In April 2004, China reported a case of SARS in a nurse who had cared for a researcher at the Chinese National Institute of Virology (NIV). While ill, the researcher had traveled twice by train from Beijing to Anhui province, where she was nursed by her mother, a physician, who fell ill and died. The nurse in turn infected five third-generation cases, causing no deaths.
Subsequent investigation uncovered three unrelated laboratory infections in different researchers at the NIV. At least of two primary patients had never worked with live SARS virus. Many shortcomings in biosecurity were found at the NIV, and the specific cause of the outbreak was traced to an inadequately inactivated preparation of SARS virus that was used in general (that is, not biosecure) laboratory areas, including one where the primary cases worked. It had not been tested to confirm its safety after inactivation, as it should have been.
Subsequent investigation uncovered three unrelated laboratory infections in different researchers at the NIV. At least of two primary patients had never worked with live SARS virus. Many shortcomings in biosecurity were found at the NIV, and the specific cause of the outbreak was traced to an inadequately inactivated preparation of SARS virus that was used in general (that is, not biosecure) laboratory areas, including one where the primary cases worked. It had not been tested to confirm its safety after inactivation, as it should have been.