Yerkes Center, OSHA Settle Death Case

In early December, Emory University in Atlanta agreed to pay $66,400 in fines and change its operating procedures in response to the December 1997 death of Elizabeth Griffin, a 22-year-old worker at its Yerkes Regional Primate Center. Griffin contracted herpes B virus, common in Old World macaques, when she was hit in the eye with fecal material, urine, or saliva while transferring a rhesus monkey to a cage.1 Though rare in humans, B virus is often lethal unless treated early with antiviral drugs such as acyclovir. It was the only job-related death in Yerkes' history. "We feel that prolonging the dispute further... would serve little purpose" --Thomas Insel In its original complaint last April, the Occupational Safety and Health Administration (OSHA) asked for more than $100,000 in fines for a number of infractions including a "willful safety and health violation." OSHA claimed that Yerkes didn't provide Griffin with "appropriate eye and face protection against monkey body fluid splashes or monkey scratches." But Emory denied it was willfully negligent in events leading up to Griffin's death, claiming that it had followed Centers for Disease Control and Prevention (CDC) guidelines. Griffin was wearing a lab coat, mask, and gloves while transporting the animal, but eyewear was considered unnecessary for what was thought to be a low-risk activity. The 1987 guidelines,2 amended in 1995,3 prescribe eyewear only for workers in direct contact with animals, and the operation Griffin was performing didn't involve handling the monkey. Also, at the time B virus was not known to cross intact mucous membranes--hers was the first documented case. According to David Davenport, an infectious disease physician in Kalamazoo, Mich., and a member of the working group that wrote the guidelines, "no one was wearing goggles routinely" unless there was a significant risk, such as aerosol from cleaning cages or bone saws used in postmortems. Yerkes did specify eyewear for aerosols. Davenport says that people started using eyewear more after Griffin's death. "It's a tragedy, but I don't think Yerkes did anything wrong." Still, the guidelines are somewhat ambiguous since they mention "other exposure to macaque secretions"2 and recommend that anyone contaminated through the eye, mouth, nose, or other mucosal surfaces should "irrigate the site at least 15 minutes with sterile saline or rapidly flowing water ...."3 According to Louisa Chapman, epidemiologist with the CDC in Atlanta, the protocols are specific enough to provide guidance but broad enough to allow flexibility. Ambiguity may be partly to blame for the Griffin incident. It's still unclear why she didn't flush her eyes after the exposure, despite a plumbed eyewash station several feet away. And she didn't immediately report the incident to Yerkes officials. "She didn't give anybody the opportunity to intervene," says Davenport. Thomas Gordon, assistant director of Yerkes, maintains that they mentioned potential eye exposure in their training materials, but the emphasis varied between documents. Yerkes workers probably thought that bites and scratches were more important. The dust hasn't settled despite the agreement. According to Yerkes director Thomas Insel, "We appealed this case because OSHA cited us unjustly for safety violations, not because of money. We have now reached a settlement because the agency finally agreed to retract or amend its most serious charges. We feel that prolonging the dispute further ... would serve little purpose." Emory was also sensitive to Griffin's parents in its decision to settle, says Gordon. He maintains that OSHA did not conduct a competent investigation and "broadened [it] because it was a big media case." OSHA "made the penalty large enough to make a big media statement" in its April announcement. But during the closing conference that's part of such investigations, OSHA "could not state which penalty was willful," despite being pressed. When Emory contested the findings, OSHA justified use of the word "willful" on the grounds that several people reported potential splash exposures after the Griffin incident. But that may not have been Yerkes' fault either. Publicity surrounding the case probably heightened consciousness--Gordon says that exposure reports went up nationwide. "OSHA to this day has not talked to those people," none of whom turned out to be infected. OSHA has not commented, despite requests from The Scientist. The two sides issued dueling press releases after the settlement. Emory maintained that OSHA actually penalized it for the post-Griffin reports, but OSHA didn't mention those incidents in its announcement three days later. Instead it stressed the need for more effective procedures to prevent illness, implying that Yerkes had been lax. Gordon also insists that OSHA cannot take credit for some of its recommendations. For example, Yerkes broadened its eyewear requirements for activities involving monkeys soon after Griffin's death (the later incidents occurred despite the fact that workers had eye protection). Yerkes also hired a safety officer in advance of OSHA's request to do so. The safety officer then instituted quarterly reviews of incident logs (to detect patterns of injury), again before the settlement. Still, Yerkes agreed to other OSHA recommendations, including patient access to physicians particularly knowledgeable in diseases of nonhuman primates and familiar with Yerkes' operation. Yerkes will also strengthen its training procedures to include "a stand-alone piece on B virus," says Gordon. Primate scientists and animal handlers are now looking forward to a meeting of the B virus working group later this month in Atlanta when changes in the guidelines will be considered. Says Davenport, "hopefully out of tragedy some good things will come." Barry A. Palevitz is a professor of botany at the University of Georgia. He can be reached online at palevitz@dogwood.botany.uga.edu. B.A. Palevitz, R. Lewis, "Death raises safety issues for primate handlers," The Scientist, 12[5]:1, March 2, 1998. Centers for Disease Control, "Guidelines for prevention of Herpesvirus Simiae (B virus) infection in monkey handlers," Morbidity and Mortality Weekly Report, 36:680-9, 1987. G.P. Holmes et al. "Guidelines for the prevention and treatment of B-virus infections in exposed persons," Clinical Infectious Diseases, 20:421-39, 1995.

Yerkes Center, OSHA Settle Death Case

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