2017-2023 Colorado State University BioLab Accidents

Recently, two FOIAs of the minutes from the CSU Biosafety Committee made the underbelly of the biolabs research industry visible to the public. Collectively, they span what happened between June 2017 to January 2024. As these documents (which can be viewed here and here) are total 412 pages, I copied out all of the passages referring to the biosafety incidents (as these are likely the main thing people care about) and hence made it reach a manageable reading length.Note: if you are aware of anything in those documents I missed, please let me know so I can include it. Additionally, the earlier meeting notes were in the initial FOIA, the later notes in the second FOIA, with an overlap in the middle (beginning in May 2020) existing between both of them.

June 14, 2017

Individual went to check on pressure testing and found door open and 2 people in area where sign indicated not to enter – Case is closed: miscommunication of pressure testing schedule.

Needle stick injury to finger, E.coli Rosetta strain – Under investigation to determine reporting requirements

PPE Slippage, PAPR slid off face during observation of necropsy of sheep that had been inoculated with Francisella tularensis – CDC form 3 filled out, individual monitored temperature.

September 13, 2017

There was a ‘near miss’ regarding a potential exposure with a Brucella sp.; results later confirmed it was B. ovis which is not known to infect humans and thus not an exposure concern

There were several protocol breaches in the TB suites during the past couple of months, many involving mislabeling or no labeling in autoclave staging area. Individuals and PIs have been contacted and reminded of proper procedures. No exposure risk or outside reporting required. The BSO had been investigating a needle stick of a CSU employee with E. coli that happened at HM a non-CSU facility, while the researcher was on sabbatical. As recommended by OSP/NIH, an incident report was filed on 9/12/17; awaiting their response on how to proceed.

November 8, 2017

i. An incident was reported of an individual who obtained a scalpel cut and during necropsy of a TB infected animal. Appropriate action was taken by the individual; Occupational health has been in contact with them. No external reporting required.

ii. An incident was reported of an individual unexpectedly getting sick and having to remove N95 mask as walking into the degowning room, appropriate action was taken. No external reporting required.

December 13, 2017

A dog that was brought to the VTH tested positive for Yersinia pestis, and later died. The dog had undergone surgical procedures prior to the Y. pestis diagnosis, thus there is potential for exposure of those involved with the surgery, including those caring for the animal before and after, and any animals that may have had contact with the infected dog. As soon as diagnosis was made, the RO was contacted who then submitted a report to CDC; both a Form 4 (for diagnosis of a select agent) and a Form 3 (release/potential exposure) have been/will be submitted. The VTH, along with Occ Health and Larimer County Public Health, have been working to contact all individuals who may have been exposed in order to instruct them for follow up. All proper procedures and reporting has been followed. To date, two individuals showing flu-like symptoms have been hospitalized and later released, but they did not test positive for plague.

February 14, 2018

There were a couple of near misses and one protocol breach, these issues have been corrected and closed. There was one splash to the eye; the individual misunderstood the requirements and was not wearing eye protection. An incident review IBC, MINUTES, 2/14/18 Page 4 of 4 meeting was conducted and additional information given. All proper reporting procedures were followed; no outside reporting required.

March 14 2018

Incident reports – while cleaning a biosafety cabinet, the room UV light can on and the individual was momentarily exposed to UV. The light has since been disabled; no further action needed.

April 11 2018

Incident reports – There was an incident where an individual cut their finger while cutting formalin fixed tissue for histology. The tissue was infected with tuberculosis, however had been fixed in formalin for 2 weeks, and the TB was presumably dead. The individual will complete baseline and follow up PPD testing. All appropriate protocols were followed; no outside reporting required.

Misc. – BRB renovations – BRB was built in 2000 and needs repairs to the floors and HVAC systems. The money is available, but not the design. This will require BRB to be shut down for a long period of time. Researchers warned that they will need at least 1.5 years notice, as there are many long term animal studies being conducted in this facility.

May 19 2018

There was a bad batch of autoclave tape, it was corrected and has been disposed of. An individual was poorly trained and left a BSL messy of animal feces and urine, this individual has now been trained properly.There was a protocol breach as there was gum found in the trash of the degowning room, the lab was given a training on how this is not safe.An individual accidently locked their keycard in a room and couldn’t access phone or egress without a keycard. This personnel followed the fire alarm SOP and was able to exit and call a lab mate. The BSO is requesting support of adding a phone to the hallways of BSL3 buildings to prevent future occurrences, the chair will draft a letter of support for this request.

June 6 2018

A cart fell into dip of the floor drain, this resulted in bruising the lab personnel’s arm. Items were chemically deconned before the fall and no open wounds were present. Considered a near miss.LAR staff member was completing mice checks and noticed dates of inoculation were written incorrectly. This staff member showered out, just in case, upon exiting and did not open any of the cages. Researcher was apologetic and will ensure they write the correct date on cages. Considered a near miss. Personnel did not follow BSL3 visitor policy and escorted a visitor without documentation, training, or tests prior to entering BSL3 space. Supervisor will inform Biosafety of results and actions taken with their group. Considered a protocol breach; no additional reporting required.Potential BBP exposure from a needle stick. Currently working with Occ. Health and will keep the Biosafety updated; no additional reporting required. Potential exposure after a visiting personnel was completing a necropsy accidently poked themselves with their knife. Occ. Health from CSU is working with individual and have notified their institution. The Biosafety will be kept up to date. CDC was contacted and a form three is being submitted.

July 11, 2018

There were two near misses:

One protocol breach involving not signing in for aerosol room use; email sent to PI and researchers; no exposure concern and no outside reporting required.

There was [also] a needle stick while collecting blood from a mouse infected with myxoma virus (which is not known to infect humans). The biosafety report was filed one week after the incident, at that time the wound was fully healed and no medical attention was needed. The incident report indicated the agent was not recombinant, however additional questions from the IBC requested follow up to confirm this; Biosafety and Occ Health with follow up with the PI.

August 8, 2018

[Not listed, just said “see table”]

September 21, 2018

[Deferred to next meeting.]

October 10, 2018

There were a couple of splashes to the eye; one occurred in the with CDW positive animals. Individual rinsed out eye in anteroom sink (no eyewash available at that time) but did not notify Biosafety until 4 months after the incident. The individual was reminded of the importance of wearing eye protection in ABSL2 animal rooms, as well as the requirement for prompt reporting. The individual has not had any issues with their eye and was reporting to biosafety in case in future issues arise. No outside reporting required. Individual cut their finger on a glass red-top tube containing a sample sent for Brucella PCR testing. The sample was PCR negative for Brucella. The individual followed all appropriate clean up and reporting procedures. It has been decided to switch to plastic tubes. Not really an incident, but FYI…A client dog with suspected tularemia was brought to the VTH; it was put into isolation and signs were posted to indicate proper PPE to use; no exposures. The RO filed a Form 4 with CDC (clinical sample identified select agent).

November 14, 2018

Accident/exposure – while microinjecting mosquitoes with chikungunya virus in the BSL3, the nanoject chord slipped and the individual made a quick movement with hand and accidentally hit finger with the injection needle. The individual later developed symptoms and sought medical treatment. There is no specific treatment for this virus, thus supportive care was given and the individual is doing better. During a follow up incident review meeting, researchers determined a different way of moving mosquitoes to prevent something like this from happening again. The individual followed all appropriate clean up and reporting procedures; no outside reporting required.Protocol breach – use of earbuds with cell phones in the BSL3. A supervisor observed this happening and confirmed with biosafety that it was not approved. Supervisor informed all personnel that earbuds and cell phones are not allowed in the BSL3.

December 12, 2018

Incident reports – there were a couple of needle sticks, both are following up with Occupational Health; one involved a recombinant agent and will require an incident report to NIH. No other outside reporting required.

January 16, 2019

One incident involved a cut from the door to the men’s shower in the men’s degowning room. The individual was asked to file an incident report and a workman’s compensation report which have not been received yet. This situation has occurred before in the woman’s locker room of the suites. To help prevent recurrence, a sign will be added to the door for both locker rooms.The second incident happened in the dirty cage wash of the A STERIS employee was putting in a new part and nearly sliced off their finger; they are following up with their occ health. It was treated as a BBP spill. No outside reporting required for either incident.

February 13, 2019

An individual stuck themselves with a needle while working with a dog that had been inoculated with Coccidioides posadasii. The individual has consulted with Occ Health; treatment is not recommended as the risk of infection is low. No outside reporting required.There was a protocol breach in the BSL3 staging area; PI contacted biosafety and personnel have been notified. No outside reporting required.There were several incidents (cut to the hand, splash to the eye, and scratch to the hand) surrounding the same group of dogs that are part of a rabies study. PPE changes have been suggested and additional eyewashes have been placed at the kennels. No outside reporting required.

March 20, 2019

Incident reports- Two reported incidents were presented. One incident is a reoccurring protocol breach that involved to PI’s. The BSO communicated with both and is awaiting a response from one of the groups regarding preventative action. The second incident involved a select agent infected animal bite. The BSO has reported to CDC and is filing a form 3. The individual is doing well after treatment and the last serology will be performed on March 25th

April 10, 2019

Two incidents and one near miss were reported.There was a potential exposure to Q fever due to a goat abortion at the Veterinary Teaching Hospital. Biosafety and Occupational Health were immediately notified. The BSO filed Form 3 and Form 4 with the Select Agent Program. Occupational health has contacted all individuals who were potentially exposed. No one has sought medical consultation, but they are aware that they can.An individual was putting an Eppendorf tube into liquid nitrogen for storage and the tube exploded. The BSO is working with the lab to determine if the agrobacterium in the tube was disarmed or not to verify the rDNA status.An individual was removing a cow brain for rabies testing and some drops of blood got on their arm. This cow was confirmed positive for rabies. The individual is vaccinated and confirmed to have acceptable titer in February of this year. A near miss safety concern was filed with the BSO and Occupational Health.

May 8, 2019

One incident originally reported at the April meeting was followed up on. Three incidents and one near miss were reported.

Follow up: An individual was putting an Eppendorf tube into liquid nitrogen for storage and the tube exploded. It was determined that the tube contained Agrobacterium tumefaciens carrying rice DNA. Because this agent is BSL1, it was determined that a report with the NIH is not required.

An individual was leaving through and waiting for the gate to close behind them when a white dodge ram skirted the waiting individual and entered the gated area without swiping their access card. The individual reentered the area to record a photo of the vehicle and reported the incident to the BSO and RBL BSL3 manager. The police were called, the owner of the vehicle was identified and their supervisor notified.

An individual was drawing blood from a Mycobacterium tuberculosis infected mouse when they passively capped the needle. It bent and punctured through the plastic cap and into the individual’s left middle finger. The individual washed the wound with soap and water, then contacted the BSO and Occupation Health. They have an appointment scheduled for medical follow up. No outside reporting required.

An individual was vaccinating a heifer restrained in a headlock with RB51 brucellosis vaccine and poked their left index finger after injecting the vaccine. The individual cleaned the wound with alcohol and betadine scrub. Occupational Health was contacted and a worker’s compensation incident report was filed. No outside reporting required.Near miss: During BSL3 training the trainer was showing the unisex shower and degowing area as the emergency evacuation location. When they tried to re-enter into the BSL3 dirty corridor the door would not open. The trainer used the fire alarm procedure to enter back into the pod 3 area to open the unisex door for the others being trained. The BSO was informed and it was determined that the door must be pulled and then pushed open after a successful access card scan. The BSO is posting a sign for that door to alert other users.

June 12, 2019

Needlestick – The individual passively capped a needle after drawing blood from TB infected mouse heart. The needle bent and went through the cap, and stuck the individual in the finger. The individual contacted Biosafety and Occ Health. During the incident review meeting, suggestions for improving the process were identified. No additional reporting required IBC,

Mouse bite – the individual was holding a mouse while it was coming out of anesthesia, as they were putting the mouse in the recovery area, it bit the individual’s finger. The individual followed up with the Occ Health provider; provider feels it is low risk. There was discussion regarding re-training for mice handling. No additional reporting required.

Two near misses: 1) Needles found in a pipet boat. Lab group informed and reminded of correct procedures. 2) During construction, one of the HEPA filter housing units was handled and removed. This was above a hallway and considered low risk. The individual was concerned about exposure and followed up with Occ Health.

July 17, 2019Protocol breach – When the facility shoe rack fell, an individual was observed coming out of the shower room with a ladder and wearing normal clothes and shoes. It was discovered that the person had not changed out and entered a dirty area then walked through the shower and locker room. The area is considered a “warm” area with low risk of exposure. Occupational health was notified and the incident is under review. No outside reporting required.

Needlestick – Occurred when an individual was drawing blood from an uninfected mouse and poked their finger when recapping the needle because it went through the cap. Occupational health was notified. The individual was reminded to avoid recapping needles.

Near miss report – An individual was working in an ABSL3 location when their PAPR air flow seemed low so they left the room to address the equipment failure. The cards were not labeled with what pathogen the animals were infected with, causing significant concern to the individual. The PI was immediately reachable to explain that it was not a high risk pathogen requiring ABSL3. Occupational health was notified and involved with the incident review. As a result of this, LAR is considering replacing PAPRs with units that have an alarm sound when the battery or air flow is low. The IBC coordinator, LAR manager, and BSO will be meeting to discuss how to address inconsistent communication between researchers and LAR when animals are infected with an agent.

August 14, 2019

Bite – An individual was performing a physical exam on a mouse with CWD that wasn’t moving. The individual coaxed the mouse to move and it bit their pointer finger on the right hand. No obvious puncture of the glove or hand. The individual contacted occupational health and did see a small cuticle break the next morning but it is unclear if it is related to the bite. No additional reporting required.Near miss report – An individual noticed liquid underneath glass bottles inoculated with Mycobacterium tuberculosis and was concerned about possible cracks in the glass. The individual notified biosafety and their supervisor who went in and treated it as a spill. It was determined that it was not a spill and rather the liquid was disinfectant that did not evaporate after the incubator cleaning and was trapped under the bottle

Bite – An individual was examining a mouse reported for paraphimosis and had the mouse restrained at the base of the tail on top of a wire cage in preparation to restrain by scruffing the mouse when it turned and bit the right-hand pointer finger. The finger was examined for punctures and washed. The individual contacted their supervisor and filed a biosafety incident report. The investigation of this incident is in process. No additional reporting required.

Near miss report – An individual was using a needle to filter material and punctured their finger with the clean needle. The injury was washed. Occupational health has been notified and the PI is training the individual on proper procedures for filtering material. v. Near miss report – A PAPR malfunctioned and died while an individual was performing job duties in a bat room. The bats were not yet infected. This PAPR had previous problems and should have been out of use. Biosafety will conduct an incident review

September 11, 2019

[Tabled for next meeting]

October 9, 2019

i. Spill – A mouse cage water bottle containing Mycobacterium avium was dropped; it cracked and spilled on the floor. The concentration of M. avium was similar to that found in drinking/tap water. The spill cleanup procedure was followed and an incident report was filed. Occupational Health was notified and the occ health doc consulted; the risk of exposure considered to be very low. No outside reporting required. ii. Needle stick – An individual pricked their finger with a needle while filling it with saline. The needle was new out of the package. Individual took off gloves, expressed wound, washed and applied bandaid and filed a report. No exposure, no outside reporting. iii. Security breach – An individual was using another lab member’s badge to enter the lab. The PI was informed of the situation. The PI spoke to the lab members and reminded them not to use each other’s badges. No additional reporting required. iv. Near misses 1. There were two reports of items not being properly staged for autoclaving. Individuals were reminded of the procedures. 2. An individual cut their finger at home; while setting up the autoclave, notice the finger was bleeding in the inner glove. The individual exited the barrier, cleaned the wound in the shower and notified biosafety. Biosafety recommended the individual use a waterproof band aid or liquid bandage to seal open wounds before entering BSL3 and discussed that it would be considered a near miss. 3. Biosafety was informed that there were red biohazard bags with autoclave tape on the floor in a BSL2 space and that some of the bags were broken and the tape was not activated/black. Upon investigation, it was determined that the bags contained supplies from a different BSL2 lab. The lab group was informed not to use biohazard bags to transport and move materials.

November 13, 2019

There were 2 near misses surrounding communication issues regarding the shutdown. Exposure risk considered to be low as PPE was worn. Biosafety recommended signage posted at the personnel locator board during future shutdowns to prevent reoccurrences.Protocol breach involving large volume bottles that were incorrectly staged for autoclaving. The group was notified of the correct procedures. No outside reporting required. iii. Protocol breach – signage not placed on door to inform others of open caging following agent exposure, thus the correct PPE was not worn. Risk of exposure considered low as individual still had on standard PPE. The group was contacted regarding adding signage. No outside reporting required.

December 11, 2019

A leak from an autoclave that passes through from a BSL3 area was noticed. It did not occur during BSL3 work or during an autoclave run. It was treated as a spill and an autoclave technician came to fix the problem.Near miss reports include individuals not using room logs correctly and incorrect storage of dirty cages. All individuals involved were identified and reminded of the correct procedures.One near miss occurred when an individual was moving an aerosol basket to the autoclave in a bag and a wire poked out, cutting both gloves but not the individual’s hand. Aerosol basket users were asked to clip and file the baskets again to remove sharp points.An when individual discovered that the plug for a flask non-virulent tuberculosis had been knocked off inside the shaking incubator, likely when someone was cleaning. The incubator was thoroughly cleaned, and the SOPs were reviewed with the staff. Incident closed, no outside reporting required.[the start of this sentence was likely a typo]An individual was filling syringes with M. bovis BCG and the syringe had a dead volume and tight total volume so they decided to suck back the total volume in a leur lock syringe, remove the capped needle, and draw the material from the leur lock with an insulin syringe. During this process the individual stuck their finger with IBC APPROVED MIN 12/11/2019 Page 4 of 5 the needle. The wound was washed and the individual is in contact with Occupational Health. They do not believe any liquid was injected into their hand. The researcher agreed to ensure that correct syringes are used in the future and that dead volumes are accounted for. No outside reporting required.

January 15, 2020

Two near misses have been reported since the last meeting.While working in the BSL3 an individual plugged a microfuge into the wall and the breaker failed resulting in loss of power to the biosafety cabinet. The individual followed procedures for a power failure, closing the sash immediately. Power returned within five minutes and the BSC was allowed to re-equilibrate before work was continued. At the time of power loss, samples were being stained for flow cytometry. No outside reporting required.The custodial staff reported biohazard bags in the regular trash. They did not dispose of the biohazardous bags with the regular trash. The PI was contacted and retrained staff. Biosafety is following up on why the bags were improperly placed in the regular trash. No outside reporting required.

February 12, 2020

N95 Shortage Due to the SARS-CoV-2 outbreak, there is a nationwide shortage of N95 respirators and suppliers are filling respirator orders on a priority basis. These are critical PPE for the safety of many of our researchers. Thus the Occupational Health Coordinator has spearheaded an effort to secure a source of respirators. A letter was written and signed by the VPR, BSO, and IBC Chair highlighting the importance of the research at CSU and the need for it to continue. The letter has been received by 3M and CSU is waiting to hear back. Other options being considered include using a different type of respirator, this would require new fit testing. In meantime, researchers have been encouraged limit unnecessary trips into the barrier whenever possible

Two near misses and one spill have been reported since the last meeting. An individual was going to use an autoclave and discovered mis-labeled animal carcass waste that needed a second autoclave bag. The individual double bagged the carcasses, relabeled the waste, and placed them in the correct location for proper autoclaving. The research group generating the waste was contacted and reminded about proper procedures. No outside reporting required.An individual discovered a 5mL pipet in the regular trash and inconsistencies in BSC sign in and out in the area. Biosafety sent an email to the groups using the space reminding them of the proper procedures. No outside reporting required.An individual looked into the warm room in the and noticed a dried spot on the floor. It was determined to be a spill from a crack in a Fernbach flask. Four people including one biosafety officer assisted with the spill cleanup. Because it occurred in the warm room, precautions regarding heat were taken. An incident review meeting is being scheduled. No outside reporting required.

March 11, 2020

Anonymous report letter: The committee was presented with a summative letter following the conclusion of a RICRO investigation into an anonymous concern. Most of the concerns were IACUC related, however some of the concerns and findings were relevant to the IBC. The PI involved has been responsive in working with the IBC chair, coordinator, and BSO to investigate and address the concerns. No additional corrective action or reporting required

Incident reports: There was one incident report of protocol breaches within the non-select agent area. Individuals were not using the BSC correctly, not covering caging correctly, and disrupting air flow by not waiting for doors to be closed before opening others. The Biosafety office is in contact with the research group for further inquiry and re-training. No outside reporting required.

April 8, 2020

N95 Shortage Ms. Van Sickle reported that the remainder of the 55 cases have been received. Due to evolving circumstances, these N95s are being managed at a very high level and there is consideration of CSU research needs as well as county public health needs. CSU research areas have transitioned to PAPR usage only. Ms. Blair reported that cabinets and PAPRs were decontaminated and moved so that researchers can don the PAPR in a clean area without an N95. There is a shortage and back order for PAPR hoods. Current SARS-CoV-2 and TB animal researchers have enough, but there are not any for additional projects or users. It is possible to share a hood by wiping the inside with 70% ethanol, however this is not ideal. The committee members were asked to notify BSO of any PAPR stockpiles that might be in storage.

[no reports]

May 13, 2020

Near miss: airflow went down due to humidity while a PI was in an animal room. The PI was wearing a PAPR at the time and followed proper protocols.Laboratory acquired infection: While research was being ramped down and stopped for change to critical operations only in March, an individual had cold symptoms and a rash. The individual believed the cold was passed from their partner, and the rash was not uncommon for this individual during stressful times. Some time later the individual realized this could have been a Zika infection because the individual did manipulations with infected mosquitoes before the symptoms occurred. The individual contacted Biosafety and Occupational Health for diagnostic testing. While waiting for the results the individual was feeling better and receive the go ahead to return to work. The initial PCR test was negative, but further testing confirmed Zika infection. The individual does not recall any off counts of mosquitoes, and typically does not experience symptoms of a mosquito bite. There were no reports of loose mosquitoes at the time and other people working in the area during this time frame were asked about symptoms with none reported. Most likely this was a mosquito bite that went undetected during a chaotic time due to COVID-19 shut downs and changes.Near miss: Autoclave bags were breaking during the autoclave cycle out from . The bags were double bagged but fell apart upon removal. The autoclave cycles were successful, so this is not considered an exposure or spill. It was determined that the bags were of poor construction and changing the bags out has solved the problem.  Protocol breach: An individual entered the BRB for work during the shutdown. At the time the work involved with the shutdown was not occurring in or impacting the area in which the individual went, and the individual wore a PAPR and used a biosafety cabinet. Because there have been three incidents like this, biosafety is reviewing the process to prevent another incident.Animal bite: An individual was working with an SARS-CoV-2 infected hamster and was bitten. The individual followed proper procedures and contacted biosafety and occupational health. Because of the transmission routes for the agent, it is considered a low risk incident but follow up is occurring. No outside reporting required.Protocol breach: An individual forgot to don an N95 when entering to dust the deer facility. The individual had noticed eye irritation and donned eye protection then forgot about the N95 before entering the infected deer room; when realized, exited and put on mask and entered to finish work. The individual is doing well. The agent used in the deer is very low risk for human infection, but the individual is being monitored.Cut: An individual was mincing infected tissue with a razor blade when they cut their finger. This happened today so biosafety and occupational health are currently investigating the incident and helping the individual. The increase in incident frequency was discussed by the committee. It seems that an increase in stress due to COVID-19 situations both at home and at work may be impacting this. There is also a mandate to be on campus as little as possible for critical research functions, which may be causing people to rush. Changes from N95 to PAPR use in these environments can interfere with peoples’ normal functioning, and has impacted the process of entering and exiting the area including lines building up to allow social distancing in the locker rooms. The committee discussed the IBC and biosafety working together to get feedback from users and addressing any issues, as nothing has been reported to biosafety. It was discussed that people may be hesitant to come forward because they do not want to have already restricted research limited further. Some suggestions for managing this include requesting researcher feedback, posting helpful guidance, and potentially starting a scheduling system to prevent locker room buildup. It was also discussed that in looking toward reopening, these challenges may increase and it is important that administrators be involved in the return to research process understand the limitations.

June 10, 2020

There have been issues with people not signing out PAPRs and using other people’s hoods. The PI investigated and determined who was responsible, then set up a calendar for people to sign out PAPRs for use. No outside reporting required.During a shipment of potentially SARS-CoV-2 infected PPE from a healthcare facility to CSU, there was no secondary containment and PPE was sticking out. Couriers were reminded to check for proper packaging of material before transport. No outside reporting required.An individual entered a non-respiratory protection area of BSL3 without a cloth face mask or social distancing. Additional cloth masks have been received for the area and the requirements for social distancing re-communicated. No outside reporting required.An individual noticed that the clean side door of an MTA was open. After egressing from the BSL3 they closed the door and contacted biosafety. No outside reporting required.

July 29, 2020

SARS-CoV-PPE recommendations 1.BSL3 in vitro and in vivo – There was a discussion regarding when surgical gowns are required for SARS-CoV-2 work in the BSL3. Gowns are required for in vivo work, but not in vitro work. Bowen’s group using back closing gowns for everything.2.BSL2 clinical samples – due to the N95 shortage, individuals working with clinical samples at BSL2 and in a BSC have not been using N95s. However many are asking for them because of high volume/concentration they are working with. Now that N95s are being decontaminated, these individuals can use N95s.3. Use of barrier/ filter tips for work in the BSL3 There was a discussion whether the use of barrier tips should be a requirement in the BSL3. It is a good idea for protection of the samples, the equipment, and the personnel. Most groups are using them, but one is not citing cost as the reason. The IBC voted and approved making the use of barrier tips a requirement in the BSL3.Letter to VPR with concerns regarding SARS-CoV-2 research and resources A draft letter was presented to the IBC for review. The letter identifies concerns raised regarding the large number of research projects involving SARS-CoV-2 which has put strains on resources such as PPE, lab space, and personnel. The IBC discussed that and its intent and supported sending it the VPR. The committee members will send their edits/comments to the IBC Coordinator by Monday, and the updated letter will be sent to the VPR.

Incident reports – There was a report of loose mouse found in [redacted], It was confirmed to be a wild mouse and all research mice were accounted for.

August 12, 2020

[not listed]

September 9, 2020

Biosafety Lab Audits a.What to do for PIs not responding b.Formalize the policy for “new” PI lab audits c. Adding lab audit dates to PARF or PI profile The BSL1/BSL2 Lab Audit policy was put into place in 2017, some PIs are not responding to the request for a lab audit or submitting their annual self-audit forms. The Biosafety Office is seeking guidance on what to do in these cases. It has also been requested to add language to the document indicating that “new PIs cannot start work until the lab has been audited”. The meeting is running long on time, so the IBC was asked to think about these items for discussion next month.

Biosafety Officer’s report.a. Incident reports – exposure concern/near miss – an individual was in the degown room when someone else entered from the BSL3 side wearing an N95. An email was sent to the group to remind them of procedures. No further action required.Note: in this meeting it also mentioned that “a.Open records request(s) – 1. Jessica Blake/Allison Young – NIH Incident Reports (2015-June 2020) 2. Prickly Research (Ed Hammond) – IBC Minutes (July 2019-July 2020)” were discussed. This may have led to less concerning information appearing in subsequent meeting notes.

October 14, 2020

Protocol breach – while counting scrubs after autoclaving and a vial of controlled substance fell out of scrub pocket and onto floor- didn't break. The vial was given to biosafety who returned it to the PI. No additional reporting required.Spill - In BSL2 lab, found spill in incubator and found it to be a micro crack in Fernbauck flask containing a RG 1 organism. Incubator was cleaned and flask discarded. No additional reporting required.Protocol/ PPE – SARS-CoV-2 being centrifuged in room where people are not being informed of the need for increased PPE (PAPRS required for SARS-CoV-2 work where N95 needed for TB work). Individual notified biosafety and biosafety reminded the researchers of the procedures. No additional reporting required. iv. Cut – individual was setting up was setting up a mosquito bloodfeed and pressed too hard and one of the glass feeders broke and cut their finger. Individual is following up with Occ Health, no additional reporting required.Protocol breach - Crushed raspberries found in locker room and smeared in BSL3 hallway. Email reminder sent to users. No additional reporting required.Splash – While transferring a pipet boat from one secondary container to another for autoclaving, the individual got splashed in the eye because the pipet boat was over filled and leaking in original bin. The individual flushed their eye and reported it to Biosafety. The users were reminded to not to overfill pipet boats and safety glasses were provided for both dirty and clean side of autoclave rooms. No additional reporting required.Hamster bite - Hamster infected with SARS-CoV-2 was waking up from anesthesia and bit the finger of the researcher, biting through the gloves. Biosafety was contacted and the individual is following up with Occ Health. Biosafety made a recommendation for a different type of glove to prevent this in the future, and an incident review meeting is being scheduled. This was not a recombinant strain, thus no additional reporting required.

Biosafety concern – A cooler labeled "COVID samples" was left by micro entrancecausing concerns. The PI was contacted and indicated the cooler was empty. The PI made a sign indicating empty cooler for pick up as well as will only put cooler out on days the cooler will be picked up.

November 11, 2020

Incident reports – Three protocol breaches were reported; none resulted in exposure. Email reminders were sent out to PIs and investigators.

December 9, 2020

i. There was a spill of less 50ml inside the BSC due to pressure in feed line of bag. Proper clean up and reporting were procedures were followed. Considered a near miss. ii. Protocol breach/potential spill - found full sharps container with lid closed on its side in the biohazard bag trash bin (biobag open) in one of the anterooms in BSL3 lab. The sharps container was disposed of properly and the area disinfected; Form 3 filed and incident review performed. iii. PPE malfunction – A researcher found a hole along seam of Tyvek suit. They were working in the BSC with agent (they were not working with animals). Risk of exposure very low; considered a near miss.

January 13, 2021

Biosafety data gathering The Biosafety Office has been contacted by a consulting organization called Gryphon that is working on a project trying to put numbers behind what biosafety does. Part of the project involves human reliability; for example, how many mistakes happen when pipetting. The other part has to do with number of man-hours in high containment and frequency of incidents. The IBC had some concerns and requested more information from the Biosafety Office. This will be sent to the IBC coordinator who will distribute to the committee.

There were three near misses; one involving a cat scratch, two involving spills. The cat and spilled materials were all non-infectious. Proper reporting protocols were followed and each is being reviewed to determine if changes in procedures are necessary.Animal scratch – while working with rabies infected cats and one reached through the kennel and snagged individual's left hand. Minor scratch but skin broke through gloved hand. Proper follow up and reporting protocols were followed. The individual is rabies vaccinated.Procedural – a concern was raised with individuals not following proper protocols for animal room cleaning, and caging. The issue was discussed and resolved.

February 10, 2021

Incident reports Near miss - PAPR died while in SARS-CoV-2 animal room. Was a TR-300 Versaflo PAPR, so individual was able to step out into anteroom to replace battery. Individual followed all proper procedures. No outside reporting required.

February 24, 2021

[tabled]

Procedural issue – incorrect procedure was used while transporting infectious materials between buildings, no outside reporting requiredSpill and airflow too negative - Fine mist of SARS-Cov-2 material sprayed onto persons PAPR and surgical gown while trying to relieve pressure from tubing during a filtration process. At that time the room airflow was too negative because the boilers had gone down. Proper clean up procedures were followed. Risk to individual considered to be low; individual tested six days post. No outside reporting required. Bat bite – an individual was bitten on the hand while trying to put a bat in its cage. The bat was from the breeding colony and was not infected, however it was tested for rabies just to be sure, the bat was negative. The correct sized gloves were purchased to prevent this in the future. No outside reporting required.Animal scratch/bite – there have been a number of bites or scratches from cats in the rabies studies. The cats are wanting to play. They are looking at adding mesh or wire to the cages so the cats cannot reach out. Also, getting properly fitting leather gloves will help. Occ Health is following up with individuals. No outside reporting required. After doing bat husbandry and doffing and deconning the PAPR, the individual noticed a crack in the hood. They were wearing an N95 and the PAPR unit did not malfunction, so risk considered to be low. PAPR hood removed/ discarded/ replaced. No outside reporting required.

April 14, 2021

Engineering – there was a puddle on the benchtop in the BSL3. Leak from ceiling where electrical piping comes out. Facilities was called and responded. No containment breach and no outside reporting required.

Safety Concern/ watch – an individual reported 3 nights of having night sweats and night sweats are symptom of TB. There was no incident or known exposure. Occupational Health is following up with the individual.

May 12, 2021

IBC non-compliance Our office became aware work in Dr. Reist’s lab that started without IBC approval. As this work involves transgenic drosophila, this will need to be reported to the NIH as an incident report. Dr. Reist has submitted the appropriate PARF and a Biosafety Lab Visit will be scheduled.

June 9, 2021

Nothing to report

Aug 11, 2021

Two mouse bites – one from a CWD infected mouse, one from a TB infected mouse. All proper procedures were followed. Individuals are following up with Occ Health. No outside reporting required.Good catch/needlestick – the needle was clean/hadn’t been used yet. Proper procedures were followed. No outside reporting required.Inventory – the Biosafety Office was asked to assist with disposal of some archive lyoph vials and found select agents in the archive. The SA vials were documented and then destroyed. The incident was reported to the CDC. Biosafety is following up that lab and others in the area.

September 8, 2021

There were three protocol breaches: two involved individuals not signing in and/or using the personnel locator board properly; one involving an autoclaved biohazard bag that was found outside on the path between two buildings on main campus with mice carcasses in it. Biosafety is following up. No outside reporting required.There was a spill of CWD mouse water containing bleach. A carboy fell off cart and cracked and spilled onto the floor. The spill was mopped up and remaining water placed in another carboy; later the spill area was rebleached with fresh disinfectant. No outside reporting required.

Oct 13, 2021

Protocol breach – improper use of airlock and sample entry. Individual was re-trained. No outside reporting required. ii. Protocol breach – inside a BSL3 freezer, a bag of infected mice carcasses was improperly stored. The individual responsible was contacted. The was no loss of containment, however a CDC Form 3 was filled out.

Note: at this meeting it was decided that incident reporting at the meetings would decrease. Specifically—"Information reported to IBC regarding incident reports There was a discussion regarding what information the IBC wanted to see every month regarding incident reports. For example, does the committee want to see everything that is reported every month, or would they prefer to only see the important incidents monthly (such as exposures or those requiring outside reporting) along with a quarterly report for all incidents which would put everything into context. The committee agreed that they still wanted to hear about all the incidents, but that putting the minor incidents into a quarterly report would be beneficial. It was agreed that this new reporting would start in January with the first quarterly report given in March."

Nov 10, 2021

Incident reports – An unexpected shipment of Mtb lung tissue samples was received by one of the TB labs. The samples are being shipped back. No exposure or outside reporting required

Dec 8 2021

No reports

January 12, 2022

No reports.

February 9, 2022

Splash in the eye – the individual was cleaning out the BSC after a necropsy of M. abscesses infected mice, then ethanol that the surgical tools had been in splashed into the person’s eye. All appropriate procedures were followed. The individual is following up with Occupational Health. No outside reporting required.

March 9, 2022

Incident reports – a researcher pricked their finger with a dissection needle while performing a necropsy on an animal infected with wild type H18N11 influenza A virus. This is considered a low-risk event; this virus has not been shown to infect humans. The individual is following up with Occupational Health. The virus was made via reverse genetics and thus an incident report is being submitted to NIH/OSP

April 13, 2022

Incident reports – quarterly report – a draft of the quarterly report was given to the IBC; this document is still considered a work in progress. The IBC was asked to review the document and provide feedback regarding the format and the balance of information. The meeting was running out of time, and it was decided to collect feedback via email.

May 11, 2022

[Skipped]

June 8, 2022

[Skipped]

August 10, 2022

Quarterly Report:

The first incident occurred while a researcher was conducting a necropsy on a mouse infected with Norwegian reindeer chronic wasting disease (CWD). The researcher’s hand slipped, and the researcher stabbed their left hand with the tip of the scissors. The researcher immediately washed the wound with soap and water then disinfected the wound with bleach. Risk Assessment: the researcher took the appropriate first aid to clean the wound and followed up with Occupational Health and the Biosafety Office. CWD is not a human pathogen. However, there is much to learn about prions and there are no therapeutics or other treatments for CWD. There is minimal risk to the researcher and no risk to CSU, the community, and environment because CWD is not a human communicable disease.

The second incident occurred when a researcher was performing a tail vein injection on a mouse infected with HN878 Mycobacterium tuberculosis. The syringe contained PBS along with a CD45- PE antibody. The mouse moved causing the bevel to come out of the tail where there was a buildup of pressure because the vein was missed. As a result, the PBS in the syringe and possibly some blood from the mouse escaped out of the biosafety cabinet (BSC) and onto the researcher’s face. The researcher had been turned sideways to obtain a better view for the injection. The researcher put the mouse in a cage and exited the BSC and the laboratory using the appropriate procedures. The researcher proceeded to the bathroom in the BSL-3 hallway and washed their face and eyes. After this the researcher returned to the laboratory and continued working. However, the researcher did not feel comfortable continuing work and was told by their co-workers to exit the BSL-3 using the appropriate procedures and showering out. The researcher showered out and washed their face/eyes for 15 minutes. Upon being notified, the CSU Biosafety Office and Occupational Health followed up with the researcher. CSU Occupational Health arranged a visit with a physician for the researcher.

September 14, 2022

[omitted]

October 12, 2022

[omitted]

November 9, 2022

[omitted]

December 14, 2022

Incident reports – There was a bat bite when a researcher was transferring a bat from its cage to the biosafety cabinet. All proper procedures were followed. The incident is not reportable to NIH or CDC. The individual is doing well. More information will be provided in the next quarterly incident report.

January 11, 2023

Pipe burst/flooding – The recent cold snap happened during a time when one of the boilers was being retrofitted. A pipe (which is located outside the building) from the fire suppression system froze and burst. Because of the negative pressure and sloped floors, copious amounts of water were drawn into the building, causing flooding in the hallway and . Luckily, no work was going on at time and there is no concern of release or exposure. The water was cleaned up and the repair process has begun.

The first incident occurred while the person was in a [BSL-3] lab to investigate damage to the floor under the biosafety cabinet. While on their hands and knees, the person scuffed their left shin on the floor. While degowning to exit the BSL 3 space, the person noticed the wound. The wound was washed with soap and water and wiped with alcohol. They then applied antiseptic and a band aid. The person filed a workmen’s comp form and reported to Biosafety. Nothing further came of this incident and it was closed.

A researcher was transferring a bat to the biosafety cabinet with their left hand, which had the standard double gloves plus a leather glove. The right hand got too close to the bat and the bat caught the right hand and double gloves with its mouth. The researcher then returned the bat to its cage, as per protocol, and left the room. The gloves were then removed and a small red spot was discovered on the right index finger. It was washed with soap and water and excised. It was then cleaned with iodine. The researcher then proceeded to exit the BSL-3 laboratory and contacted their PI. This bat had been vaccinated against Middle East Respiratory Syndrome Coronavirus (MERS-CoV). The vaccine was a protein antigen and not recombinant. The bat had then been challenged with MERS-CoV that came from a human isolate five days prior (wildtype, 2014). The bat did not show any clinical signs of MERS.

On Friday, December 23rd around 9:30 pm, RO Moritz was contacted by CSUPD after they responded to a burst pipe from the fire suppression system in the hallway outside the Regional Biocontainment Lab (RBL). This was due to very low temperatures. They proceeded to ask her to come in and assess the situation. She came and assessed the situation and determined she needed assistance. ARO Marlenee joined her on site around 10:30 pm. They donned the appropriate PPE for the space and entered the RBL through the one set of locker rooms that were dry. They proceeded to go through each individual room inside the RBL to determine whether there was water. They proceeded to take all absorbent material out of spill kits and gather all the available disinfectant and made berms in front of all areas where water could potentially get back out of the facility (locker rooms, transfer material rooms). They poured disinfectant in all areas with water. Then they exited the BSL-3 space, following the exit SOP through the dry locker room. In the morning, RO Moritz returned to assess the stability of the situation and make sure the berms were holding. After donning the appropriate PPE and entering through the dry locker room, she determined the berms were holding and that due to dry air and the number of air changes, water was starting to evaporate. She also determined that the situation could wait until Tuesday when CSU officially opened. She continued to enter the area daily to monitor the situation and take note of the water levels that decreased day by day. On the morning of December 24th, RO Moritz notified the Federal Select Agent program through the emergency phone number and spoke with the Form 3 group. It was determined that since no select agents were out of the freezer in the area that had water in them, a form 3 was not required. Fortunately, no research was active in the areas where water was found due to the holiday.

Note: At this time, they mentioned CBRMC— “Bat facility update - A local community group has expressed fears surrounding the construction of the new bat facility on . They are concerned the facility could be used for research with high-risk group organisms (RG3&4) and worry that a containment failure would be catastrophic to the community and potentially the world. OVPR communications and biosafety are working together to address these concerns and reiterate the purpose of this facility, which is to house current and future research bat breeding colonies and provide ABSL-2 level space. It will not be used for any research involving risk group 3 or 4 organisms.”

March 8, 2023

[omitted]

April 12, 2023

The first incident occurred while the researcher was handling a mouse that was infected with Mycobacterium abscessus ATCC19977. The researcher was attempting to scruff the mouse to orally dose it with compounds. The mouse was able to turn in the researcher’s grip and bite the left pointer finger. The researcher contained the mouse back in its cage and then proceeded to wash their hands with soap and water. An incident form was completed with Biosafety as was the Occupational Health incident form.

Biosafety spoke with the researcher to address any concerns related to restraining mice. The person was fairly new to mouse restraint and has gone through retraining with another lab

Reporting Requirements: This incident did not require a report to any outside agencies because it did not contain any recombinant material.

A researcher placed 96 well plates with vero cells infected with SARS-CoV-2 in a biohazard bag for disposal. The bag was removed from the biosafety cabinet and placed in an autoclave pan. It was observed that the bag had leaked liquid on the biosafety cabinet work space and also in the autoclave pan. The autoclave pan was then immediately placed back in the biosafety cabinet and the material was placed in a second autoclave bag. It was then wiped down with disinfectant and removed from the biosafety cabinet. The autoclave pan and the biosafety cabinet were both thoroughly cleaned with disinfectant and treated as a spill in the cabinet. The floor was also cleaned with disinfectant. The researcher then reported the incident to their supervisor.

NIH incident report An incident report was submitted to the NIH OSP on April 23rd. The incident involved a researcher who poked their thumb while bleeding a mouse infected with Mycobacterium tuberculosis Erdman-Lux, a luciferase expressing strain of M. tuberculosis Erdman. The risk of exposure is considered low, as the mice were previously treated with highly effective therapeutics, and they typically have not found M. tuberculosis in the blood of infected mice. The individual consulted with Occupational Health and is doing fine

July 19, 2023

Description: The first incident occurred while the researcher was collecting submandibular blood from a mouse with a 4 mm lancet and poked the base of their left thumb while in the process of setting down the lancet to pick up the vial for blood collection. This mouse was infected with Mycobacterium tuberculosis that had been transformed with pFCA-LuxAB. The luciferase signal was expressed from Erdman-Lux. The researcher reported that they normally use a thumb guard for this procedure but did not have one at this particular location and chose to do the procedure anyway. They contained the mouse and washed their hand with soap and water until the bleeding stopped.

Description: It was reported by LAR staff that they observed researchers in the RBL ABSL-2 space who were handling mice and not wearing the required PPE (lab coats and gloves). Signs are posted on the doors listing all PPE requirements for each animal room in this space.

August 9, 2023

[omitted]

October 11, 2023

Q3 Report: a water leak from a humidifying system. No exposure or release concern. No external reporting required

Description: A filter housing broke on one of the new Evoqua water units (humidifying pump system) in the attic of Phase III during the evening of September 25th. It is unclear how long the water was running but the manager of the space received an alarm when the humidity in the insectary chamber below this attic space alarmed. It was, however, a large quantity of water that penetrated into the lab space below.

November 8, 2023

[omitted]This report includes “ White Coat Waste Project - The five most recent IBC meeting minutes” (and nothing else) which presumably means they discussed having to give over some of their meeting minutes to them and much of what was actually said did not end up in the meeting minutes.

December 13, 2023

[omitted]

January 17, 2024

[omitted]