Incident Response Overview

A response was initiated when university officials discovered something unexpected. In the stockroom freezer, alongside the stored P. shigelloides, there was also a vial labeled N. meningitidis.

As a result, it was determined that 33 individuals associated with the lab class had been exposed. State public health officials were called in to assist with risk assessments, sample testing, and provide recommendations regarding public health. They also contributed to the investigation.

Health Recommendations

The health officials advised that all exposed individuals should begin a 10-day course of post-exposure prophylactic antibiotics. Out of those 33, only one person did not start the antibiotics. Interestingly, 15 of them, representing 45 percent, had previously received at least one meningococcal vaccination. However, two individuals went to seek emergency treatment due to headaches and underwent spinal taps to rule out N. meningitidis infection.

Days later, the state’s public health lab analyzed two samples from the concerning lab experiment. Using mass spectrometry and whole-genome sequencing, they identified the unknown bacterium as N. sicca, which is nonpathogenic and related to N. meningitidis.

The state lab repeated the carbohydrate fermentation tests conducted by the lab students, which had originally led to the identification as N. meningitidis. They replicated the findings and ultimately determined that the unusual N. sicca isolate was an “atypical carbohydrate fermenter,” which caused the confusion and initial exposure scare.

Fortunately, in the end, everyone was safe, but the class did face significant anxiety and unnecessary medical interventions. Following this, state and federal health officials launched an investigation into how a dangerous pathogen ended up stored alongside benign bacteria and what led to their mix-up.

According to the investigation, there were inadequate inventory controls for properly identifying, labeling, storing, and segregating biological materials. Additionally, they noted issues like insufficient supervision of stockroom employees, lack of personal protective equipment, and poor documentation regarding sample inventory and custody.

In response to these findings, university officials stated that they would be revising their procedures and protocols significantly.