-occurring materials that are encountered in the workplace, possibly through health care work and associated laboratory activities, or during the handling or
processing of animal or plant-derived materials.
However, the key issue is that these biologically-derived materials and associated microorganisms have the potential to cause occupational ill-health and disease and therefore exposure
to them must be controlled.
In this element, we begin our examination of biological agents by reviewing the various types of
agent and the health effects that arise from exposure. We then move on to consider the occupational situations where exposure might occur, reviewing specific groups of workers at risk and
also particular workplace ill-health conditions caused by biological agents.

1.1 Types of biological agent.

When considering biological hazards, it is the considerable range of commonly-encountered micro-organisms that first springs to mind. We therefore begin by examining the principal categories
of micro-organism.
In addition to naturally-occurring agents, science is now able to alter the genetic material of organisms by a process called genetic engineering. Such genetic modifications introduce new risks
of enhanced pathogenicity or other hazardous properties, so genetic manipulation is an activity
that requires strict control.
Consequently, we look at these issues before we discuss the problems associated with organisms that cause harm through the production of chemical toxins rather than by biological action.
Types of Biological Hazard.
The Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as amended 2005)

defines a micro-organism as "a microbiological entity, cellular or non-cellular, which is capable of

replication or of transferring genetic material". There are thousands of species of microorganisms but only a few of them are harmful to humans, and of these it is the ones that are capable of causing occupational ill-health with which we are concerned.
The three main categories of micro-organism with which we are concerned are bacteria, fungi
and viruses.

In order to see bacteria and viruses, we must magnify them thousands of times.
Bacteria.
Bacteria are single-celled organisms that reproduce by division. They vary widely in shape (with
the shape being used to classify and name types of bacteria) and include spheres (cocci), rods
(bacilli) and spirals (spirochetes). Some bacilli (such as anthrax) form spores which enable them
to survive adverse conditions such as heat, cold and lack of water.

1. Cylindrical (rods).
2. Cocci in Clusters (e.g. gram-positive staphylococci).
2. Spiral-shaped (e.g. spirilla, heliobacter pylori).
Fungi.
The category of microfungi includes moulds and yeasts but excludes larger fungi such as mushrooms. Some microfungi produce toxins (mycotoxins) that are harmful to humans. Many fungi reproduce by forming spores that are released, dispersed and find a suitable environment in which
to grow. It is the inhalation of organic dust contaminated with fungi spores (mouldy cellulosebased material such as straw) that causes the biological pneumoconioses such as farmer's lung.
Viruses.
Viruses are included as micro-organisms but are not strictly "alive". They are self-replicating
molecules (genetic material contained in a protein shell) that invade host cells, take control of the
cell material to produce more viruses, and release these viruses to enter other host cells.
Hepatitis and AIDS are two diseases of occupational significance that are caused by viruses present in human body fluids.

1. Virus (cubic) (e.g. hepatitis).

2. Fungus ([Link]).
3. Virus (helix) (e.g. influenza).
Genetic Manipulation.
Genetic manipulation is a scientific technique whereby the genetic material of an organism is altered in a way that does not occur naturally. The concern over this technique arises from the possibility that genetically modifying organisms may result in:

Organisms with enhanced pathogenicity.

Harmless organisms being converted into hazardous ones.
The introduction of cancer-producing sequences into a host.

The release of potentially harmful organisms into the environment.

As a result of this public concern, legislation was introduced to control such activities in the form
of the Genetically Modified Organisms (Contained Use) Regulations 2000 (as amended).
The main requirement of the Regulations is that genetic modification must not be carried out
unless a suitable and sufficient assessment of risks (both to human health and the environment)
is carried out.
The first stage of the risk assessment is to classify genetically modified organisms into either
Group I or Group II. Activities involving genetic modification, as defined by the Genetically Modified Organisms (Contained Use) Regulations 2000 (as amended) must be notified to the Health
and Safety Executive, and consent obtained for work with Group II organisms.
The risk assessment must take into account:

Characteristics of the original organism.

Characteristics of the modified organism.
Risks to health from the genetically modified organism, (e.g. ability to colonise, potential
for survival, stability, pathogenicity, toxicity).
Environmental considerations, (e.g. survival, multiplication, methods of monitoring, impact
on the environment).
Guidance on carrying out the risk assessment is given in the Advisory Committee on Genetic Manipulation (ACGM) Note 7, "Guidance on the Risk Assessment of Operations Involving the Contained Use of Genetically Modified Organisms".

Numerical values are placed on the three critical stages of harm arising from the genetically modified organism:

The ability of the modified organism to colonise a host (access).

The likelihood that recombinant genes will be expressed as polypeptides (expression).
The likelihood that expressed polypeptides will harm the host (damage).

If the three factors are multiplied together, a combined risk factor is obtained which is used to determine the level of containment needed. We shall discuss containment levels for biological hazards in more detail in the next study unit but levels vary from 1, which involves basic good laboratory practice and is adequate for low risk materials, to 4, which requires an isolated laboratory
with access via an airlock and all work carried out in a totally enclosed cabinet.
The deliberate release of genetically-modified organisms into the environment requires careful
risk assessment. If a hazardous organism were to become established in the environment, serious and irreversible damage could result.
Further information:
Guidance from the Health and Safety Commission's Advisory Committee on Genetic Modification
Also INDG86 - Contained use of genetically modified organisms

Toxic Hazards.
It is also possible for damage to health to occur through exposure to microbiological products,
even when the organism from which they are derived is dead. Some organisms produce potent
toxins that are chemical in nature and therefore persist in the material after biological activity
ceases. There are three different categories of toxin:

Endotoxins, which are formed within the micro-organism and are released when it dies.
Examples include toxins released from dead bacteria in refuse, sewage sludge and con-

taminated water.
Exotoxins, which diffuse out of the micro-organism and affect tissues in other parts of the
body.
Mycotoxins, which are produced by fungi growing on foodstuffs.

Further reading materials are available here

[Link]

1.2 Video: Avian/Swine Flu Update - April 25 2009.

Although questions regarding swine flu will not appear in the exam, this news bulletin is very current and should help make connections with the content in the rest of this unit.
[Link]

2 Assessment and Control of Risk

Although you can draw some comparisons between health effects on the body of biological
agents and of chemical agents, biological agents have the following special properties:

They are living things and can therefore evolve and change rapidly, with new biological
agents appearing regularly.
Their presence is not readily detectable.
Infectious diseases can be transmitted from person to person which poses a community
risk.
Exposure to very low numbers of organisms may be sufficient to cause disease.
Initial low numbers of organisms may multiply rapidly under the right conditions to result in
an infective dose.

Modes of Transmission.
Biological agents can gain entry to the human body via the standard routes that we have already
discussed, i.e.

Inhalation into the respiratory tract.

Ingestion into the gastrointestinal tract.
Absorption or penetration of the skin.

A further important route for biological agents is absorption through moist surfaces, such as the
conjunctiva of the eye.
Inhalation.
Bioaerosols consisting of suspensions of very small particles (bacteria, spores, organic dusts)
generated when materials containing them are disturbed, can be inhaled into the respiratory tract.
The usual defence mechanisms for airborne contaminants which depend on particle size apply
(refer back in this course) but both materials entrapped by the cilia, and smaller particles entering
the alveoli, may initiate an infection or an allergy.
Ingestion.
Biological agents may enter the body through contaminated food and drink, or by hand contact
with contaminated surfaces and then hand-to-mouth transfer. The gastric juices may be sufficient
to destroy some agents, but ingestion of contaminated material is a potential transmission route,
particularly in laboratory environments where control measures prohibit consumption of food or

drink.
Skin Contact.
Micro-organisms are able to enter the body through cuts, scratches and abrasions. Skin is rarely
completely intact and the minute size of bacteria and viruses allows entry to what might appear to
be an impermeable skin barrier. A further route is that of "injection", where needle-stick injuries
involving contaminated sharp implements such as needles or glassware and even bites and
stings from infected insects or mites, can allow entry of biological agents through the skin.
Entry Through the Conjunctivae.
The membranes surrounding the eye are very thin and allow a route of entry to biological agents.
Any contaminated fluids or aerosols which are able to contact the eye can be absorbed across
the membrane.
Other Routes.
Certain circumstances may offer a combination of transmission routes, including direct contact
with an infected person or animal, and contact with infected materials (blood, body fluids, tissues,
organs) where the route of entry may be by any of those discussed above.
Mechanisms of Attack on the Body.
The actual mechanism of attack on the body depends on the particular biological agent (type of
agent, route of entry, site of action), but there are a number of factors that need to be taken into
consideration when assessing the likelihood of infection.
One measure of ability to cause infection (infectivity) is the dose required to infect 50% of a population by a given route (termed ID50 and similar in concept to LD50 for toxins). However, in practice data may be difficult to obtain and those based on animal experiments may not be completely
relevant to human exposure. Another problem is that different strains of the same organism may
have very different infectivities.
Once biological agents have gained entry to the body, the mechanism of attack may result in a
range of outcomes. These may involve invasion of host tissues, damage to the host defence systems, multiplying, production of toxins and production of inflammation or damage including allergic reaction via the immune system.
The efficiency with which the agent affects these outcomes is termed virulence and is a measure
of the ability of the agent to inflict general harm on the host. For agents that result in death of the
host, virulence can be expressed as ID50; the dose required to kill half of a given population.
Highly virulent organisms are those that cause death or serious disease in a high proportion of
the hosts that they infect.
Signs and Symptoms of the Disease.
The human body has a range of defence mechanisms which serve to protect the individual
against diseases caused by biological agents. We considered these previously when we studied
the defence mechanisms of the body against chemical agents. They include:

The skin, which acts as a barrier when intact.

The mechanism of the respiratory tract, which deals with dust and solid particles (cilia escalator).
Acidic pH levels in the stomach, which can destroy bacteria.
Protective enzymes in saliva and tears.

If these defence mechanisms are breached then the body's immune system begins to operate,
triggered by antigens produced by the organism. The body produces white blood cells to engulf
the invading organism, and antibodies in the blood that specifically neutralise toxins and kill invading organisms.
An overreaction to invading antigens may result in an allergic reaction with the usual symptoms of

skin reaction, rhinitis, coughs, wheezes and asthma.

Immunity, either long-term or short-term, may be obtained by vaccination.
The effects of attack by micro-organisms may be:
Acute - occurring over a short time-scale.
There will be an incubation period (varying from a few days to several weeks, which is characteristic of the organism), then symptoms occur which are an indication of three outcomes:

Elimination of the organism and recovery.

Latent chronic infection (targets include heart, brain, joints).
The defences of the host are overwhelmed and death occurs.

Chronic - symptoms may remain over weeks or months.

Organisms may remain in the host for long periods without symptoms but carriers may be able to
pass the infection on to others (Hepatitis B is an example of this).
Toxic - these are biological in origin but chemical in nature and consequently can cause serious
harm. We have already examined the production of endotoxins, exotoxins and mycotoxins in this
study unit.
Allergenic - symptoms include skin reactions, coughs, wheezes, rhinitis, asthma and allergic alveolitis.

2.1 Occupational Groups at Risk.

Exposure to Biological Hazards.
Agricultural workers.
One of the principal sources of biological hazard for agricultural workers is animal disease transmissible to humans (zoonoses). Such diseases may be transmitted directly from the animals by
contact with body fluids, or during slaughter. Infection may also occur indirectly by handling animal products such as wool, hides and hair. We shall consider specific examples of zoonoses later
in this element.
In addition to animals and animal products, agricultural workers may be at risk from exposure to
sewage and polluted water (polio, leptospirosis, Hepatitis A), tetanus infection from broken skin in
contact with soil, and alveolitis or asthma resulting from exposure to fungally contaminated dusts
from decaying organic matter (farmer's lung).
Health service workers/laboratory workers.
This group of workers can be exposed to a range of microbiological hazards, both in a laboratory
setting and also by contacting potentially infected products, generally in hospitals.
In microbiological laboratories, a wide variety of pathogens are handled during investigations on
clinical material to determine the causes of certain diseases. There is the risk of laboratoryacquired infection and we shall discuss the strict control measures required later in this element.
In addition, clinical waste from hospitals and health care premises may contain pathogenic microorganisms and disposal must be carefully controlled.
Micro-organisms, especially viruses, may be present in the blood of humans who are infected,
even if they are not ill. Biological agents may be transferred to workers by contact (broken or
wounded skin, mucous membranes, accidental injection by "sharps") with infected blood or body
fluids. Infections of particular concern are hepatitis and HIV.
Biological agents responsible for certain infections may be transmitted from patients to staff in
health care premises. Transmission may be direct by aerosols (coughing and sneezing) or by

contact with infected body fluids, either through broken skin or the hand-to-mouth route.
Other groups of workers at risk include:

Mortuary workers, emergency services, first aiders, laundry workers: exposure to human
tissue and body fluids (hepatitis, HIV).
Sewage and construction workers: exposure to sewage and polluted water (polio, leptospirosis, hepatitis A).
Food handlers: exposure to infected food (gastroenteritis, food poisoning).

HSE link: Specific infections at work

Vulnerable Groups.
Within the groups of persons at risk from exposure to biological hazards, there are certain sections of the population that are particularly vulnerable:
The Elderly, Debilitated or Chronically Sick.
These persons have a reduced resistance to infection, and in a hospital or health care environment are particularly at risk. Some of the more serious outbreaks of Legionnaires' Disease have
occurred in hospitals, where susceptible patients have suffered fatal illness following exposure to
legionella-contaminated aerosols. Similarly, salmonella outbreaks in such environments can have
serious consequences.
Pregnant and Breast-feeding Women and Their Children.
This is a susceptible group that we have already identified in connection with chemical agents;
you will not be surprised that they are also at greater risk from exposure to certain infections.
Many agents can be transmitted to the unborn child in the placenta or via milk after birth (Hepatitis B, HIV, typhoid). The rubella virus (German measles) can cause abortion or physical damage
to the unborn child.
People with Suppressed Immune System.
People with a suppressed immune system are less able to resist infection than other individuals.
Reasons for the immune system becoming suppressed include treatment with drugs specifically
designed to suppress the immune system for clinical reasons, suppression as a result of exposure to ionising radiation or disease such as infection with HIV.

2.2 Specific Conditions Caused by Biological Agents.

On the 25th March 2010, a meeting of experts on occupational diseases held at the International
Labour Office adopted a new list of occupational diseases designed to assist countries in the
prevention, recording, notification and, if applicable, compensation of illnesses caused by work.
The list strengthens the process of identification, recording and notification procedures for occupational accidents and diseases, with the aim of identifying their causes, establishing preventative measures, promoting the harmonisation of recording and notification systems, and improving
the compensation process in the case of occupational accidents and occupational diseases.
The panel of experts examined a proposed list of occupational diseases developed through tripartite consultations, on the basis of increased recognition of occupational diseases at the national and international levels, new and emerging risk factors and the improvement of diagnostic
techniques. It was recognised that there was a need for a simplified procedure for updating lists
of occupational diseases, and the ILO decided on the adoption of certain proposals with regard to
the recording and notification of occupational accidents and diseases, and to the regular review
and updating of a list of occupational diseases.
The revised list includes a range of internationally recognised occupational diseases, from illnesses caused by chemical, physical and biological agents to respiratory, skin and musculoskele-

tal disorders and occupational cancer. It also includes a section on mental and behavioural disorders. Once approved by the ILO Governing Body at its March 2010 Session, the new list replaced
the one in the Annex to the Recommendation concerning the List of Occupational Diseases and
the Recording and Notification of Occupational Accidents and Diseases, 2002, (No. 194).
Participants at the meeting followed a set of general criteria to decide what specific diseases to
include in the updated list:

that there is a causal relationship with a specific agent, exposure or work process;
that they occur in connection with the work environment and/or in specific occupations;
that they occur among the groups of persons concerned with a frequency which exceeds
the average incidence within the rest of the population; and
that there is scientific evidence of a clearly defined pattern of disease following exposure
and plausibility of cause.

The original List of Occupational Diseases Recommendation (no.194) was adopted at the 90th
Session of the International Labour Conference in 2002. A first meeting of experts to revise the
list took place in 2005. The revised 2010 list marked the culmination of the review process.
The responsibilities of individual members.
A national list of occupational diseases for the purposes of prevention, recording, notification and,
if applicable, compensation should be established by the competent authority, in consultation with
the most representative organisations of employers and workers, by methods appropriate to national conditions and practice, and by stages as necessary. This list should:
(a) for the purposes of prevention, recording, notification and compensation comprise, at the
least, the diseases enumerated in Schedule I of the Employment Injury Benefits Convention,
1964, as amended in 1980;
(b) comprise, to the extent possible, other diseases contained in the list of occupational diseases
as annexed to this Recommendation; and
(c) comprise, to the extent possible, a section entitled "Suspected occupational diseases".
Each Member should furnish annually to the International Labour Office comprehensive statistics
on occupational accidents and diseases and, as appropriate, dangerous occurrences and commuting accidents with a view to facilitating the international exchange and comparison of these
statistics.
On the revised list of Occupational Diseases 2010, the following biological agents are listed:

1.3.1. Brucellosis
1.3.2. Hepatitis viruses
1.3.3. Human immunodeficiency virus (HIV)
1.3.4. Tetanus
1.3.5. Tuberculosis
1.3.6. Toxic or inflammatory syndromes associated with bacterial or fungal contaminants
1.3.7. Anthrax
1.3.8. Leptospirosis
1.3.9. Diseases caused by other biological agents at work not mentioned in the preceding
items where a direct link is established scientifically, or determined by methods appropriate to national conditions and practice, between the exposure to these biological agents
arising from work activities and the disease(s) contracted by the worker.

The next section of this course will deal with those biological agents, their effects and causes. As
well as those agents identified in the ILO list, we shall also consider others as per the following
table.
Disease

Cause

Zoonoses :

Brucellosis

Brucella abortus

Q Fever

Coxiella burnetii

Orf

Virus

Psittacosis

Chlamydia psittaci

Anthrax

Bacillus anthracis

Glanders

Pseudomonas mallei

Legionnaires' Disease

Legionella pneumophilia

Pontiac Fever

Legionella pneumophilia

Leptospira :

Weil's Disease

L. icterohaemorrhagiae

Fungi :

Farmer's Lung

Micropolyspora faeni

Bagassosis

Aspergillus fumigatus

Bacilli :

Table 1.1
When reading through this section, remember that the primary objective is the control and prevention of the disease. As a general rule, the control strategies for biological health hazards are
the same as for chemicals and are therefore similar to the strategies identified by the Control of
Substances Hazardous to Health Regulations, which we dealt with earlier.
However, where control of biological hazards is considered, it becomes important to understand
that the problem involves "active" pathogens rather than "inanimate" chemicals. Control must
therefore be extended to cover action taken against infectious diseases. For example, in dealing
with Weil's Disease it can be achieved in three stages:
Control at source - kill the rats - dry or sterilise the area.
Control the person - personal protection and hygiene - safe method of work.
Control the disease - prophylactic immunisation - antibody testing - issue of warning cards.
Control of biological hazards is an important consideration; however, we will refer to control
measures in this section as we examine specific diseases.
Zoonoses.
Zoonoses are animal infections that may be transmitted to people in the course of their work.
About 140 are known, and we shall now discuss the important ones.

2.3 Brucellosis (Undulant Fever, Malta Fever).

The bacterium may infect people handling cattle or pigs, or their carcasses in abattoirs. In 1973,
brucellosis was added to the list of prescribed diseases. The pathogen is Brucella abortus in cattle and B. suis in pigs. In a study carried out in Somerset in 1964 on 38 patients, it was found
that:

23 had habitual contact with cows;

17 were farmers or farm labourers;
5 were veterinary surgeons.

The illness is not very severe, but it may continue over a long period and wear the patient out.

There is a loss of appetite, headache, insomnia and slight fever. In the evenings, neuralgic pains
and swellings in the joints appear. Eventually, the patient may become emaciated and exhausted.
In the UK, a policy of eradication has been pursued since the 1960s by destroying any infected
cattle.

2.4 Q Fever.
This was first recognised after an attack of illness among Brisbane abattoir workers in 1937, and
given the name Q (for query) fever. In 1949, it was recognised among farm workers in England
and is known to occur in farm workers, abattoir workers and veterinary surgeons. The causative
agent, Coxiella burnetii, has been found in cows and sheep. It is not considered as serious as
brucellosis and takes the form of cold or flu-like symptoms.

2.5 Orf.
This is a contagious pustular dermatitis of viral origin, mainly affecting farm workers, shepherds,
sheep shearers, butchers and abattoir workers. It has also been reported amongst housewives
and cooks preparing sheep's heads for the table.
At first, the lesion is a dark-red spot or pimple on the hand, arm or face, which enlarges until it
reaches 1 to 4 cm diameter. Later, it becomes ulcerated, exuding clear fluid and pus. Apart from
local tenderness, there may also be headaches and tiredness. Complete recovery occurs in
about three weeks.
Prevention is largely a question of good hygiene and covering any skin wounds to stop infection
by the virus.

2.6 Psittacosis.
A virus-like bacterium of poultry, game and other birds, which can be fatal to man if untreated.
Hygiene and personal protection are the best preventive measures for poultry workers.
The illness sets in suddenly after an incubation period of two to three weeks. There is a fever,
headache and lethargy. Pulmonary symptoms follow in a few days, characterised by a nonexpectorant cough and shallow rapid breathing similar to a mild bronchitis. Mortality may be as
high as 20%, particularly in the elderly.
The practice of allowing psittacine birds to climb up the arm onto the head and shoulders and
feeding them from mouth to beak is to be deplored. In poultry flocks, the disease is controlled by
killing sick birds accompanied by intensive treatment of infected flocks.

2.7 Anthrax.
An acute, infectious disease of farm animals caused by a bacterium. Although rare in the UK, it
can be transmitted to man by contact with infected hair, hides, excrement or products such as
bone meal. It is still common in third world countries, and can be imported into the UK by accident
on animal products. It is fatal without treatment.
The initial lesion is a small red spot or pimple which rapidly takes on an ulcerated appearance. By
the third day, it turns a browny colour with secondary blisters surrounding it in the form of a ring.
By about the fifth day the lesion becomes covered by a dry, almost black scab. Typically, there is

also swelling of the lymph glands and the temperature rises to 100 to 102F. Today, more than
96% of cases respond to treatment by penicillin.

2.8 Pulmonary Anthrax.

This used to be known as Woolsorters' Disease (after an outbreak among alpaca and mohair
sorters in Bradford in 1847) and is caused by inhaling the pathogen. Diagnosis is very difficult,
and death usually follows in three or four days.
Control has been achieved by killing and burning infected animals and by sterilising imported
animal products such as horse hair, sheep's wool, bone meal, etc, with steam or proprietary sterilising solutions. It has a certain notoriety as a biological warfare agent. In 1942, the British Government tested anthrax on sheep on the Scottish island of Gruinard. As a result, the island was
quarantined for forty-eight years and has only recently been declared safe. However, doubts still
remain about the active nature of the disease.

2.9 Glanders.
An infectious disease of horses, donkeys and mules caused by the pathogen Pseudomonas
mallei; it is transmitted to humans by nasal or mouth secretions from the infected animal.
After an incubation period of about a week, abscesses appear on the hands, arms or face and
the skin around the abscess becomes very inflamed. The inside of the nose may become ulcerated, emitting a sticky discharge. This condition, which has been described as the most painful
disease which man can suffer, may last for up to four months but is treatable with modern antibiotics.

2.10 Control Strategy for Zoonoses.

The most common route of entry is via the skin, which is facilitated by open cuts, sores or abrasions which provide direct entry into the bloodstream. Other routes include inhalation of contaminated dust, contact with the conjunctiva of the eyes, direct injection through cuts from infected
animal bites, and direct ingestion via hands.
The first stage of a control strategy is to assess those people at risk. Factors to consider include
the work being carried out, susceptibility to infection of the workers, how infections might occur,
and how likely exposure to infection is. Once a significant potential health hazard has been identified, then the control strategy can be based on established occupational hygiene principles.
The first priority for preventing occupational exposure to zoonoses is to eliminate the infections
from the animal stock, usually by protecting exposed animals through immunisation and improvement of their environment.
Workers should be protected by suitable environmental hygiene controls and wearing protective
clothing including hand, arm, foot and leg protection. Where animal products likely to emit infected dust are handled (e.g. wool, skin, hides, pelts), exhaust ventilation and possibly respiratory
protective equipment should be provided to prevent airborne infection. Specific immunisation of
workers may be necessary.
Clean and hygienic animal living conditions and disinfection of stalls will also ensure better hygiene in factory premises, and will reduce the probability of infection. Automation to reduce human contact and enclosure of aerosol-producing activities will reduce exposure to infection. Finally, medical checks, training and information, procedures, instruction and records will give

added protection to workers.

2.11 Video: Zoonose.

IB5.2.11 Video: Zoonose
[Link]

2.12 Legionella.
The bacterium, Legionella pneumophilia, is responsible for two important workplace conditions,
Legionnaires' Disease and Pontiac Fever.
The first identified outbreak of Legionnaires' Disease occurred among people who had attended a
Pennsylvanian State Convention of the American Legion in 1976. Delegates subsequently suffered respiratory illness and the bacterium Legionella pneumophilia was isolated from lung
specimens.
Pontiac Fever is a shorter, more feverish illness, without the complications of pneumonia. Legionellosis is the generic term used to cover Legionnaires' Disease and Pontiac Fever.
Microbiology.
L. pneumophilia is one species of a genus of bacteria grouped under the name Legionella. They
are rod-shaped organisms, widespread in natural water sources and found in rivers, lakes,
streams, mud and soil as well as man-made water systems. To date, at least 34 different species
of legionella are recognised. L. pneumophilia is apparently the most pathogenic, and is the species most commonly associated with disease outbreaks.
The ecology of Legionella in water systems is not fully understood, but the following conditions
have been found to affect its rate of growth:

Water temperatures in the range of 25-45C favour growth. It is uncommon to find proliferation below 20C and it does not survive above 60C. Organisms may remain dormant
in cool water, multiplying only when the temperature reaches a certain level.
The presence of sediment, sludge, scale and organic material can act as a source of nutrients.

Commonly encountered organisms in water systems, such as algae, amoebae and other bacteria, may serve as an additional nutrient source for Legionella. Algal slime may provide a stable
habitat for multiplication and survival.
Incorporation of Legionella in slime on surfaces in contact with water can protect the organisms
from concentrations of biocides which would otherwise kill or inhibit those organisms freely suspended in water.
In order to identify L. pneumophilia in the laboratory, the bacteria are recovered from concentrated water samples by propagation of the organism in a nutrient growth medium. Samples are
incubated at around 37C and colonies take up to 7 days to appear. Legionella can be recognised by visual examination of the colonies, followed by laboratory techniques to identify species
and serogroup.
Symptoms.
Legionnaires' Disease is a type of pneumonia. As well as affecting the lungs, it may also have
serious effects on other organs of the body. Infection is caused by inhaling airborne droplets or
particles containing viable legionella, which are small enough to pass deep into the lungs and be

deposited in the alveoli.

The infectious dose is not known, and there is reported to be a 1% attack rate; so that for every
hundred persons exposed, generally only one will develop symptoms of disease.
Legionnaires' Disease usually has an incubation period of 3 to 6 days. Males are more likely to be
affected than females by a ratio of 3 to 1. Most reported cases occur in the 40 to 70 year age
group. Although healthy individuals may develop Legionnaires' Disease, people at greatest risk
include smokers, alcoholics and patients with cancer, chronic respiratory or kidney disease. The
case fatality rate is approximately 12%, but in immuno-suppressed patients or those with other
underlying disease, this figure may be higher.
Initial symptoms include high fever, chills, headache and muscle pain. A dry cough soon develops
and most patients suffer difficulty with breathing. About a third of patients also develop diarrhoea
or vomiting, and about half become confused or delirious.
Exposure to Legionella can also lead to Pontiac Fever, which is a milder condition with an incubation period between 5 hours and 3 days. The illness usually lasts between 2 and 3 days. The
symptoms of Pontiac Fever are similar to those of moderate to severe influenza, with headache,
tiredness, fever and in a small proportion of cases nausea, vomiting and coughing. No deaths
have been reported. A high percentage of those at risk develop Pontiac Fever in comparison to
the lower attack rate of Legionnaires' Disease.
In recent years, up to 300 cases of Legionnaires' Disease have been reported each year in England and Wales, compared to 180,000 estimated cases of pneumonia from all causes. Clusters of
cases have occurred in outbreaks associated with hotels, factories and hospitals.
Occurrence.
Legionella is common in natural water sources and therefore random sampling of water systems
will often yield positive results. Because the infectious dose and the variation in susceptibility are
not fully understood, it is difficult to determine risk solely on the basis of water sampling results.
For these reasons, random water sampling is not advocated. However, sampling can be used to
monitor precautionary measures, such as water treatment, or to trace the source of infection. The
Approved Code of Practice, The Prevention or Control of Legionellosis including Legionnaires'
Disease, identifies the following systems as potentially at risk:

Water systems incorporating a cooling tower.

Water systems incorporating an evaporating condenser.
Hot water services of volume greater than 300 litres and hot/cold water services where
occupants are susceptible, i.e. health care premises.
Humidifiers and air washers creating a spray of water droplets above 20C.
Spa baths and pools.

2.13 Legionella - Assessment of Risk.

The Approved Code requires employers to manage risk by:

identifying and assessing sources of risk;

preparing a scheme for preventing or controlling the risk;
implementing and managing precautions;
keeping records of the precautions.

The risk assessment should take account of:

the potential for drop formation;

water temperature;

the risk to those who inhale droplets and

the means of preventing and controlling risk.

Droplets may be created by spraying, bubbling and impact with hard surfaces. Large drops may
be reduced to respirable size by evaporation.
Particular attention should be paid to populations which contain a high proportion of susceptible
people (hospitals or nursing homes), and situations where there are a large number of such people at risk.
Control Measures.
The main aim is to avoid conditions where Legionella can proliferate, and to avoid creating sprays
or aerosols.
Growth of Legionella can be inhibited by:

avoiding water temperatures between 20C and 45C (an important factor in controlling
the risk);
avoiding water stagnation and slimes which harbour Legionella and encourage growth;
avoiding the use of materials in a system which can harbour or provide nutrient for the organisms;
keeping the system clean and preventing a build-up of sediments;
using appropriate water treatment chemicals.

2.14 Leptospira.
These are a particular type of long, flexible, spiral bacteria termed spirochaetes. The variety Leptospira icterohaemorrhagiae is responsible for the condition Weil's Disease. In 1886, Dr Adolf
Weil (1848-1916) published an account of four cases of an infectious jaundice which led to the
recognition of a symptom-complex of fever, jaundice and enlargement of the liver, haemorrhages
and feverish relapses, under the designation of Weil's Disease. The symptoms give rise to other
names for the disease including Leptospirosis, Leptospiral Jaundice, Spirochaetal Jaundice, Spirochaetosis icterohaemorrhagica, Infective Haemorrhagic Jaundice and Mud Fever.
Exposure Hazard.
An increasing number of sporadic cases of jaundice where workers are brought into contact with
water or mud and slime contaminated by rats, focused suspicion on rats as being the primary
cause of the disease. Leptospira icterohaemorrhagiae is found in the kidneys of rats from all over
the world and reaches the outside in excretions of urine; it is from this source that humans are
infected.
There is now mounting evidence that the spirochaete can pass through intact skin and in the UK,
the disease has been confirmed in coal miners, bargemen, canal workers, sewer workers, fish
cleaners, filleters, porters and mongers, tripe scrapers, pig workers, butchers, workers in abattoirs, stable workers, rat catchers and agricultural workers employed in hedging and ditching. A
disturbing finding is that an increasing number of water sports enthusiasts are becoming infected
as rat populations multiply. It is of interest that a less virulent form of the disease can be caused
by L. canicola, a canine leptospirosis.
Symptoms.
The disease can be divided into three stages:
Stage I: Fever with flu-like symptoms lasting for about a week. (It is for this reason that workers at
risk should carry a card for presentation to their GP on the appearance of any flu-like symptoms,

so that the possibility of the onset of Weil's Disease may be considered.)

Stage II: By the start of the second week, the fever has abated and jaundice becomes more obvious (sometimes making its appearance as early as the fourth day). This toxic stage is the result
of the development of antibodies in the blood and the excretion of the Leptospirus in the urine.
About 5-10% may die at this stage.
Stage III: The convalescent period. In severe cases, the jaundice may be present for three or four
weeks, with a second fever usually occurring, lasting for up to two weeks. Recovery can take
many weeks or months, with patients remaining very tired and lethargic for a considerable time.
Control
Intensive and systematic destruction of rats should be carried out in infested areas, and further
control can be achieved by cleaning and removing material soiled by rat urine. The disease is always associated with wet conditions. Control of the disease in sewer workers is difficult, but prophylactic immunisation seems to offer the best solution, together with a campaign of antibody
testing. In addition, all "at risk" workers should carry a card warning of the dangers, stressing personal cleanliness and hygiene, explaining the need for protective clothing and alerting doctors to
the possibility of the disease.
As a consequence of a successive run of mild winters, both urban and rural rat populations have
increased considerably, leading to a proportional increase in disease risk. In the UK, there are
other rat-borne diseases transmitted by the same route as Weil's Disease, including Haverhill Fever and Hanta Fever (the viruses of which are also spread by voles and mice). Plague (Yersinia
pestis) is transmitted to humans by rat-fleas, but epizootics in rat populations invariably precede
epidemics in man.
In regard to personal exposure control, it is essential to ensure that people subject to potential
risk are aware of the causes and symptoms; are given instruction in suitable first-aid precautions
(e.g. covering existing skin wounds, cleaning and disinfecting all fresh wounds); notify a GP if influenza-like symptoms occur; and notify public authorities if rat infestation is noticed in a work
area.
Removal of work activities from an infested site is a wise precaution if practicable; in the case of
leisure activities, it may be a least-work option to transfer the activity from a freshwater to a seawater location, since rats do not prefer such an environment and dilution of any pollution will be
greater.

2.15 Fungi.
The main occupational problem arising from fungi is inhalation of dusty spores, which can lead to
the following respiratory disorders:
Extrinsic Allergic Alveolitis - this is a pneumoconiosis. Bernadino Ramazzini (1633-1714) described respiratory disorders due to dusts, among flax and silk workers in Italy in 1713, since
when many similar conditions have been identified, including

Farmer's Lung,
Bagassosis and
Aspergillosis.

2.16 Farmers Lung.

Straw and hay quickly become mouldy if left wet in the field after cutting. The moisture encour-

ages the rapid growth of green-grey dusty moulds, mostly Micropolyspora faeni, which produce
clouds of dusty spores when handled. The average size of these spores is about 1 micron, so
that when inhaled, they penetrate to the alveoli. It has been estimated that a farm worker handling mouldy hay may inhale as many as a million spores a minute.
An association between farmer's lung and mouldy hay had been known since the 1930s but the
specific cause eluded people and there was much debate as to whether the disease was allergic
in nature. Professor Jacob 'Jack' Pepys (1914-1996) and his colleagues discovered a specific
cause (allergy to moulds) and developed a blood test for farmer's lung which has remained routine in clinical practice ever since.
It became clear that there were many variants of this particular form of allergic lung disease (for
which the term extrinsic allergic alveolitis was coined). Related conditions included bird breeder's
(fancier's) lung and a similar allergic lung problem caused by inhaled pituitary snuff used in the
treatment of diabetes insipidus.
Pepys and his team also described these diseases and their causes. He furthermore achieved
international acclaim for his work on allergic bronchopulmonary aspergillosis and allergic lung
diseases caused by fungi. These complex conditions, which can be fatal if unrecognised, were
found by Pepys and his team to have a basic immunological nature. This enabled them to explain
the patterns of tissue destruction and develop further specific diagnostic tests. He also pioneered
"experimental models" of provoked asthma and extrinsic allergic alveolitis in the clinical laboratory
and in this way was able not only to unravel disease processes but also to explain the basis of
the mode of action of various anti-allergic drugs.
The first symptoms are usually the development of a dry cough with little or no expectoration,
sometimes accompanied by a general malaise, weakness and a slight fever, often mistaken for
flu. The most outstanding feature, however, is extreme shortness of breath on exertion but, although moist sounds may be heard in the lungs, radiographs of the chest are normal.
After the first exposure or illness, recovery is swift following removal of the individual from the
dust source. With repeated exposures, the disease becomes more debilitating and chest X-rays
show a fine alveolar mottling with some compensatory emphysema in the form of larger air-sacs.
At this stage, the symptoms may disappear after a few months away from the exposure site, but
chest X-rays may remain abnormal for up to six months or more. However, with successive seasonal exposures, the disease becomes chronic, leading to pulmonary fibrosis, emphysema and
bronchiectasis, by which time it may be irreversible.

2.17 Cryptosporidiosis.
Cryptosporidiosis (krip-toe-spo-rid-e-o-sis), is a diarrhoeal disease caused by a microscopic
parasite, Cryptosporidium parvum. It can live in the intestine of humans and animals such as cattle, dogs, and cats and is passed in the stool of an infected person or animal. Both the disease
and the parasite are also known as "Crypto." During the past two decades, Crypto has become
recognised as one of the most common causes of waterborne disease (drinking and recreational)
in humans. Cryptosporidium can be found in any environment that is contaminated by the faeces
of infected humans or animals, as well as lakes, rivers, water reservoirs, and ground water contaminated by these surface waters. The parasite is highly resistant to chlorine, which is commonly
used as a disinfectant in water treatment plants.
Transmission can occur by coming into contact with faeces of infected humans or animals, including:

Consumption of contaminated water or food.

Person-to-person contact, particularly in child care settings.
Handling of infected pets or farm animals.

Sexual activity that involves contact with faeces.

Symptoms appear 2 to 12 days after exposure to infected faeces.

While symptoms usually include diarrhoea, stomach cramps, fever, and nausea, some infected
people may have no symptoms. People with normal immune systems usually have symptoms for
one to two weeks and then recover fully. However, people with weakened immune systems, such
as cancer patients, organ transplant recipients, and HIV-infected persons, may have more severe
diarrhoea that can persist long enough to become life-threatening.
There is no specific treatment for cryptosporidiosis.
Replacing fluid lost through diarrhoea may be needed. Healthy people normally recover within
two weeks. Patients with severe or long-lasting diarrhoea should consult their doctor.
Cryptosporidiosis can be prevented.

Avoid drinking untreated water from lakes, streams, springs, or any other untreated
sources.
Boil any water of unknown quality for at least one minute before consumption (including
water used in drinks and to make ice).
Avoid any direct contact with human or animal faeces.
Wash hands after using the toilet, changing nappies, and before handling food or eating.
Wash hands after contact with, or cleaning up after, pets.
Wash hands after gardening or other direct contact with the soil.
Wash fruits and vegetables before eating them.
Avoid unpasteurised milk products.
Avoid swallowing water during swimming, even in public swimming pools.

People with weakened immune systems may want to take extra action to reduce the risk:

Boil water, or use certain filters or bottled water for all the water you drink including tooth
brushing.
Check with your doctor to see if you should take any other measures to avoid cryptosporidiosis if you have a weakened immune system.

2.18 Bagassosis.
"Bagasse" is a word of French origin covering the cellulose fibres of cane-sugar after the sugar
has been extracted. This waste material is used in the manufacture of fibreboard. However, if
samples of bagasse are examined, they may be found to contain as much as 240 million fungal
spores per gram, including rusts (Pucciniales), moulds (Aspergillus and Micropolysporans), together with species of Penicillium, Mucor, Rhizopus and saprophytic fungi.
Bagassosis is classified as a prescribed disease or injury, due to the biological agents extrinsic
allergic alveolitis, in Schedule 1, Part 1 of the Social Security (Industrial Injuries) (Prescribed Diseases) Regulations 1985, as variously amended. Its aetiology and pathology are very similar to
Farmer's Lung.

2.19 Aspergillosis
Just as the term pneumoconiosis collectively describes all the diseases of the lung and respiratory system caused by animal, vegetable, fungal and mineral dusts, so Aspergillosis is an allembracing term to describe the types of extrinsic allergic alveolitis (sometimes called by the more

general name "asthma") caused by the spores of the Aspergillus fungus. The most frequently encountered Aspergilli are fumigatus and niger. All are found as a mould on cellulosic fibres such as
hay, straw, jute, flax, hemp, sugar-cane, etc.

2.20 Hepatitis
There are a number of other biological agents which are able to cause diseases which have relevance in the workplace.
Hepatitis.
In recent years, infectious hepatitis has become the most common occupational disease amongst
medical staff; those at risk include doctors, surgeons, nurses and ancillary staff such as hospital
porters. Refuse disposal operatives form another group increasingly at risk from this severe form
of jaundice. Infection amongst health workers is a result of contact with blood or excreta of patients suffering from viral hepatitis, or in who the disease is still in its incubation stage.
Hospital porters and refuse disposal operatives appear to be at risk from carelessly discarded
syringes and other "sharps" in disposable plastic sacks. The problem is becoming more severe
with the increase in drug addiction and the use of shared needles (a practice which is also
thought to be responsible for the spread of AIDS among drug abusers).
The course of the disease is very much like that of Weil's Disease, but is usually much less severe and normally self-limiting, with recovery in about six weeks. In about 5% of cases, chronic
infectious hepatitis follows, leading to cirrhosis and possibly death.
Persons exposed to the risk, which may include firemen and ambulance workers in addition to
those already mentioned, can be protected with injections of gammaglobulin. In all cases, protective disposable gloves should be worn and hands and arms washed regularly with disinfectant.

2.21 [Link]
What is E. coli?
E. coli is short for Escherichia coli. In fact, they form part of whats known as the gut flora bacteria that naturally exist in the gut and help to keep the gut healthy and working properly. Most
strains are harmless but some are able to produce toxins that can cause symptoms in humans.
For instance, one strain of E. coli is often responsible for bladder infections. Others can cause
food poisoning and other infections. One particularly virulent group of bacteria are known as Vero
cytotoxin-producing E. coli (VTEC) and these are usually responsible for causing serious illness.
In some (rare) cases they can even prove fatal. Outbreaks have also been linked to the O157
strain.
How is the E. coli infection passed on?
The infection is usually passed on by faecal matter reaching the mouth. Contact with contaminated food such as meat which has not been cooked properly, unpasteurised milk and cheese,
eating unwashed vegetables which may have been infected by manure from infected cattle and
also contact with animals, are common sources of infection. Drinking or swimming in infected water, such as river water, stream water or water from drinking wells.
The virulent VTEC form of E. coli can be found in the intestines of healthy animals including
cows, sheep and goats. People can be infected through contact with these animals, or by being
exposed to animal faeces, for example at a farm.
Symptoms

Symptoms usually appear around 3-4 days after being in contact with the infection. The exact nature of the symptoms really depends on the type of E. coli that a person has been in contact with.
They can range from mild diarrhoea to more severe stomach cramps, vomiting and diarrhoea that
might contain [Link] symptoms can last up to seven days if there are no complications.
Complications
Its estimated that between five and ten per cent of people will experience complications which
can be more severe and even life threatening. Two serious conditions known as haemolytic
uraemic syndrome (HUS) and thrombotic thrombocytopaenic purpura (TTP) affect the blood,
kidneys and, in severe cases, the central nervous system.
Treatment
Some infections will go away of their own accord without the need for any treatment. Others, such
as bladder infections, usually respond well to a short course of antibiotics. Intestinal infections are
usually treated through rehydration, as fluid may be lost through diarrhoea.
Good hygiene can help prevent the infection being passed on. Its really important to wash and
thoroughly dry the hands after going to the toilet and touching animals, for instance at farms.
Make sure that food is cooked thoroughly.
Keep raw and cooked food apart during food preparation and wash your hands after handling
raw meat.
If someone has E. coli infection, wash all dirty clothes, bedding and towels in the washing machine on the hottest cycle possible. Clean toilet seats, toilet bowls, flush handles, taps and wash
hand basins after use with detergent and hot water, followed by a household disinfectant.

2.22 MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections in humans. It may also be called multidrug-resistant Staphylococcus
aureus or oxacillin-resistant Staphylococcus aureus (ORSA).
MRSA was discovered in 1961 in the United Kingdom. It made its first major appearance in the
United States in 1981 among intravenous drug users. MRSA is often referred to in the press as a
"superbug". The number of MRSA infections in the United States has been increasing significantly. A 2007 report in Emerging Infectious Diseases, a publication of the Centers for Disease
Control and Prevention (CDC), estimated the number of MRSA infections in hospitals doubled
nationwide, from approximately 127,000 in 1999 to 278,000 in 2005, while at the same time annual deaths increased from 11,000 to more than 17,000. Another study led by the CDC and published in the October 17, 2007 issue of the Journal of the American Medical Association estimated that MRSA would have been responsible for 94,360 serious infections and associated with
18,650 hospital stay-related deaths in the United States in 2005. These figures suggest that
MRSA infections are responsible for more deaths in the U.S. each year than AIDS.
The Office for National Statistics reported 1,629 MRSA-related deaths in England and Wales during 2005, indicating a MRSA-related mortality rate half the rate of that in the United States for
2005, even though the figures from the British source were explained to be high because of "improved levels of reporting, possibly brought about by the continued high public profile of the disease" during the time of the 2005 United Kingdom General Election. MRSA is thought to have
caused 1,652 deaths in 2006 in UK up from 51 in 1993.
Signs and symptoms.
[Link] most commonly colonizes the nostrils, although the rest of the respiratory tract, opened
wounds, intravenous catheters, and urinary tract are also potential sites for infection. Healthy individuals may carry MRSA asymptomatically for periods ranging from a few weeks to many years.

Patients with compromised immune systems are at a significantly greater risk of symptomatic
secondary infection.
MRSA can be detected by swabbing most of the nostrils of patients and isolating the bacteria
found inside. Combined with extra sanitary measures for those in contact with infected patients,
screening patients admitted to hospitals has been found to be effective in minimizing the spread
of MRSA in hospitals
MRSA may progress substantially within 2448 hours of initial topical symptoms. After 72 hours
MRSA can take hold in human tissues and eventually become resistant to treatment. The initial
presentation of MRSA is small red bumps that resemble pimples, spider bites, or boils that may
be accompanied by fever and occasionally rashes. Within a few days the bumps become larger,
more painful, and eventually open into deep, pus-filled boils.
At risk populations include:
People with weak immune systems (people living with HIV/AIDS, cancer patients, transplant recipients, severe asthmatics, etc.)
Diabetics.
Intravenous drug users.
Use of quinolone antibiotics.
Young children.
The elderly.
College students living in dormitories.
People staying or working in a health care facility for an extended period of time.
People who spend time in coastal waters where MRSA is present.
People who spend time in confined spaces with other people, including prison inmates and individuals who spend considerable time in changerooms or gyms.
Many MRSA infections occur in hospitals and healthcare facilities, with a higher incidence rate in
nursing homes or long-term care facilities. Healthcare provider-to-patient transfer is common, especially when healthcare providers move from patient to patient without performing necessary
hand-washing techniques between patients.
Prevention - Screening programs.
Patient screening upon hospital admission, with nasal cultures, prevents the cohabitation of
MRSA carriers with non-carriers, and exposure to infected surfaces. The test used (whether a
rapid molecular method or traditional culture) is not as important as the implementation of active
screening.
In some UK hospitals screening for MRSA is performed for every patient and all NHS surgical
patients, except for minor surgeries, are previously checked for MRSA. There is no community
screening in the UK; however, screening of individuals is offered by some private companies.
In a US cohort of 1,300 healthy children, 2.4% carried MRSA in their nose.
Surface sanitising .
Alcohol has been proven to be an effective surface sanitiser against MRSA. Quaternary ammonium can be used in conjunction with alcohol to extend the longevity of the sanitising action. The
prevention of infections involves routine and terminal cleaning.
In healthcare environments, MRSA can survive on surfaces and fabrics, including privacy curtains
or garments worn by care providers. Complete surface sanitation is necessary to eliminate MRSA
in areas where patients are recovering from invasive procedures. Testing patients for MRSA upon
admission, isolating MRSA-positive patients, decolonisation of MRSA-positive patients, and terminal cleaning of patients' rooms and all other clinical areas they occupy is the current best practice protocol for MRSA.
Hand washing.
At the end of August 2004, after a successful pilot scheme to tackle MRSA, the National Health
Service announced its 'Clean Your Hands' campaign. Wards were required to ensure that alcohol-based hand rubs are placed near all beds so that staff can hand wash more regularly.
As we mentioned in a previous section on rapid mutation rates, MRSA is acquiring more resis-

tance to some disinfectants and antiseptics. Although alcohol-based rubs remain somewhat effective, a more effective strategy is to wash hands with running water and an anti-microbial
cleanser with persistent killing action, such as Chlorhexidine
Essential oil diffusion.
An in vitro study on the inhibition of MRSA by essential oil diffusion found that 72 of 91 investigated essential oils exhibited zones of inhibition in soy agar plates streaked with MRSA. The
most effective of these were lemongrass oil, lemon myrtle oil, mountain savory oil, cinnamon oil
and melissa oil. Of these, lemongrass essential oil was the most effective, completely inhibiting all
MRSA colony growth. Tea tree oil also kills all MRSA strains that have been tested

2.23 [Link]
Clostridium difficile, also known as "C. diff", is a species of bacteria of the genus Clostridium that
causes severe diarrhoea and other intestinal disease when competing bacteria in the gut flora are
wiped out by antibiotics.
C. difficile is the most serious cause of antibiotic-associated diarrhoea and can lead to pseudomembranous colitis, a severe infection of the colon, often resulting from eradication of the normal gut flora by antibiotics.
In a very small percentage of the adult population, C. difficile bacteria naturally reside in the gut.
Other people accidentally ingest spores of the bacteria while they are patients in a hospital, nursing home, or similar facility. When the bacteria are in a colon in which the normal gut flora has
been destroyed, the gut becomes overrun with C. difficile. This overpopulation is harmful because
the bacteria release toxins that can cause bloating and diarrhoea with abdominal pain, which may
become severe. C. difficile infections are the most common cause of pseudomembranous colitis,
and in rare cases this can progress to toxic megacolon, which can be life-threatening.
Latent symptoms of C. difficile infection often mimic some flu-like symptoms and can mimic disease flare in patients with inflammatory bowel disease-associated colitis. Often, mild cases of C.
difficile infection can be cured by discontinuing the antibiotics responsible. In more serious cases,
oral administration of first metronidazole, and if that fails then secondly vancomycin, are currently
the treatments of choice.
Prevention.
The most effective method for preventing [Link] is proper antimicrobial prescribing. In the
hospital setting, where it is most common, nearly all patients that develop it are exposed to antimicrobials. Although proper antimicrobial prescribing sounds easy to do, approximately 50% of antimicrobial use is considered inappropriate.
In Britain, the testing of all hospital inpatients over the age of 65 with diarrhoea for C. difficile became a compulsory NHS practice in January 2008, when it became evident that many outbreaks
were being disguised as Norovirus by hospital managers, who can be dismissed by the Department of Health if C. difficile infection rates are too high, but cannot be dismissed as a result of a
Norovirus outbreak.
Infection control measures, such as wearing gloves when caring for patients with [Link] have
been proven to be effective at prevention. This works by limiting the spread of C. difficile in the
hospital setting. In addition, washing with soap and water will eliminate the spores from contaminated hands, but alcohol-based hand rubs are ineffective. Bleach wipes containing 0.55 percent
sodium hypochlorite have been shown to kill the spores and prevent transmission between patients.
Treatment with various oral supplements containing live bacteria has been studied in efforts to
prevent Clostridium difficile-associated infection/disease.
Hydrogen peroxide vapor (HPV) systems used to sterilise a patient room post discharge has
been shown to reduce infection rates and to reduce risk of infection to subsequent patients. One

study showed that incidence of [Link] was reduced by 53% though use of HPV, a second
study showed only a 42% reduction in rates through use of HPV.
In a limited clinical trial, a C. difficile anti-toxoid vaccine was reported to improve patient outcomes. Further testing will be required to validate this trial.
Notable outbreaks:
June 4th, 2003, two outbreaks of a highly virulent strain of this bacterium were reported in Montreal, Quebec and Calgary, Alberta, in Canada. Sources put the death count as low as 36 and as
high as 89, with approximately 1,400 cases in 2003 and within the first few months of 2004. C.
difficile infections continued to be a problem in the Quebec health care system in late 2004. As of
March 2005, it had spread into the Toronto, Ontario area, hospitalising 10 people.
A similar outbreak took place at Stoke Mandeville Hospital in the United Kingdom between 2003
and 2005.
October 1st, 2006, C. difficile was said to have killed at least 49 people at hospitals in Leicester,
England over eight months, according to a National Health Service investigation. Another 29 similar cases were investigated by coroners.
October 27th, 2006, 9 deaths were attributed to the bacterium in Quebec, Canada.
November 18th, 2006, the bacterium was reported to have been responsible for 12 deaths in
Quebec, Canada. This 12th reported death was only two days after the St. Hyacinthe's Honor
Mercier announced that the outbreak was under control. Thirty-one patients were diagnosed with
Clostridium difficile. Cleaning crews took measures in an attempt to clear the outbreak.
C. difficile was mentioned on 6,480 death certificates in 2006 in the UK.
February 27th, 2007, a new outbreak was identified at Trillium Health Centre in Mississauga,
Ontario, where 14 people were diagnosed with the bacteria. The bacteria was of the same strain
as the one in Quebec.
Between February and June 2007, three patients at Loughlinstown Hospital in Dublin, Ireland
were found by the coroner to have died as a result of C. difficile infection. In an inquest, the
Coroner's Court found that the hospital had no designated infection control team or consultant
microbiologist on staff.
October 2007, Maidstone and Tunbridge Wells NHS Trust was heavily criticised by the Healthcare Commission regarding its handling of a major outbreak of C. difficile in its hospitals in Kent
from April 2004 to September 2006. In its report, the Commission estimated that about 90 patients "definitely or probably" died as a result of the infection.
November 2007, the 027 strain has spread into several hospitals in southern Finland, with ten
deaths out of 115 infected patients reported.
November 2009, four deaths at Our Lady of Lourdes Hospital in Ireland, have possible links to
Clostridium difficile infection. A further 12 patients tested positive for infection, and another 20
show signs of infection, 10 November 2009.
March 2010, From February 2009 to February 2010 199 patients at Herlev hospital in Denmark
was suspected of being infected with the 027 strain. In the first half of 2009, 29 died in hospitals
in Copenhagen after they were infected with the bacterium.
May 2010, A total of 138 patients at four different hospitals in Denmark infected with the 027
strain plus some isolated occurrences at other hospitals

2.24 [Link]
Norovirus is an RNA virus that causes approximately 90% of epidemic non-bacterial outbreaks of
gastroenteritis around the world and may be responsible for 50% of all foodborne outbreaks of
gastroenteritis in the US. Norovirus affects people of all ages. The viruses are transmitted by faecally contaminated food or water, by person-to-person contact,[4] and via aerosolization of the
virus and subsequent contamination of surfaces.
After infection, immunity to norovirus is usually incomplete and temporary. There is an inherited
predisposition to infection, and individuals with blood type O are more often infected, while blood

types B and AB can confer partial protection against symptomatic infection.

Outbreaks of norovirus infection often occur in closed or semi-closed communities, such as longterm care facilities, overnight camps, hospitals, prisons, dormitories, and cruise ships where the
infection spreads very rapidly either by person-to-person transmission or through contaminated
food. Many norovirus outbreaks have been traced to food that was handled by one infected person.
Norovirus is rapidly inactivated by either sufficient heating or by chlorine-based disinfectants, but
the virus is less susceptible to alcohols and detergents as it does not have a lipid envelope.
Noroviruses are transmitted directly from person to person and indirectly via contaminated
fomites, water and food. They are highly contagious, with as few as one to ten virus particles being able to cause infection. Transmission occurs through ingesting contaminated food and water
and by person-to-person spread. Transmission is through fecal-oral, can be aerosolised when
those stricken with the illness vomit and can be aerosolized by a toilet flush when vomit or diarrhea is present; infection can follow eating food or breathing air near an episode of vomiting, even
if cleaned up. The viruses continue to be shed after symptoms have subsided and shedding can
still be detected many weeks after infection.
Norovirus is extremely infectious. In one outbreak at an international scout jamboree in the Netherlands, each person with gastroenteritis infected an average of 14 people before increased hygiene measures were put in place. Even after these new measures were enacted an average ill
person still infected 2.1 other people. A study of eleven outbreaks lists the suspected mode of
transmission as person-to-person in seven outbreaks, foodborne in two, waterborne in one, and
one unknown. The source of waterborne outbreaks may include water from municipal supplies,
wells, recreational lakes, swimming pools and ice machines.
Shellfish and salad ingredients are the foods most often implicated in norovirus outbreaks. Ingestion of shellfish that have not been sufficiently heated poses a high risk for norovirus infection.
Foods other than shellfish may be contaminated by infected food handlers.
When a person becomes infected with norovirus, the virus begins to multiply within the small intestine. After approximately 1 to 2 days, norovirus symptoms can appear. The principal symptom
is acute gastroenteritis that develops between 24 and 48 hours after exposure, and lasts for 24
60 hours. The disease is usually self-limiting, and characterised by nausea, vomiting, diarrhea,
and abdominal pain; and in some cases, loss of taste. General lethargy, weakness, muscle
aches, headache, and low-grade fever may occur.
Severe illness is rare: although people are frequently treated at the emergency ward, they are
rarely admitted to the hospital. The number of deaths from norovirus in the US is estimated to be
around 300 each year, with most of these occurring in the very young, elderly, and persons with
weakened immune systems. Symptoms may become life-threatening in these groups if dehydration is ignored or not treated.
Hand washing is an effective method to reduce the spread of norovirus pathogens. Sanitising of
surfaces where the norovirus may be present is recommended. Alcohol rubs are not very effective at dealing with Norovirus.
In health-care environments, the prevention of nosocomial infections involves routine and terminal cleaning. Nonflammable alcohol vapor in CO2 systems are used in health care environments
where medical electronics would be adversely affected by aerosolised chlorine or other caustic
compounds.

2.25 Pandemic flu

An influenza pandemic is an epidemic of an influenza virus that spreads on a worldwide scale
and infects a large proportion of the human population. In contrast to the regular seasonal epidemics of influenza, these pandemics occur irregularly, with the 1918 Spanish flu the most seri-

ous pandemic in recent history. Pandemics can cause high levels of mortality, with the Spanish
influenza estimated as being responsible for the deaths of over 50 million people. There have
been about three influenza pandemics in each century for the last 300 years. The most recent
one was the 2009 flu pandemic.
Influenza pandemics occur when a new strain of the influenza virus is transmitted to humans from
another animal species. Species that are thought to be important in the emergence of new human strains are pigs, chickens and ducks. These novel strains are unaffected by any immunity
people may have to older strains of human influenza and can therefore spread extremely rapidly
and infect very large numbers of people. Influenza A viruses can occasionally be transmitted from
wild birds to other species causing outbreaks in domestic poultry and may give rise to human influenza pandemics.
The World Health Organization (WHO) has produced a six-stage classification that describes the
process by which a novel influenza virus moves from the first few infections in humans through to
a pandemic. This starts with the virus mostly infecting animals, with a few cases where animals
infect people, then moves through the stage where the virus begins to spread directly between
people, and ends with a pandemic when infections from the new virus have spread worldwide.
One strain of virus that may produce a pandemic in the future is a highly pathogenic variation of
the H5N1 subtype of Influenza A virus. On 11th June 2009, a new strain of H1N1 influenza was
declared to be a global pandemic (Stage 6) by the World Health Organization after evidence of
spreading in the southern hemisphere. The 13th November 2009 worldwide update by the UN's
World Health Organization (WHO) stated that worldwide more than 206 countries and overseas
territories or communities have reported 503,536 laboratory confirmed cases of pandemic influenza H1N1 2009, including over 6250 deaths.
Influenza, commonly known as flu, is an infectious disease of birds and mammals caused by an
RNA virus of the family Orthomyxoviridae (the influenza viruses). In humans, common symptoms
of influenza infection are fever, sore throat, muscle pains, severe headache, coughing, and
weakness and fatigue. In more serious cases, influenza causes pneumonia, which can be fatal,
particularly in young children and the elderly. While sometimes confused with the common cold,
influenza is a much more severe disease and is caused by a different type of virus. Although
nausea and vomiting can be produced, especially in children, these symptoms are more characteristic of the unrelated gastroenteritis, which is sometimes called "stomach flu" or "24-hour flu."
Typically, influenza is transmitted from infected mammals through the air by coughs or sneezes,
creating aerosols containing the virus, and from infected birds through their droppings. Influenza
can also be transmitted by saliva, nasal secretions, feces and blood. Healthy individuals can become infected if they breathe in a virus-laden aerosol directly, or if they touch their eyes, nose or
mouth after touching any of the aforementioned bodily fluids (or surfaces contaminated with those
fluids). Flu viruses can remain infectious for about one week at human body temperature, over 30
days at 0C (32F), and indefinitely at very low temperatures (such as lakes in northeast Siberia).
Most influenza strains can be inactivated easily by disinfectants and detergents.
Flu spreads around the world in seasonal epidemics. Three influenza pandemics occurred in the
20th century and killed tens of millions of people, with each of these pandemics being caused by
the appearance of a new strain of the virus in humans. Often, these new strains result from the
spread of an existing flu virus to humans from other animal species. When it first killed humans in
Asia in the 1990s, a deadly avian strain of H5N1 posed a great risk for a new influenza pandemic;
however, this virus did not mutate to spread easily between people.
Vaccinations against influenza are most commonly given to high-risk humans in industrialised
countries and to farmed poultry. The most common human vaccine is the trivalent influenza vaccine that contains purified and inactivated material from three viral strains. Typically this vaccine
includes material from two influenza A virus subtypes and one influenza B virus strain. A vaccine
formulated for one year may be ineffective in the following year, since the influenza virus changes
rapidly over time and different strains become dominant. Antiviral drugs can be used to treat influenza, with neuraminidase inhibitors being particularly effective.

Some pandemics are relatively minor such as the one in 1957 called "Asian flu" (1 4 million
dead, depending on source). Others have a higher Pandemic Severity Index whose severity warrants more comprehensive social isolation measures.
The 1918 pandemic killed tens of millions and sickened hundreds of millions; the loss of this
many people in the population caused upheaval and psychological damage to many people.
There were not enough doctors, hospital rooms, or medical supplies for the living as they contacted the disease. Dead bodies were often left unburied as few people were available to deal
with them. There can be great social disruption as well as a sense of fear. Efforts to deal with
pandemics can leave a great deal to be desired because of human selfishness, lack of trust, illegal behavior, and ignorance.
Wave nature.
Flu pandemics typically come in waves. The 18891890 and 19181919 flu pandemics each
came in three or four waves of increasing lethality. But within a wave, mortality was greater at the
beginning of the wave.
Strategies to slow down a flu pandemic:
Vaccines.
Anti-viral drugs.
Public Response Measures:
Social distancing.
Respiratory hygiene.
Handwashing Hygiene.
Other hygiene.
Masks.
Risk communication.

2.26 Malaria
What is malaria ?
Malaria is caused by an infection of the red blood cells with a tiny organism or parasite called a
protozoa. There are four important species of the malaria protozoa (Plasmodium falciparum,
Plasmodium vivax, Plasmodium ovale and Plasmodium malariae) and each has a slightly different [Link] organisms are carried from person to person by the Anopheles mosquito. When
it bites an infected person, the mosquito sucks up blood containing the parasite, which may then
be passed on to the mosquito's next victim.
The main symptoms of malaria
A fever that occurs in regular episodes, with sweating and shivers (known as rigors), and exhaustion (because of anaemia). In some cases, it can affect the brain or kidneys
Who is at risk of malaria ?
Malaria occurs where the Anopheles mosquito breeds, predominantly in rural tropical areas such
as regions in Africa, the Middle East, Asia and central America. Malaria is a major killer in many
countries where resources for prevention, proper diagnosis and drug treatments are lacking. If
diagnosed promptly, it can be easily treated but the symptoms can be vague. On average, symptoms develop 10 days to four weeks after being bitten, but symptoms can appear up to a year
later.
The most severe form of the disease is cerebral malaria, which is fatal in up to six per cent of
adults, mainly because it's not diagnosed until it's too late.

Preventing malaria
By far the most important step is to avoid being bitten by mosquitoes by:
Using effective insect repellent
Wearing long sleeves and full-length trousers
Staying in accommodation with screen doors and closing windows
Taking the recommended antimalarial drugs, however even when taken exactly as advised, antimalarial drugs are not 100 per cent effective, so the other preventive measures listed above
should also be taken. A major problem is the steady increase in malaria's resistance to drugs
used in both prevention and treatment.
Treatment
Treatment is with antimalarial [Link] the past decade, considerable progress has been
made in the search for a malaria vaccine, and it's hoped one will be available within the next five
to 10 years

2.27 Snake bites

A snake will sometimes bite in self-defence if disturbed or provoked. Some snakes are venomous
and can inject venom (toxin) as they bite. A bite from a venomous snake is a medical emergency
as they can be deadly if not treated quickly. The risk of snakebite envenoming is a public health
hazard that many people in the rural tropics, Africa, Asia, Oceania and Latin America, face on a
daily basis.
Who is at risk?
Snakebite envenoming is a common cause of occupational injury affecting agricultural workers
and hunters with important socioeconomic implications. Open-plan housing and the practice of
sleeping on the floor, common in tropical regions, also exposes people to bites from nocturnal
snakes. Overall women, children and farmers are the most common victims of snakebites.
Poisonous snake bites include bites by any of the following:
Puff Adder
Forest Cobra
Tiger Snake
Desert Horned Viper
Common Krait
Boomslang
Tiger Rattlesnake
Black Mamba
Eastern Brown Snake
Russells Viper
Inland Taipan (fierce snake)
Hook-nosed sea snake
Symptoms
If an adder injects venom when it bites, it can cause serious symptoms including:
redness and swelling in the area of the bite
nausea (feeling sick)
vomiting
dizziness

A foreign snake that injects venom when it bites can also cause:
shock
muscle paralysis (an inability to move one or more muscles of the body).
Sometimes, venomous snakes can bite without injecting venom. This is called a dry bite' and
may cause:
mild pain (from the snake's teeth puncturing the skin)
anxiety
Treatment
Antivenoms can prevent or reverse most of the snakebite envenomings effects, and play a crucial
role in minimizing mortality and morbidity. These preparations are included in the WHO List of
Essential Medicines.
What to do after a snake bite
Immediately after being bitten by a snake you should:
remain calm and don't panic; snake bites, particularly those that occur in the UK, are not often
serious and rarely deadly
try to remember the shape, size and colour of the snake
keep the part of your body that has been bitten as still as possible to prevent the venom spreading around your body
remove jewellery and watches from the bitten limb because they could cut into your skin if the
limb swells
do not attempt to remove any clothing, such as trousers
Seek immediate medical assistance to request an ambulance or visit your nearest accident and
emergency (A&E) department. It is also helpful to give healthcare professionals a description of
the snake to help identify it.
Preventing snake bites
Follow the advice listed below if you are in an area where venomous snakes are found.
Look out for warning notices on heaths and commons.
Wear boots and long trousers.
Never pick up a snake, even if you think it is harmless or appears dead.
Never put your hand in a hole or crevice -for example, between rocks. If you need to retrieve
something, stand well back and use a stick to reach it.
If you find yourself very close to a snake, stand completely still. Most snakes only strike at moving targets. If you remain calm and still, the snake will escape without harming you.

2.28 Contaminated water

Possible causes of water contamination include:
Sewage - contains bacteria such as E. coli and other contaminates that can slip into our drinking
water
Improper disposal of industrial waste asbestos, mercury, lead.
Improper disposal of radioactive waste extremely hazardous to human health
Oil spills can contain benzene compounds which can cause serious health injuries.
Atmospheric decomposition smog and toxic gases released into the atmosphere then mix with
water supplies during rainfall.
Eutrophication excess fertilizer leaks into water supply.

2.29 Dermatitis Caused by Biological Agents.

Many biological agents cause a severe dermatitic response, but here we shall only summarise a
few. Dermatitis of biological origin may be due to plant products such as leaves, stems, sap,
roots, bulbs, flowers, fruits, vegetables, wood dusts, resins and lacquers; or to other living kingdoms, including bacteria, viruses, fungi, helminth parasites, insects and mites.
Irritant Effects of Plants.
Initially, the response may be an itching of the fingers, hands or forearms after contact with the
causative plant, usually the leaves, stem or sap arising from pruning or de-budding operations.
Eventually, affected parts become reddened and in severe cases, blisters and severe itching develop. Blisters are often discrete on the fingers and confluent (running into each other) on the
hands or forearms.
Some examples of plants causing a dermatitic response:
Liliaceae
Daffodils, narcissi, jonquils, tulips and hyacinths
Primulaceae
Primroses, polyanthus
Anacardiaceae
Poison ivy, poison oak, poison sumac, elder, or ash
The active substances in most plants are often alkaloids or organic acids, e.g.

Stinging nettles, formic acid.

Windflower (anemones), an alkaloid (anemonine).
Citrus fruits, terpene hydrocarbons.
Poison ivy, anacardol (a phenol derivative).

An interesting recent phenomenon is Strimmers' Itch or Strimmers' Disease. A strimmer is a polemounted device used for cutting grass close to the edges of lawns, against pathways and up to
the base of trees. The operating part is a rotating plastic blade or filament which revolves at high
speed to cut the grass. This results in a fine aerosol of grass "juices" or sap being thrown out in a
mist around the cutting head.
In more robust agricultural models, the head is powered by a petrol engine and the strimmer is
used to cut back weeds and brushwood in addition to the grasses. The resultant aerosol is rich in
alkaloids which become deposited around the operators' ankles and lower legs causing a severe
dermatitic response. It was not until strimmers came to be used in large numbers (thousands
have now been sold) that the problem was picked up in the Out-patients Departments of hospital
allergy clinics.
The remedy is to wear proper protective clothing around the lower legs and ankles; shorts should
never be worn.
Occupations exposed to the irritant effects of plants include florists, horticulturists, gardeners,
nurserymen, market gardeners, field labourers, fruit-pickers, hop-pickers, perfumiers and pharmacists.
Irritant Effects of Toxic Woods.
Carpenters, wood machinists, sawyers, lumberjacks, workers in timber yards, wood polishers,
cabinet-makers, shipwrights and furniture-makers are some of the occupations which develop
dermatitis from contact with wood dusts, and in severe cases may even go on to develop asthma
or cancers of the nasal cavity.
Alkaloids are the main active ingredient, and woods known to cause dermatitis include satinwood,
ebony, teak, boxwood, iroko and many other tropical hardwoods. Teak splinters may even produce severe blood poisoning.

Insects, Mites, Etc.

Caterpillar dermatitis: caused mainly by hairy caterpillars such as those of the Brown-tail Moth. It
is not always necessary to touch the caterpillars. One road-sweeper who had been working beneath trees infested by "brown-tails" developed severe skin problems within a few hours.
Mites: are responsible for grain itch, barley itch, grocers' itch, millers' itch and copra itch.
Prevention is largely a matter of education and good hygiene, coupled with the use of proper protective clothing. Protection, however, is not without its own dangers for the inside of gloves,
gauntlets, boots and aprons can easily become contaminated by the active agent. Indeed, contamination inside gloves or boots holds the harmful substances in close, warm, humid contact
with the skin for hours at a time. Education and good hygiene is important if a man touches the
contaminant outside his gloves with his fingers before going to the toilet. Hence, it is essential to
stress the need for washing before going to the toilet.

2.30 AIDS.
Acquired Immune Deficiency Syndrome (AIDS) is a condition caused by the Human Immunodeficiency Virus (HIV), which attacks the immune system by which the human body can resist infections. The virus is found in most body fluids, but is delicate and relatively easily killed by heat and
chemicals. It has a low infectivity and transmission is thought to be more likely with repeated exposure to infection rather than to a single contact.
The occupational risk comes from accidental inoculation or contamination of a cut or abrasion
with the blood or body fluids of an infected person. Various studies of groups around the world,
who have been occupationally exposed to HIV positive people, usually by accidental inoculation,
have revealed only a handful of occupationally-acquired infections.
Doctors, nurses, dentists, laboratory and hospital support staff are identified as workers who can
be at some risk, since they may come into close contact with body fluids and hence face the possibility of infection through an exposed cut or by accidental injection. Other workers possibly at
risk might include community, welfare, custodial and emergency service workers, but there have
been no cases of infection arising from these activities at all. Many thousands of health care
workers have come into direct contact with HIV-infected blood and body fluids through needle
stick injuries and other accidents, but only a very small number of occupationally-acquired infections have been reported.
Many of the precautions taken against other infections, especially Hepatitis B, will be equally effective against HIV. The Advisory Committee on Dangerous Pathogens published nursing guidelines for community nurses, which described some of the necessary precautions:

Proper facilities must exist in a person's home before undertaking patient care.
Supplies of protective clothing must be available.
Care must be ensured in the handling of sharps.
Disinfection of surfaces.

For other health care workers, experience has shown that the precautions which should already
be in operation to protect staff from other infections are generally appropriate for preventing infection by the AIDS virus. They include:

Prevention of puncture wounds, cuts and abrasions in the presence of blood and body fluids; and the protection of existing wounds and skin lesions.
Application of simple protective measures designed to avoid contamination of the person
or clothing; and good basic hygiene practices including regular hand washing.
Control of surface contamination with blood and body fluids by containment and disinfection.

Safe disposal of contaminated waste especially sharps.

Another occupational group potentially at risk from infection are first aiders. All first aiders should
be made aware of the importance of protection against infectious diseases such as the HIV virus,
as well as Hepatitis B.
No vaccine is yet available to give protection against HIV. Although HIV is known not to be
transmitted by contact with body fluids, it would not be possible for a first aider to tell if such fluids
contained blood in which HIV can be transmitted. First aiders should therefore treat all body fluids
as potentially contagious and, wherever possible, wear disposable gloves.
If it is not feasible to don protective clothing, first aiders should always wash with soap and water
any part of the body where contact with body fluids is made. In addition, all cuts and abrasions
should be covered by a waterproof dressing at all times.
No HIV infection is known to have occurred through mouth-to-mouth resuscitation. The risk of infection is considered to be extremely small. However, where there is concern, it is possible to
provide resuscitation aids comprising a small plastic sheet with an air valve fitted. These devices
allow mouth-to-mouth resuscitation to take place while preventing direct contact with the victim.

2.31 Sick Building Syndrome

Although not strictly the direct result of biological health hazards, sick building syndrome is a
phenomenon that we must look at some stage of the course.
Airborne micro-organisms have been suggested as one of many factors that could be responsible
for the condition, so we shall look at sick building syndrome in this section on biologically related
illnesses, although you will soon realise that the condition is thought to be multi-causal.
The common feature of "sick buildings" is that the occupants suffer from a measurably higher incidence of illness than would be expected, for no readily identifiable reason. Symptoms may include ear, nose and throat irritation; skin rashes; lethargy; headaches; respiratory infections and
nausea. Lack of a clear definition of the condition, plus the subjective nature of many of the
symptoms experienced, means that most investigations have proved inconclusive.
A number of patterns have emerged, however. The syndrome occurs predominantly in airconditioned buildings; but also in ones which are naturally ventilated. The victims tend to be in
low-status jobs and have little or no control over their working environment; more complaints are
recorded in the public than in the private sector; symptoms are more frequent in offices with large
numbers of employees; and are also reported with greater frequency in the afternoons than in the
mornings.
So far, there is no unequivocal evidence to pin the cause of sick building syndrome to any one
factor; hence the cause is likely to be due to a number of factors, some of which may be biological, others not. Researchers have postulated a number of possible causes, which we shall consider briefly.
The first is airborne contaminants. Potential sources include building occupants; building fabric
and furnishings; office machinery; heaters; and ventilation or air-conditioning systems. Pollutants
from occupants are principally carbon dioxide and cigarette smoke, although since workplaces
became smoke-free, this problem has been greatly reduced. "Off-gassing" from the fabric and
furnishings of buildings has been shown to be linked with sick building syndrome, pollutants including formaldehyde, organics and solvent vapours and dust and fibres.
Ozone from photocopiers is a consideration, but investigations in photocopier rooms have shown
this as unlikely to be a cause of symptoms unless there is poor ventilation. Legionnaires' Disease,
humidifier fever and various infections are known to have been transmitted via ventilation systems, but these readily identifiable illnesses are not the same as sick building syndrome.
Even where air conditioning systems do not contain humidifiers, items of plant can act as breed-

ing sites for organic growth, and can release microorganisms into the airstream. Airborne contaminants may cause sick building syndrome symptoms through several mechanisms, including
toxicity, irritations, infection and allergy.
Other factors worthy of consideration are inadequate ventilation and low humidity. Several "temporarily sick buildings" have been "cured" by increasing ventilation, amongst other measures.
The overall conclusion is that sick building syndrome is a complex phenomenon with a number of
causes, possibly influenced by the victims' reaction and attitude to the working environment.

2.32 Severe acute respiratory syndrome (SARS)

SARS was an atypical pneumonia that was first reported in Asia in February 2003. Over the next
few months, the illness spread to more than two dozen countries in Asia, North America, South
America, and Europe before the SARS global outbreak of 2003 was contained. The last case in
this outbreak occurred in June 2003.
According to the World Health Organisation (WHO), a total of 8,437 people worldwide became
sick with SARS during the 2003 outbreak; 813 of these died (a mortality rate of 9.636%).
After the Chinese government suppressed news of the SARS outbreak, the disease spread rapidly, reaching Hong Kong and Vietnam in late February 2003, and then to other countries via international travellers.
In May 2005 the disease itself was declared 'eradicated' by the WHO and it became the second
disease in mankind to receive this label (the other was smallpox). The New York Times reported
that "not a single case of severe acute respiratory syndrome has been reported this year or in late
2004. It is the first winter without a case since the initial outbreak in late 2002. In addition, the
epidemic strain of SARS that caused at least 813 deaths worldwide by June of 2003 has not
been seen outside a laboratory since then."
Causative organism.
In late May 2003, studies from samples of wild animals sold as food in the local market in Guangdong, China found that the SARS coronavirus could be isolated from civet cats. This suggests
that the SARS virus crossed the xenographic barrier from civet cats. In September 2005, a study
was released from China which found that 40 percent of a sample of Horseshoe bats collected
near Hong Kong were infected with a close genetic relative of SARS, raising the possibility that
SARS originated in bats and spread to humans either directly, or through civet cats. The bats did
not show any visible signs of disease. Further investigations are ongoing.

Civet cats

2.33 Summary
In this study unit, we have looked at biological hazards. The types of biological hazards are fungi,
bacteria and viruses. Genetic manipulation is a technique whereby the genetic material of an organism is altered in a way that does not occur naturally. Genetic modification must not be carried
out unless a suitable and sufficient assessment of risks (to human health and the environment) is
carried out.
Some organisms produce potent toxins that are chemical in nature and persist in the material after biological activity ceases; there are three different categories: exotoxins; endotoxins; and mycotoxins.

We looked at the health effects of biological agents by considering modes of transmission, the
mechanisms of attack on the body, and signs and symptoms of the disease. The effects of attack
by micro-organisms may be: acute; chronic; toxic or allergenic.
Particularly vulnerable groups include the elderly, debilitated or chronically sick; pregnant and
breast-feeding women and their children; and people with suppressed immune syndrome.
We ended the study unit by looking at the causes and symptoms of a number of specific conditions caused by biological agents.
Many people work in environments where they may come into contact with such organisms:

agricultural workers;
bird handling;
building trade workers involved in roof repair etc;
construction workers;
emergency services;
first aiders;
food handlers;
health care;
laboratory animals;
laundry workers;
mortuary workers;
pet shops and garden centres;
sewerage and drainage systems;
textile work using animal hair;
veterinary work.

Zoonotic infections overview this highlights source, organism, route of entry and protective
measure and will be a useful revision tool.

2.34 Implementing risk control measures

In this element of your course, we began our examination of biological agents by reviewing the
various types of agent encountered in the workplace and the health effects that could arise from
exposure. We then considered the occupational situations where exposure might occur, reviewed
specific groups of workers at risk and also particular workplace ill-health conditions caused by
biological agents.
We shall now continue our investigation of biological agents by considering how biological risks
are assessed and what control strategies are available. We begin with a study of the risk assessment of biological agents, reviewing the legal requirement for risk assessment, then examining the risk assessment procedure in more detail. We then move on to consider the range of control measures that can be applied to biological agents, their effectiveness and practical implementation.
Next, we look in more detail at the control of specific biological hazards such as laboratory work,
biological materials of human origin and work with animals, and also specific requirements to ensure the safe handling of biological materials, including disposal and emergency procedures. Finally, we consider monitoring techniques such as pre-employment screening, health surveillance
and biological monitoring.

2.35 Risk Assessment of Biological Hazards

Legal Requirements.
The requirement to carry out risk assessments on biological hazards is contained in the following
legislation:
Management of Health and Safety at Work Regulations 1999.
These Regulations contain a general requirement to assess the risks to the health and safety of
employees and others as a result of exposure at work.
Assessments must be reviewed if there are significant changes, or it is thought that the assessment is no longer valid for other reasons.
The Regulations add a specific requirement that women of child-bearing age be given special
consideration in the risk assessment, which should consider risks to the health and safety of new
or expectant mothers, or to their babies.
Control of Substances Hazardous to Health Regulations 2002.
These Regulations specifically require a suitable and sufficient assessment of the risks to health
from biological agents. Schedule 3 of the Regulations is specifically concerned with biological
agents.
Assessments must be reviewed if there are significant changes, or it is thought that the assessment is no longer valid for other reasons.
Genetically Modified Organisms (Contained Use) Regulations 2002
These Regulations require a suitable and sufficient assessment to be carried out of the risks to
health and the environment arising from genetic modification.
The assessment should include a classification of the organisms for statutory notification purposes, and specify the required level of containment for the organisms being used.

Figure 2.1 Overlap of duties.

Risk Assessment Procedure.
The legislation outlined above requires employers to carry out an assessment of the risks to employees of any biological agents used or created by their work, and to carry out the steps necessary to protect those workers and any other persons affected by the activities.
The general approach to risk assessment is similar to that which we have already considered in
relation to the COSHH Regulations. In the case of biological agents, the COSHH Regulations require a classification of micro-organisms based on the perceived hazard to healthy individuals.
The classification is into four groups of increasing hazard, based on consideration of:

ability to cause human disease;

possible hazard to workers;
likelihood of spread of disease in the community;
availability of prophylaxis and treatment.

Table 2.1 shows how each hazard classification category relates to the parameters listed above.
Category

Ability to Cause

Hazard to

Spread in the

Prophylaxis and

Human Disease

Workers

Community

Treatment

Group 1

unlikely

Group 2

possible

possible

unlikely

available

Group 3

serious

serious

possible

available

Group 4

severe

serious

likely

not available

Table 2.1: Hazard Categorisation of Micro-organisms

The main points that need to be considered in making an assessment of the risks to health of
workers exposed to biological agents are:

The identity of the agent.

The hazard group of the agent.
The nature of the disease it may cause (seriousness and availability of vaccination or
treatment).
Quantity of the agent in use.
Possibility of escape into the environment causing human disease.
General health of employees (susceptibility).
Numbers likely to be exposed.
Competence and training of workers.
Facilities for monitoring exposure.

In practice, the written risk assessment can be conveniently divided into two sections:
(a) The assessment of risk:

Identification of hazards.
Persons at risk.
Risk evaluation.

(b) The arrangements for controlling the risk:

Control measures.
Safe systems of work.
Responsibilities.
Medical surveillance.
Monitoring.
Review arrangements.

The actual procedure for carrying out the risk assessment includes the following stages:

Example blank Biological Risk Assessment

2.36 Control Strategies for Biological Agents

We have already referred to the role of the Control of Substances Hazardous to Health Regulations 2002 (COSHH) in the assessment and control of biological agents. The COSHH Regulations set out a strategy of assessment and control for biological agents that require:

An assessment of the risks to workers of exposure to biological agents.

Exposure to be prevented by substitution of less hazardous agents.
Introduction and testing of control measures.

Informing employees of hazards encountered at work.

Records kept of employees exposed to biological agents in Hazard Groups 3 and 4.
Notification to the HSE of first use of biological agents in Hazard Groups 2, 3 and 4.
Notification to the HSE of consignment or import of biological agents in Hazard Group 4
and some in Group 3.
Monitoring of employee exposure.
Introduction of health surveillance where relevant.

The objectives of control measures are to prevent or minimise the escape of biological agents
and the risk of illness caused by exposure to biological agents if they do escape. The philosophy
of control is based on a series of "barriers" which serve to isolate the agent from the person at
risk.
Consequently the agent may be confined by:
Primary barriers around the hazard to prevent escape of the agent into the environment, which
include:

Physical containment.
Good laboratory practice.
Specially-designed equipment.

Secondary barriers to protect the worker by providing:

awareness of the hazard;

medical supervision;
personal protective equipment;
washing and hygiene facilities.

Tertiary barriers around the premises to prevent:

access by unauthorised persons;

escape of solid, liquid and gaseous effluents and wastes.

The control measures employed for work with biological agents can be categorised and prioritised
in accordance with the hierarchy of control measures that we have encountered previously. We
shall look at these in turn.
The hierarchy of control:

eradication,
reduced virulence,
change of work method to minimise or suppress generation of aerosols,
isolation and segregation,
containment,
ventilation (HEPA filters),
sharps control,
immunisation,
decontamination and disinfection.

Eradication.
The first priority for control is always to eliminate or substitute the hazard for an agent that presents a lower risk. In laboratory work, it may be possible to substitute virulent strains of microbiological organisms with less virulent strains that will still give satisfactory laboratory results. A
number of laboratory practical experiments that previously would have used biological materials
have now been replaced with models or simulations.

The risk of Legionella contamination has been eliminated in a number of building air-conditioning
systems by taking spray humidification equipment out of use.
Reduced Virulence.
It may be possible to substitute the hazard for an agent that presents a lower risk. In laboratory
work, it may be possible to substitute virulent strains of microbiological organisms with less virulent strains that will still give satisfactory laboratory results.
The risk of working with biological material in laboratories can be reduced by measures such as
screening human specimens for blood-borne virus infections and using heat treatment to reduce
the number of potentially hazardous organisms present.
Change of Work Method and Aerosols.
If micro-organisms are grown, then the culture medium is usually closed by a cotton wool bung or
a micro-filter. This will prevent the medium becoming contaminated from external micro organisms and reduce the risk of the culture forming an aerosol. Aerosols can be minimised by handling any liquid suspension in such a container.
In research laboratories, the containers have to be opened to remove samples, etc. therefore it is
important to minimise agitation. If an aerosol is likely to be produced, then it is important to contain the aerosol in a suitable fume cupboard.
Isolation and Segregation.
A common risk control method is to reduce individual exposure. In this context, work with hazardous biological agents needs to be segregated from less hazardous work so only those whose
work requires them to come into close contact could ever be exposed. Similarly, infected animals
and, in hospitals, infected people may need to be isolated from others to reduce the risk of any
infection spreading.
Containment.
The range of engineering controls available for biological agents is similar to that we examined for
chemical agents. You will remember that the controls included glove boxes which provided complete containment and enclosure, fume hoods providing partial containment and enclosure, local
exhaust ventilation using captor hoods or receptor hoods to capture the airborne contaminant at
source, and dilution ventilation for low concentrations of low toxicity contaminants.
However, because of the complexity of the way in which biological agents cause harm, protection
using engineering controls involves more than simply ensuring that workplace exposure limits are
not exceeded, which is the approach taken with chemical agents.
Engineering control for laboratory work with biological agents (health and veterinary care facilities, laboratories and animal rooms) is based on the concept of "containment" and the COSHH
Regulations specify minimum levels of containment that correspond to the four Hazard Groups
that we examined earlier.
So, ordinarily a Hazard Group 2 Agent must be contained at Containment Level 2 as a minimum,
unless a higher hazard group agent is suspected of being present, in which case a higher level is
selected.
Level 1 is suitable for handling agents that are unlikely to cause human disease. In practice, this
means that no engineering controls are necessary, work takes place on the open bench but
aerosol production must be minimised and basic standards of good microbiological practice observed.
Level 2 involves the same measures, but procedures that are likely to give rise to infectious aerosols must be carried out in microbiological safety cabinets (see later).
Level 3 laboratories must be separated from other activities in the building, be sealable for fumigation, be maintained at negative pressure and have extracted air filtered through a high efficiency filter. Work would normally be carried out in a microbiological safety cabinet.
Level 4 laboratories are maximum containment facilities with entry through an airlock, input and

extract air filtered and work carried out in closed safety cabinets.
Filtration.
Ideally, the air from any extraction unit should be filtered and discharged to the outside of the
building. In many cases, however, this is not practical. More often, filtration will be considered as
an alternative to external discharge.
Where soldering operations are carried out, an external wall or window filtration will be the only
options.
Where filters are used, they must be of a suitable type and regularly checked to ensure that they
are not saturated. Fumes from rosin-cored solder contain both particulates and gaseous products, such as formaldehyde.
The filters must, therefore, be designed to deal with both - the particulate filter being positioned
before the gas filter to prevent it from being clogged. In some systems, it may be possible to
clean or replace the particulate filter several times before replacing the gas filter.
Effective filtration of particulates can be achieved by use of a High Efficiency Particle Arrestor
(HEPA) filter. Gaseous products a normally removed by an activated carbon filter.

2.37 A typical Biosafety Level 1 laboratory

2.38 A typical Biosafety Level 2 laboratory

Procedures likely to generate aerosols are performed within a biological safety cabinet. Doors are
kept closed and are posted with appropriate hazard signs. Potentially contaminated wastes are
separated from the general waste stream.

2.39 A typical Biosafety Level 3 laboratory

The laboratory is separated from general traffic flow and accessed through an anteroom (double
door entry or basic laboratory Bio-safety Level 2) or an airlock.
An autoclave is available within the facility for decontamination of wastes prior to disposal.
A sink with hands-free operation is available. Inward directional airflow is established, and all
work with infectious materials is conducted within a biological safety cabinet.
Later in this study unit, we will examine the control of specific biological hazards in laboratories in
further detail and look at the design and operation of microbiological safety cabinets.

2.40 Personal Protective Equipment

Personal protective equipment occupies a position low in the hierarchy of control measures when

dealing with biological agents, as it does generally for occupational health risks. However, there
are specific occasions when the use of personal protective equipment is necessary to supplement
other control measures. The use of personal protective equipment can be related to the potential
routes of entry of biological agents into the body.
Absorption Through the Skin.
Gloves give protection to either intact or broken skin where biological agents may penetrate. In
addition, all cuts, wounds and sores should be covered even when gloves are worn.
Absorption Through the Conjunctivae.
Earlier, we identified the conjunctivae of the eye as an area where biological agents can gain access to the body, so where there is a risk of splashing of infected materials into the eyes, goggles, safety spectacles or visors will be required. Eye protection also prevents accidental touching
of the eyes by contaminated fingers.
Inhalation Into the Lungs.
The prevention of generation of aerosols containing micro-organisms by careful handling and
processing of biological materials, and also the use of physical containment, is the primary control
strategy to prevent airborne contamination by biological agents. However, under some circumstances it may be necessary to use respiratory protection to supplement existing controls. A
common example of this is the use of airstream helmets in animal houses to prevent inhalation of
potentially allergenic dusts.
The general use of personal protective equipment as a control measure against biological agents
follows the general principles that you will have encountered in your Part 1 studies. However, the
following example of its application in microbiological laboratories (particularly those operating
under containment levels 2, 3 and 4) will illustrate these principles.
Laboratory coats or gowns are worn to protect clothing from contamination. They are usually
high-necked with back or side fastenings and close fitting cuffs. They need to be changed regularly and autoclaved before laundering to ensure that any biological contamination is sterilised.
Gloves to protect the hands from contact with contamination are worn and if there is a high risk of
the gloves being torn or punctured, two pairs should be worn together.
Visors may need to be worn to protect the face if there is a risk of splashing.
Positive pressure particulate respirators may be required if there is a risk of inhaling harmful organisms. This may be a concern following accidental releases.
Immunisation/Vaccination.
Vaccines consist of dead or live attenuated organisms that, when administered to individuals, are
able to initiate immunity to potentially infectious doses of organisms that could cause ill-health or
disease. Where appropriate vaccines exist, consideration should be given to the vaccination of
staff at risk from exposure to harmful organisms.
In some cases, e.g. clinical work where there is a Hepatitis B risk, vaccination may be a requirement before work in high risk areas is allowed to commence. However, vaccination can never be
considered to be the principal defence against infection, only a risk reduction measure. Protection
can never be guaranteed since certain individuals may not develop immunity after vaccination. A
further problem is the possibility of adverse reaction to the vaccine with some persons. The possible side-effects must be considered before the decision to vaccinate is taken.
The following vaccinations are recommended for particular categories of staff:

Health care workers: rubella, TB, Hepatitis B.

Sewage workers: tetanus, Hepatitis A.
Agricultural/horticultural workers: tetanus.

2.41 Biohazard Signs

The biohazard sign required by COSHH regulation 7(6) (a) shall be in the form shown in figure
2.2

Figure 2.2: Biohazard Sign

Personal Hygiene Measures.
Good personal hygiene is essential to minimise infection. This includes appropriate washing facilities with a relevant biocide, keeping nails clean, not eating, drinking or smoking and suitable facilities for storage of outside clothing.
Effluent and Waste Disposal.
Microbiological materials will remain hazardous after use and should therefore be rendered safe
before disposal. Heat treatment, involving autoclaving or incineration, is the best way to kill
microbiological organisms but it is also possible to use chemical disinfection.
Clinical waste is a controlled waste; it is normally double-bagged in distinctively-labelled heavyduty yellow plastic bags for storage prior to collection and disposal. Persons handling clinical
waste for disposal must be adequately trained and equipped with protective clothing.
Sharps Control.
Sharps include scalpels, needles, blood lances and any sharp instrument that is capable of puncturing the skin. The Royal College of Nursing advises that contaminated sharps should not be
passed from hand to hand. Handling is kept to a minimum and they should be placed in a special
container at the point of use that conforms to BS7320. This should be stored away from the public.

2.42 Control of Specific Biological Hazards

We have examined the range of general control measures for biological agents; now we must
look at some specific areas where special controls are necessary.
Laboratory Work and Containment.
We have already referred to the COSHH Regulations and the fact that the Regulations specify
minimum levels of containment that correspond to the four Hazard Groups for biological agents.
There is a specific code of practice, "The Categorisation of Pathogens According to Hazard and
Categories of Containment" which sets out detailed requirements for the use of biological agents
and genetically modified organisms in laboratories.
Specific requirements include:
Containment Level 1 (good microbiological practice).

Impervious, easy to clean surfaces.

Sink for hand washing.
Inward air flow.
Door closed while work in progress.
Laboratory coats worn and removed on leaving.
No eating, drinking, mouth pipetting.
Hands to be washed and disinfected.
Minimisation of aerosol production.
Effective cleaning and disinfecting of surfaces.
Careful control of waste.

Reporting of accidents and incidents.

Containment Level 2 (as level 1 plus).

Washbasin near exit and non-hand operated taps.

Restricted access.
Access to autoclave in building.
Aerosol generation to be contained in safety cabinet.

Containment Level 3 (as level 1 and 2 plus).

Room able to be sealed for fumigation.

Laboratory under negative pressure and exhausted air passes through high efficiency filters.
Protective gowns to be worn only in laboratory and autoclaved before laundering.
Possible need for an airlock.
Work to take place in safety cabinets.

Containment Level 4 (as level 1-3 plus).

Laboratory isolated with controlled entry via airlock and shower.

Laboratory under negative pressure and exhausted air passes through two high efficiency
filters.
Complete change of clothing to be worn and shower before leaving.
Special emergency arrangements to be in place.
All work to take place in a totally enclosed cabinet.

Microbiological Safety Cabinets.

An essential part of the control strategy for microbiological agents in laboratories is to use specific
engineering controls based on ventilated enclosures to contain any airborne contamination generated by the work.
The degree of enclosure depends on the Hazard Group of the biological agent and three different
types of microbiological safety cabinet are used.
British Standard 5726 (1992): "Microbiological Safety Cabinets" gives the design features and the
specification of each type of cabinet; their method of operation is briefly described below. Table
2.2 compares the differences.

2.43 Class I
These are open fronted cabinets where air is drawn in, filtered through a high efficiency particulate air (HEPA) filter and discharged to atmosphere. The cabinet protects the operator only from
agents that might infect the operator by airborne routes (Figure 2.3).

Figure 2.3: Schematic diagram of a Class I biological safety cabinet.

Key:
A = front opening.
B = sash.
C = exhaust HEPA filter.

D = exhaust plenum.

2.44 Class II
These are open-fronted cabinets where air is drawn in, exhausted through slits in the front base
of the cabinet, then filtered through a (HEPA) filter. The air drawn down over the open front forms
a curtain to prevent the escape of aerosols back into the laboratory. A proportion of the air is discharged to atmosphere but the rest is re-circulated through the cabinet.
These cabinets protect the operator and also the work from external contamination. They are
suitable for work with Hazard Group 2 organisms and possible Hazard Group 3 organisms if indicated by the risk assessment (Figure 2.4 (A) and (B)).

Figure 2.4 (A): Schematic representation of a Class IIA1 biological safety cabinet.
Key:
A = front opening.
B = sash.
C = exhaust HEPA filter.
D = rear plenum.
E = supply HEPA filter.
F = blower.

Figure 2.4 (B): Schematic diagram of a Class IIB1 biological safety cabinet.
Key:
A = front opening.
B = sash.
C = exhaust HEPA filter.
D = supply HEPA filter.
E = negative-pressure exhaust plenum.
F = blower.
G = HEPA filter for supply air. Connection of the cabinet exhaust to the building exhaust air system is required.

2.45 Class III

These are totally-enclosed, leak-proof cabinets where the operator works through glove ports. Air
is drawn in and extracted through HEPA filters and discharged to atmosphere.
These cabinets protect both the operator and the work from external contamination. They are
suitable for work with Hazard Group 3 and 4 organisms (Figure 2.5).

Figure 2.5: Schematic representation of a Class III biological safety cabinet (glove box).

Key:
A = glove ports for arm-length gloves.
B = sash.
C = double-exhaust HEPA filters.
D = supply HEPA filter.
E = double-ended autoclave or pass-through box.
F = chemical dunk tank.
Connection of the cabinet exhaust to an independent building exhaust air system is required.
The degree of protection given by the open-fronted cabinets can be determined by releasing an
aerosol such as potassium iodide particles in the cabinet and measuring the quantity that escapes outside. Points to note include:
Draughts created in front of the cabinets will reduce their efficiency.
Cabinets will need regular maintenance including a filter test.
Since the cabinets are engineering controls required by COSHH, they will need inspection and
test every 14 months.

2.46 Differences between Class I, II and III biological safety cabinets

Table 2.2. Differences between Class I, II and III biological safety cabinets (BSCs)
BSC
FACE VEAIRFLOW (%) RE- EXHAUST SYSTEM
LOCITY
CIRCULATED EX(m/s)
HAUSTED
Class I*
0.36
0
100
Hard duct
Class IIA1
0.380.51
70
30
Exhaust to room or thimble
connection
Class IIA2
Exhaust to room or thimble
vented to the
0.51
70
30
connection
outside*
Class IIB1*
0.51
30
70
Hard duct
Class IIB2*
0.51
0
100
Hard duct
Class III*
NA
0
100
Hard duct
NA, not applicable.
* All biologically contaminated ducts are under negative pressure or are surrounded by
negative pressure ducts and plenums.

2.47 Biological Materials of Human Origin

These include body fluids (blood, plasma), excretions (urine, faeces) or human tissues. A range
of workers including sewage workers, health care workers, clinical laboratory staff, mortuary staff,
first aiders and emergency service workers may be occupationally exposed. It is important that
these materials are handled carefully, since it should be assumed that they contain infectious
agents.
Under laboratory conditions, it may be possible to reduce the risk by screening materials for infectious agents or inactivating harmful organisms by heat, radiation or chemicals. However, general
precautions should include:

Protection of wounds and cuts with waterproof dressings and/or gloves.

Avoiding exposure to sharps.

Use of face and eye protection if there is a risk of splashing.

Use of protective clothing to avoid personal contamination.

Work with Animals.

Animals may harbour infections that can be transmitted to humans (zoonoses). The method of
transmission can be through direct contact, bites and inhalation of aerosols as well as from consumption of contaminated animal products.
We covered the main control measures for occupational zoonoses earlier in this element but we
can summarise them as:

Covering cuts.
Wearing gloves, protective clothing and eye protection.
General hygiene and cleanliness.

You will remember that when we covered leptospirosis, we considered the additional measure of
avoiding contact with rats and water contaminated with rat urine.
In addition, careful selection, quarantining, inspection for disease, isolation if sick and cleaning of
accommodation can reduce the likelihood of animal infections developing and spreading.
Another occupational condition associated with handling animals is asthma or other allergic conditions. The agents responsible include proteins from animal tissues, urine, fur and feathers, and
bird droppings. Protection may need to include protective clothing, gloves and dust masks or respirators.

2.48 Safe Handling of Biological Agents.

We have already made reference to a number of elements of safe working practice for biological
agents such as minimising the production of aerosols, hygiene measures and personal protective
equipment. However, there are three further aspects of the safe handling of biological agents that
we need to consider here:

Disinfection.
Disposal.
Emergency Procedures.

Disinfection.
This is a process whereby biological agents capable of causing disease are killed or rendered
harmless by exposure to certain chemicals known as disinfectants or biocides.
The main categories of disinfectants commonly in use are:

Hypochlorites (chlorine-based bleach) - effective on bacteria, spores, viruses and fungi.

Alcohols - used for skin disinfection or surface decontamination.
Phenolics - effective on bacteria, some viruses and fungi.
Gluteraldehyde (commonly used in hospitals but exposure to humans must be controlled
within exposure limits) - effective on bacteria, spores viruses and fungi.

To ensure effective deactivation of biological agents by disinfectants the following parameters

must be established:

Concentration required.
Exposure time necessary.

Frequency of changing or renewal.

Inactivation by proteins or other materials.
Effect of mixing with other substances.
Harmful properties to humans and precautions required.

Another commonly-used method to kill biological agents is sterilisation. The principal methods
used are:

Incineration for clinical waste at temperatures up to 1000C.

Dry heat for metal and glass equipment at 160-180C for 1-2 hours.
Steam in an autoclave at 121C (pressurised) for 20 minutes.
Ionising radiation used for sterile medical equipment as well as in the food industry.

Disposal.
Microbiological materials will remain hazardous after use and should therefore be rendered safe
before disposal. Heat treatment, involving autoclaving or incineration, is the best way to kill
microbiological organisms but it is also possible to use chemical disinfection.
Clinical waste is normally double-bagged in distinctively-labelled heavy-duty yellow plastic bags
for storage prior to collection and disposal. Persons handling clinical waste for disposal must be
adequately trained and equipped with protective clothing.
Emergency Procedures.
In view of the risks associated with working with biological agents, it is important that there are
plans in place to deal with emergencies. Emergency plans should also be supported with staff
training in both spillage control and treatment of persons exposed to biological agents.
In the event of spillages or loss of containment, emergency kits should be available to deal with
the incident. These may need to include:

Personal protective equipment including respirators.

Disinfectants.
Absorbent material for liquid spills and disposal bags or containers.

In addition, where there might be the risk of airborne contamination, the area would need to be
evacuated and isolated, with entry confined to persons wearing appropriate personal and respiratory protective equipment. Before re-entry was possible, it might be necessary to fumigate the
area to ensure that all micro-organisms were destroyed.

2.49 Baseline Testing and Health Surveillance

Despite the strict control measures that we have considered above it is still necessary to monitor
the exposure of employees working with biological hazards to detect any potential for occupational ill-health before it occurs.
Pre-employment Screening
At the pre-employment stage it is possible to identify persons who may be particularly vulnerable
to the effects of exposure to biological agents. This is usually done through a questionnaire or by
an interview with an occupational health nurse or doctor. In the case of biological agents a second area of concern is those persons who may be carrying infectious organisms which could be
hazardous to persons that they might come into contact with. Examples include health care workers infected with Hepatitis B.
Health Surveillance
Health surveillance is important where occupational ill-health could occur and there are valid

techniques for its detection; the form that it takes depends on the nature of the hazard. Where the
risks are minimal all that may be required are occasional health checks by a nurse, or even selfchecks. Where the risk is greater, regular medical examinations by an occupational health physician could be necessary.
The main aims of health surveillance of persons exposed to biological agents include early detection of signs of ill-health and periodic testing to monitor for disease development including exposure to biological respiratory sensitisers. Other important considerations are the assessment of
immune status and possible further need for vaccination.
Biological Monitoring
Biological monitoring is a technique that we have already examined which is used to detect evidence of actual or potential harm occurring within the human body. The application of this technique to monitor the effects of exposure to biological agents usually involves taking samples from
the individual concerned and attempting to detect the presence of agents with the potential for
harm. Methods of detection include microscopy, biochemical tests or immunological tests for example.

2.50 Hospitals and Laboratory Work

In such environments, potential exposure might take the form of body fluids (blood, plasma), excretions (urine, faeces) or human tissues. A range of workers including health care workers, clinical laboratory staff, mortuary staff, first-aiders and emergency service workers may be occupationally exposed. It is important that these materials are handled carefully, since it should be assumed that they contain infectious agents.
Under laboratory conditions, it may be possible to reduce the risk by screening materials for infectious agents or inactivating harmful organisms by heat, radiation or chemicals. However, general
precautions should include:

Protection of wounds and cuts with waterproof dressings and/or gloves.

Avoiding exposure to sharps.
Use of face and eye protection if there is a risk of splashing.
Use of protective clothing to avoid personal contamination.

Depending on organisms dealt with, you may have to adopt a containment level approach (as
described earlier). Laboratories performing routine diagnostic work (e.g. processing of specimens
in biochemistry or haematology laboratories) should be generally working at Containment Level 2.

2.51 Animal Houses

In animal houses or rooms, workers may be exposed to various pathogens with which the animals
have been intentionally infected, e.g. animal research laboratories, or already have or may have
been exposed, e.g. quarantine areas at national borders. Some of these infections can be transmitted to humans (zoonoses). The method of transmission can be through direct contact, bites and
inhalation of aerosols as well as from consumption of contaminated animal products. Monkeys are
a particular hazard as monkey viruses can cause serious disease in man.
The main control measures are:

Covering cuts.
Wearing gloves, protective clothing and eye protection.
General hygiene and cleanliness.
Security (to prevent animals from escaping).

Proper disposal of waste from animals.

A containment level approach (discussed earlier) may be needed - depending on the hazard category of the agents, animals may need to be isolated in cages within safety cabinets with HEPA filtration.
For leptospirosis, we need to consider the additional measure of avoiding contact with rats and water contaminated with rat urine.
In addition, careful selection, quarantining, inspection for disease, isolation if sick and cleaning of
accommodation can reduce the likelihood of animal infections developing and spreading.
Another occupational condition associated with handling animals is asthma or other allergic conditions. The agents responsible include proteins from animal tissues, urine, fur and feathers, and bird
droppings. Protection may need to include protective clothing, gloves and dust masks or respirators.

2.52 Summary
In this study unit, we have looked at the control of biological hazards. Employers have to carry out
a risk assessment of any biological agents used or created in employees' work, including a classification of micro-organisms based on the perceived hazard to healthy individuals.
Control barriers for biological agents include primary barriers around the hazard to prevent escape of the agent into the environment; secondary barriers to protect the worker; and tertiary barriers around the premises. The familiar hierarchy of measures including elimination and reduction,
engineering controls and personal protective equipment, as well as vaccination, are used.
The classification of containment into levels 1 to 4 and the three classes of microbiological safety
cabinets are important in laboratory work. Specific precautions are necessary relating to working
with human biological materials and when working with animals.
The safe handling of biological agents, including methods of disinfection and disposal, and the
monitoring of exposure to biological agents by pre-employment screening and health surveillance
completed our coverage of controls for biological hazards.

2.53 Further reading

Also visit [Link]

Page 1.
_____ are single celled organisms that reproduce by division. They vary widely in shape (with the
shape being used to classify and name types of bacteria) and include spheres (cocci), rods (bacilli) and spirals (spirochetes).
Multiple Choice (HP)
Answer 1:

Viruses

Response 1:
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Answer 2:

Bacteria

Response 2:
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Answer 3:

Fungi

Response 3:
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Page 2
_____ - An acute infectious disease of farm animals caused by a bacterium. Although rare in the
UK, it can be transmitted to man by contact with infected hair, hides, excrement or products such
as bonemeal. It is still common in third world countries and can be imported into the UK by accident on animal products. It is fatal without treatment.
Multiple Choice (HP)
Answer 1:

Brucellosis

Response 1:
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Answer 2:

Anthrax

Response 2:
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Answer 3:

Q Fever

Response 3:
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Answer 4:

Psittacosis

Response 4:
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Page 3.
The correct combination of the hierarchy of control is:
Multiple Choice (HP)
Answer 1:
Response 1:

eradication, segregation, reduced virulence

Jump 1:

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Answer 2:

eradication, reduced virulence, change of work method

Response 2:
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Answer 3:

isolation and segregation, eradication, change of work method

Response 3:
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Answer 4:

eradication, reduced virulence, segregation

Response 4:
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Page 4
_____ laboratories must be separated from other activities in the building, be sealable for fumigation, be maintained at negative pressure and have extracted air filtered through a high efficiency
filter. Work would normally be carried out in a microbiological safety cabinet.
Multiple Choice (HP)
Answer 1:

Level 1

Response 1:
Jump 1:

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Answer 2:

Level 2

Response 2:
Jump 2:

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Answer 3:

Level 3

Response 3:
Jump 3:

Next page

Answer 4:

Level 4

Response 4:
Jump 4:

This page