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OccupationalMedicine 201Plageman,Corvallis,OR97331-5801 Phone541-737-7566Confidentialfax541-737-9694 Email:[email protected] ExposureResponsePlanforLaboratoryHandlingofListeriamonocytogenes BackgroundInformation: L.monocytoenesisamotilegram-positiverod.Itproducesdiseaseandasymptomaticcarriersinboth humansandanimals.Theorganismhasbeenisolatedfromsoil,animalfeedaswellascontaminated humanfoodandsurfacesoffoodprocessingequipment.Thediseaseistermedlisteriosis.Mosthuman infectionsfollowconsumptionofcontaminatedrawfoods.Refrigerationdoesnotslowgrowthof bacteriasignificantly.Skinandeyecontacthaveledtooccupationallyacquiredinfections.Transplacental infectionscanresultinmiscarriage,prematuredelivery,stillbirthorneonataldeath. Listeriosisinpregnancy:Occursmostlyduringthethirdtrimester,andischaracterizedbya“flulike” illnesswithsymptomssuchasfever,chills,malaise,arthralgia,backpain,anddiarrhea.Inmanycases theinfectionissubclinicalorunapparent;however,intrauterineinfectionofthefetuscanleadtofetal death,spontaneousabortion,prematuredelivery,orthebirthofafetusthatdiesshortlyafterbirth. Survivingnewbornswithlisteriosisareoftenclassifiedas“earlyonset”or“lateonset”.Earlyonset neonatallisteriosisduetotransplacentalinfectionoftenpresentsaspneumoniaand/orsepsis.Severe diseasecanresultinwidespreadgranulomas(granulomatosisinfantisepticum).Lateonsetneonatal listeriosisoccursfrominfectionduringbirth,withneonatesshowingsymptomsofmeningitisoneto severalweeksafterbirth.Inbothearlyandlateonsetneonatallisteriosis,themortalityraterangesfrom 20to30%. ListeriosisoftheCNS:Meningitisisthemostfrequentlyrecognizedlisterialinfection.Common symptomsoflisteriosisoftheCNSincludehighfever,nuchalrigidity,tremorand/orataxia,andseizures. Themostcommonformofnon-meningiticformofCNSlisteriosisisencephalitisinvolvingthebrainstem (rhombencephalitis). Febrilegastroenteritis:Anon-invasiveformoflisteriosisthatmanifestsassymptomstypicalof gastroenteritis,forexample,fever,diarrhea,andvomiting. Glandularlisteriosis:Resemblesinfectiousmononucleosiswithswellingofthesalivaryglandsandnuchal lymphnodes. Locallisteriosis:Canmanifestaspapulesandpustulesonthehandsandarmsfollowingdirectcontact withinfectiousmaterial,andcanbeaccompaniedbyconstitutionalsymptoms(fever,myalgia,and/or headache). Typhoidlisteriosis:Characterizedbyhighfeverandisparticularlyfrequentinimmunocompromised individuals. Atypicallisteriosis:Rarecasesofhavebeendescribedwithsymptomssuchasendocarditis,purulent (mononuclear)pleuralexudates,pneumonia,urethritis,andabscesses. 1 ExposureIncident:Anyexposureoftheagenttotheeyes,noseormouth,nonintactskinorinhalationof aersols.Diagnosisisoftendelayedbecausesymptomsaresimilartootheragents.Ifyouworkwithor arearoundthisagent,bringthistoyourhealthcareprovider’sattention.Theinfectiousdoseisunknown andisbelievedtovarywithbothstrainandhostsusceptibility.Labacquiredinfectionshaverarelybeen reported. ReportingExposureIncidents:AllexposureincidentsmustbereportedimmediatelytothePrincipal Investigator/labsupervisorandseekimmediatemedicalevaluation.Wheneverthereisanaccident involvingListeria,theBiosafetyOfficermustbenotified. Pre-exposureHealthScreening: PriortobeginningworkwithoraroundListeria,thePIoranEmployeeHealthProfessionalwillinform theworkeroftherisksandsymptomsofexposure.Listeriosisprimarilyaffectsolderadults,pregnant women,newborns,andadultswithweakenedimmunesystems.Basedontheseriousnessoftheeffects, pregnantwomenmayconsideravoidingoccupationalexposure.Workerswithadditionalconcernsabout pre-existingmedicalconditionsshouldscheduleanindividualappointmentwiththeOccupational Medicinephysicianbycalling541-737-7566.Note:ImmunizationforListeriaisnotavailable. ThefollowingdiseasesandmedicationsareriskfactorsforListeriainfection,mostofwhichare associatedwithatleastsomedegreeofimmunosuppression: • • • • • • • • • • • Glucocorticoidtherapy Hematologicmalignancies Solidtumors Organtransplantation(especiallyrenal) AIDS Treatmentwithtumornecrosisfactor-alphaantagonists Diabetesmellitus End-stagerenaldisease(includinghemodialysisandperitonealdialysis) Ironoverload Collagen-vasculardiseases Otherseriouschronicnonmalignantdiseases Liverdiseaseandalcoholism Pregnantwomenare20timesmorelikelytobecomeinfectedthannon-pregnanthealthyadults. Infectioncanoccuratanytimeduringpregnancy,butitismostcommonduringthethirdtrimester whentheimmunesystemissomewhatsuppressed.Discussionwithahealthcareprovidedis recommended.Useofantacidsandmedicationsthatblockgastricacidproductionincreasestheriskof infection.Self-identificationandsubsequentdiscussionasnotedaboveshouldbeconsidered. Precautions: Labcoat.Gloveswhendirectskincontactwithinfectedmaterialsoranimalsisunavoidable.Eye protectionmustbeusedwherethereisaknownorpotentialriskofexposuretosplashes.Allprocedures thatmayproduceaerosols,orinvolvehighconcentrationsorlargevolumesshouldbeconductedina biologicalsafetycabinet(BSC).Theuseofneedles,syringes,andothersharpobjectsshouldbestrictly limited.Additionalprecautionsshouldbeconsideredwithworkinvolvinganimalsorlargescale activities. 2 AfteranExposureIncidentOccurs: ImmediateActionbyRouteofExposure: • Needlestick,AnimalBiteorLaceration:Washtheareawithsoapandrunningwater. • Mucousmembranes(eye,nose,mouth):Ifcontaminatedmaterialissplashedorsprayed contaminatingtheeyes,noseormouth:Flushtheeyesfor10-15minutes.Rinsemouthoutwith cleanwateranddonotswallow. • Inhalation:Ifcontaminatedmaterialsareaerosolizedoutsideofprimarycontainmentand potentiallyinhaled,rinsemouthtwiceexpellingtherinsate.Donotswallow. MedicalEvaluationandFollow-up: • Followingtheexposureandimmediateactionsstatedabove,facultyandstaffshouldcontactthe CorvallisClinicduringbusinesshoursat541-753-1785or1-866-209-7711afterbusinesshours. StudentworkersshouldbeevaluatedatStudentHealthServicesassoonaspossiblebythe OccupationalHealthPhysicianandcontactOSUOccupationalMedicineat541-737-7566.Suchcases willbehandledasapossiblelaboratory-acquiredlisteriosis. SignsandSymptomsofDisease: • Influenzalikesymptomsincludingfeverandchills • Nausea/vomiting • Pregnantwomenmayexperiencemildflu-likesymptoms,headaches,muscleaches,fever, nausea,andvomiting.Iftheinfectionspreadstothenervoussystemitcancausestiffneck, disorientation,orconvulsions. Theincubationperiodisvariablewithamedianof3weeksandarangeof3-70days. PLEASENOTE:Workersmustbeawareoftheremarkablylongincubationperiodoflisteriosis,as symptomsmayoccurmonthsafteranexposure.Ifanexposedindividualexperiencessignsorsymptoms oflisteriosis,immediatelynotifythePIandthecampusBiosafetyOfficerandbeevaluatedbya physician.Themoreseriouscasesoflisteriosismaytakeonetosixweekstodevelop.Thesecasesmay resultinmeningitis(braininfections)andsepticemia(bacteriainthebloodstream).Bothhaveahigh mortalityrate. Post-exposureProphylaxis: Thereiscurrentlynopostexposurepre-symptomprophylaxisforlisteriosis. OregonDepartmentofPublicHealthclassifieslisteriosisasareportabledisease.Itmustbereportedto theLocalBoardofHealthimmediatelybytheattendingphysician.Thisdiseaseisalsoreportableonthe nationallevel.IfanemployeedevelopssignsandsymptomsassociatedwithListeriaexposureinthe absenceofanexposureincident,thePIandBiosafetyOfficershallbenotifiedimmediately.Isolated infectionwillbeconsideredlaboratory-acquireduntilprovenotherwise. 3