The HSE held formal investigations into more than 40 mishaps at specialist laboratories between June 2015 and July 2017, amounting to one every two to three weeks. Beyond the breaches that spread infections were blunders that led to dengue virus – which kills 20,000 people worldwide each year – being posted by mistake; staff handling potentially lethal bacteria and fungi with inadequate protection; and one occasion where students at the University of the West of England unwittingly studied live meningitis-causing germs which they thought had been killed by heat treatment.
Of the scientists who became infected in the line of work, one was admitted to hospital after falling ill with salmonella poisoning at Pall Life Sciences, a private medical company. Another picked up a paratyphoid infection at Nottingham University Hospitals NHS Trust; four contracted Shigella at Brighton and Sussex University Hospitals NHS Trust, and a biomedical scientist at The Royal Free Hospital in London became sick with two different strains of gastrointestinal bug after testing an infected stool sample.
In Britain, microbes that are a risk to human health are ranked by hazard groups. The most harmful are listed in groups 3 and 4. Group 3 bugs, such as those that cause anthrax and leprosy, can pose a serious hazard to employees, and may spread to the community, but there is usually a vaccine or treatment. Group 4 pathogens, such as Ebola, are more dangerous. These are a serious threat to employees and the community, and there is often no vaccine or treatment. The germs must be handled in labs that meet strict safety and security requirements.
The HSE investigated a number of close shaves. In August 2015, scientists at Bristol University accidentally posted live dengue virus – a group 3 germ carried by mosquitoes in south-east Asia – to Glasgow University’s Centre for Virus Research. Because the person who packed the material had no idea it contained live dengue, the parcel did not meet safety requirements for posting dangerous agents. With luck, the package did not leak; it arrived in one piece and was spotted on arrival at the lab, where staff destroyed the material.
On another occasion, a diagnostic lab called Viapath posted a hazard group 3 bacteria called Chlamydia psittaci, which can cause pneumonia, to PHE’s infectious disease unit in north London. The sample was improperly labelled and, on arrival, was handled in a way that could have infected the PHE lab worker. The HSE found failings on both sides.
“The sector has a good health and safety record, with a high level of control of the most hazardous organisms,” an HSE spokesperson said. “There have been a limited number of instances over the past two years where biological agents have been received by UK labs from other labs within the UK that were unsolicited, mislabelled or unlabelled. However these cases are in the minority and there was no significant threat to public health.”
In other incidents, the airflows that are carefully controlled to contain airborne bugs failed at a lab run by the Medicines and Healthcare Products Regulatory Agency, while at a high security lab run by the same regulator, an egg containing flu virus fell off a tray and smashed on the floor, prompting a hurried evacuation of the lab.
Other potentially dangerous bugs have arrived from outside the UK. In 2015, the US Army revealed that its chemical and biological defence facility at Dugway Proving Ground in Utah unwittingly shipped live anthrax to seven countries after failing to kill the spores properly. Responding to Freedom of Information requests from the Guardian, the US army said it shipped one batch to a UK lab in 2007, and 13 more to three UK labs in 2009. One of the 2009 batches contained a vial of yet another unsolicited pathogen: live but weakened Yersinia pestis, the bacteria that cause the plague. Scientists at Dugway spotted the mistake the same day and called ahead to warn the UK authorities, who hastily drew up a plan to move the bugs to a more secure lab for disposal.
Tim Trevan, a former UN weapons inspector who now runs Chrome Biosafety and Biosecurity Consulting in Maryland, said safety breaches are often wrongly explained away as human error. “Blaming it on human error doesn’t help you learn, it doesn’t help you improve. You have to look deeper and ask: ‘what are the environmental or cultural issues that are driving these things?’”
“There is nearly always something obvious that can be done to improve safety,” he added. “One way to address issues in the lab is you don’t wait for things to go wrong in a major way: you look at the near-misses. You actively scan your work on a daily or weekly basis for things that didn’t turn out as expected. If you do that, you get a better understanding of how things can go wrong.”
“Another approach is to ask people who are doing the work what is the most dangerous or difficult thing they do. Or what keeps them up at night. These are always good pointers to where, on a proactive basis, you should be addressing things that could go wrong.”