BioSafety Manual. Thompson Rivers University. Stay ere

Transcription

1 Thompson Rivers University Revision: B Revision Date: Page: 1 of 47 Procedure Identification: OHS: BioSafety Manual Owner: TRU Biosafety Officer Approved By: TRU Biosafety Committee BioSafety Manual

2 Page: 2 of 47 REV. REASON FOR REVISION ISSUE DATE ISSUED BY A Original Issue April 2010 TRU Biosafety Officer B Revised format TRU Biosafety Officer

3 Page: 3 of 47 DISCLAIMER The materials contained in this document have been compiled from sources believed to be reliable and to represent the best opinions on the subject. This document is intended to serve only as a starting point for good practices and does not purport to specify minimal legal standards. No warranty, guarantee, or representation is made by TRU as to the accuracy or sufficiency of information contained herein, and TRU assumes no responsibility in connection therewith. This document is intended to provide basic guidelines for safe practices. Therefore, it cannot be assumed that all necessary warning and precautionary measures are contained in this document and that other or additional information or measures may not be required. Users of this document should consult alternate sources of safety information prior to undertaking specific tasks. ACKNOWLEDGEMENTS Thanks to the Occupational Health and Safety Department of Wilfred Laurier University for giving permission to use their Biosafety Manual as a template for this manual.

4 TABLE OF CONTENTS Page: 4 of INTRODUCTION Scope Definitions Regulatory Forces and Guidelines Material Safety Data Sheets CLASSIFICATION OF BIOLOGICAL AGENTS Risk Groups Categories of Pathogens Inventory BIOSAFETY CONTAINMENT LEVELS Biosafety Containment Level 1 (CL1) Standard Microbiological Practices Special Practices Containment Equipment Laboratory Facilities Biosafety Containment Level 2 (CL2) Standard Microbiological Practices Special Practices Containment Equipment Laboratory Facilities GENERAL SAFETY PRACTICES AND PROCEDURES General Laboratory Safety Practices Cultivation of Bacteria on Laboratory Media Working with Laboratory Animals Working with Human Pathogens (Infectious Agents) Human Bloodborne Pathogens Universal Blood and Body Fluid Precautions General Precautions Biosafety Signs and Labels Access/Security Controls Cell Culture Training Requirements Personal Protective Equipment Lab Coats Gloves BIOLOGICAL SAFETY CABINETS Class I Biological Safety Cabinet Class II Biological Safety Cabinet Working in a Biological Safety Cabinet Certification of Biological Safety Cabinets...22

5 Page: 5 of LABORATORY EQUIPMENT SAFE OPERATING PROCEDURES Sonicators Centrifuges Vacuum DECONTAMINATION Sterilization Steam Sterilization Disinfection Chemical Disinfectants Decontamination of Biohazardous Materials DISPOSAL OF BIOHAZARDOUS WASTE EMERGENCY PROCEDURES Spills Biohazardous spill inside a Biological Safety Cabinet Biohazardous spill outside a Biological Safety Cabinet Accidents / Incidents Animal Bites and Scratches...30 Worker...30 Supervisor / Principal Investigator Exposure to Infectious and Communicable Disease Agents TRANSPORTATION OF BIOHAZARDOUS MATERIAL Definitions Internal versus External Infectious Substances Infectious Substances Internal Transportation Packaging Requirements Within the Laboratory From one Laboratory to Another Outside the Facilitiy...33 APPENDIX A: TRU LEVEL II BIOHAZARD MATERIAL INVENTORY APPENDIX B: BIOHAZARDOUS MATERIAL USE APPLICATION FORM APPENDIX C: STUDENT WORKING IN RESTRICTED AREA CONTRACT APPENDIX D: RISK ASSESSMENT TOOL... 44

6 1. INTRODUCTION 1.1 Scope Page: 6 of 47 This manual describes requirements and procedures established for work with potentially hazardous biological agents. These are applicable to all laboratory research activities and teaching labs that may involve exposure to these agents. The manual is based upon the Health Canada Laboratory Guidelines (2004 edition) and reflects best practices. 1.2 Regulatory Forces and Guidelines Guidelines developed by Public Health Agency of Canada (PHAC) form the basis for the biosafety practices included in this manual. These guidelines must be followed to ensure the continuation of granted funds from federal agencies. The PHAC Laboratory guidelines: Mandate the establishment of an Institutional Biosafety Committee (IBC) for the review and oversight of biological research. Outline roles and responsibilities for biosafety. Establish the practices, procedures, and conditions under which work with biological agents must be conducted. Obtainment, possession, use, or transfer of any biological agent or toxin is strictly controlled by federal regulations. Importation of human pathogens is regulated by the Importation of Human Pathogens Regulations. The Health of Animals Act and its regulations give the Canadian Food Inspection Agency (CFIA) the authority to control the use of significant animal pathogens associated with reportable animal diseases. The requirements for packaging and shipment of biomedical materials are governed by the Transportation of Dangerous Goods Regulations (TDGR), which are administered by Transport Canada. 1.3 Definitions Infectious agent (Risk Group 2): An organism that is capable of producing an infection or infectious disease. Infectiousness: The relative ease with which a disease is transmitted to other hosts. Human pathogen (Risk Group 2): An organism infectious to and capable of causing disease in humans. Opportunistic microorganism (Risk Group 1): Organisms that take advantage of temporary decreases in a host s immune defences to cause infection. Under normal circumstances do not cause disease. 1.4 Compliance Enforcement Policy TRU assumes the responsibility of ensuring to PHAC and the Canadian Food Inspection Agency (CFIA) that the use of biohazards will be undertaken in a safe manner and in compliance with Health Canada and CFIA guidelines. The Biosafety Officer (BSO) is responsible for ensuring compliance enforcement. All supervisors are responsible ensuring their students comply with TRU safe operating procedures (SOPs) All compliance violations are categorized as major or minor offences. The categories aid in determining the

7 Page: 7 of 47 level of risk or immediate danger to safety and health, and suggest the response that may be required when issues of non- compliance are identified by Occupational Health and Safety (OHS). All deficiencies must be in writing to the AVP Research and Graduate Studies, including the corrective action taken. Any offence occurring twice in any one- year period will be considered a second offence. A major offence is a violation that causes immediate risk or danger to safety and health, or could cause a release of biohazards into the environment or the community. Examples of major offences include: 1. Use or storage of food/drink or smoking in the laboratory. 2. Inadequate training of new staff. 3. Refusal to participate in the Level 2 Inspection Program. 4. Unauthorized possession/use of biohazards. 5. Inadequate or unsafe storage areas for biohazards. A minor offence is an infraction that poses no immediate risk or threat to safety, health, or the environment. Examples include: 1. Inadequate signage 2. Inadequate posting (i.e. permit posting) 3. Inappropriate use of biohazard warning labels Actions Following a Major Offence: 1. First Offense: A written notification will be sent to the Permit Holder or Supervisor by the Biosafety Officer () with a copy to the Department Chair, the Manager of OH&S and the Biosafety Committee Chair. Immediate correction of the violation is required, and a written reply to the BSO in 7 days. If the written reply i snot received within 7 days, a second notice will be sent, with a copy to the Dean of the Faculty. If there is no response within 7 days to the second notice, a meeting will be arranged with the Permit Holder, Department Chair, and the Manager of OH&S. 2. Second Offense: The Permit Holder will be notified in writing by the Biosafety Officer that the permit will be suspended until a meeting with the Biosafety Committee can be held to discuss the offence(s). 3. Third Offence: The Biosafety Officer will recommend to the Biosafety Committee that the Permit Holder s permit be cancelled. This recommendation will be copied to the Dean of the Faculty of Science, the Department Chair, and the Manager of OH&S. Actions Following a Minor Offence: 1. First Offense: A written notification will be sent by the BSO to the Permit Holder or Supervisor with a copy to the Department Chair, the Manager of OH&S and the Biosafety Committee Chair. Corrective action of the violation is required, with a written reply in 21 days. If the written reply is not received within 21 days, a second notice will be copied to the Dean of the Faculty. If there is no response within 14 days of the second notice, a meeting will be arranged the BSO with the Permit Holder, the Department Chair, and the Manager of EOHS. 2. Second Offence: A meeting will be arranged by the BSO with the Permit Holder or Supervisor, the Department Chair, and the Manager of OH&S, to review the issues.

8 Page: 8 of Third Offence: The Permit Holder will be notified in writing by the Biosafety Officer that the permit will be suspended until a meeting with the Biosafety Committee can be held. 4. Fourth Offence: The Biosafety Officer will recommend permit cancellation to the Biosafety Committee. Note: For the second, third and fourth occurrences, notification of the actions outlined above will be copied to the Dean of the Faculty, the Department Chair, the Manager of OH&S and the Biosafety Committee Chair. 1.5 Material Safety Data Sheets Material Safety Data Sheets for infectious microorganisms (biological agents) have been prepared by the Office of Biosafety, Laboratory Centre for Disease Control, Health Canada. These MSDS are available on the Internet via a hyperlink at aspc.gc.ca/msds- ftss/index.html. These MSDS contain health hazard information, recommended precautions, spill clean- up procedures, and other information that is relevant specifically to the laboratory setting. They serve as an additional safety resource for laboratory personnel working with biological agents. MSDSs for chemicals used in TRU laboratories can be found clicking on the MSDS icon on any TRU computer desktop.

9 2. CLASSIFICATION OF BIOLOGICAL AGENTS 2.1 Risk Groups Page: 9 of 47 Biological agents are categorized into risk groups based on the relative hazards they pose. The factors used to determine an agent s risk group includes its pathogenicity, infective dose, mode of transmission, host range, availability of effective preventive measures and availability of effective treatment. These classifications presume ordinary circumstances in the research laboratory or growth in small volumes for diagnostic and experimental purposes. Risk Group 1 (low individual and community risk) A biological agent that is unlikely to cause disease in healthy workers or animals. Risk Group 2 (moderate individual risk, limited community risk) A biological agent that can cause human or animal disease but, under normal circumstances, is unlikely to be a serious hazard to laboratory workers, the community, livestock, or the environment. Laboratory exposures rarely cause infection leading to serious disease; effective treatment and preventative measures are available and the risk of dissemination is limited. Risk Group 3 (high individual risk, low community risk) A biological agent that usually causes serious human or animal disease, or can result in serious economic consequences, but does not ordinarily spread by casual contact from one individual to another, or can be treated by antimicrobial or antiparasitic agents. Risk Group 4 (high individual risk, high community risk) A biological agent that usually produces very serious human or animal disease, often untreatable, and which may be readily transmitted from one individual to another, or from animal to human or vice- versa, directly or indirectly, or by casual contact. An abbreviated list of organisms by Risk Group can be found in Appendix A. Since these classifications are updated regularly, a complete and current list should be consulted by contacting the Office of Laboratory Security at (613) or accessing the web site at aspc.gc.ca/ols- bsl/index.html 2.2 Categories of Pathogens As a general precaution, the risk group for agents should be raised when manipulation may result in the production of infectious droplets or aerosols. Agents with similar pathogenic characteristics that are not included in these lists should be considered in the same risk category. Since many agents may be referred to in the literature by a variety of names, the Supervisor in consultation with the Biosafety Officer must fully verify an unlisted organism s characteristics before determining a classification. 2.3 Inventory Inventory records are maintained by the Biosafety Officer. The Biosafety Committee will review the list of registered materials annually. Inventory shall include material from commercial, university or private institutions regardless of whether it is a gift or purchased. The Principal Investigator (PI) or Supervisor will be responsible for properly providing the BSO with the biological materials acquired from outside sources. All new organisms must be registered with the Biosafety Officer before they are introduced to TRU

10 Page: 10 of 47 Registration assists the Biosafety Officer in developing a catalogue/inventory of biohazardous materials on campus, and registration is used by the Biosafety Committee to assist in assigning biological safety levels (Risk Group category) to each agent. It also helps to ensure that research teams are working with these materials in a manner that is safe for everyone s protection and that appropriate permits are obtained. Importation requirements and forms may be obtained from: Public Health Agency of Canada at aspc.gc.ca/ols- bsl/index.html Canadian Food Inspection Agency at

11 Page: 11 of BIOSAFETY CONTAINMENT LEVELS Classification of biological agents into Risk Groups does NOT establish guidelines for handling agents safely in the laboratory setting. Therefore, Containment Levels have been established to provide end users with a description of the minimum containment required. Containment Levels describe the characteristics of the agent and the engineering, operational, technical and physical requirements for manipulating it safely. Risk assessment is a critical step in the selection of an appropriate Containment Level for any biohazardous work. A detailed assessment should be conducted to determine both containment level facility requirements and operational practices requirements. The risk assessment should include the Risk Group information, the potential for aerosol generation, the quantity and concentration of the agent, the agent s stability and the type of work (e.g., in vitro, in vivo). It is the responsibility of the Principal Investigator (PI)/Supervisor in consultation with the BSO to conduct risk assessments and to require the highest appropriate level of containment available for manipulation of specific infectious agents. 3.1 Biosafety Containment Level 1 (CL 1) Containment Level 1 (CL1) applies to the basic laboratory, which handles agents requiring no special design features beyond those suitable for a well- designed and functional laboratory. Biological safety cabinets (BSCs) are not required. Work may be done on an open bench top, and containment is achieved through the use of practices normally employed in a basic microbiology laboratory Standard Microbiological Practices Access to the laboratory is limited or restricted at the discretion of the Principal Investigator or Lab Supervisor when experiments are in progress. Work surfaces are decontaminated at the beginning and end of the day and after any spill of viable material. All contaminated liquid wastes are decontaminated before disposal. Persons must wash their hands after handling viable organisms and before leaving the laboratory. All procedures are performed carefully to minimize the creation of aerosols Special Practices Contaminated materials that are to be decontaminated at another location must be placed in a durable, leak- proof container which is closed before being removed from the laboratory (e.g. Biohazardous sharps) Such containers should be wiped with disinfectant solution before leaving the lab. An insect and rodent control program must be in effect Containment Equipment Special containment equipment is generally not required for manipulation of agents assigned to Biosafety Containment Level I Laboratory Facilities The laboratory is designed so that it can be easily cleaned.

12 Procedure Identification: OHS: BioSafety Manual Revision: B Revision Date: Bench tops are impervious to water and resistant to acids, alkalis, and organic solvents. 3.2 Biosafety Containment Level 2 (CL 2) Page: 12 of 47 The primary exposure hazards associated with organisms requiring Containment Level 2 are through ingestion, inoculation and mucous membrane routes. Agents requiring CL2 facilities are not generally transmitted by airborne routes, but care must be taken to avoid the generation of aerosols (aerosols can settle on bench tops and become an ingestion hazard through contamination of the hands) or splashes. Primary containment devices such as BSCs and centrifuges with sealed rotors or safety cups must be used, along with appropriate personal protective equipment (i.e., gloves, laboratory coats, protective eyewear). Environmental contamination must be minimized through the use of handwashing sinks and decontamination facilities (autoclaves) Standard Microbiological Practices Access to the laboratory is limited or restricted by the Principal Investigator or Supervisor. Work surfaces are decontaminated at the beginning and end of the day and after any spill of viable material. All infectious liquid or solid wastes must be decontaminated before disposal. All persons are required to wash their hands after handling infectious materials and before leaving the lab. All procedures must be performed carefully to minimize the creation of aerosols. Procedures that create aerosols must be conducted in a biological safety cabinet. Lab coats must remain in the laboratory. Lab coats and gloves are to be removed if the worker leaves the laboratory for any reason Special Practices Contaminated materials to be decontaminated at another location must be placed in durable leak- proof containers that are closed before being removed from the laboratory, e.g. biohazardous sharps The PI or Lab Supervisor limits access to the laboratory. In general, anyone at increased risk of acquiring infection is not allowed in the laboratory. The PI or Lab Supervisor is responsible for assessing each circumstance and determining who may enter or work in the laboratory. If the use of an infectious agent(s) requires special provisions (e.g. vaccination), a biohazard warning sign must be posted on the access door to the laboratory area. The biohazard warning sign should identify the infectious agent(s), provide the name(s) of the PI and/or other responsible persons, and indicate the special requirements for entering the laboratory. An insect and rodent control program must be in effect. Special care must be taken to avoid skin contamination with infectious materials; gloves must be worn when skin contact with infectious materials is possible. All waste from laboratories must be appropriately decontaminated before disposal. Hypodermic needles and syringes may be used only for injection and aspiration of fluids from diaphragm bottles.

13 Spills and accidents that result in overt exposure to infectious materials must be reported immediately to the PI and the Biosafety Officer. When appropriate (considering the agent handled), baseline serum samples for laboratory personnel should be collected. Infectious agents must be stored inside a leak proof container that is clearly labelled Containment Equipment Biological safety cabinets (class I or II) must be used whenever: Procedures with a high potential for creating infectious aerosols are conducted. These may include centrifuging, blending, vigorous shaking or mixing, sonic disruption, and opening containers of infectious materials. High concentrations or large volumes of infectious agents are used. Such materials must be centrifuged in a biological safety cabinet and opened in a biological safety cabinet. Page: 13 of 47 Air from these cabinets may be recirculated to the room only after passage through a high- efficiency particulate air (HEPA) filter Laboratory Facilities The laboratory is designed so that it can be easily cleaned. Bench tops are impervious to water and resistant to acids, alkalis and organic solvents. Each laboratory shall contain a sink for hand washing. Coat hooks must be provided near the exit for laboratory coats. Such coats are to be kept separate from streetcoats. A biohazard sign with appropriate information must be posted on the entrance of the laboratory. A list of all infectious agents being used in laboratory must be posted on the entrance of the laboratory. All the biological agents used at TRU require Biosafety Containment Level 1 or 2. NO EMPLOYEE WILL PERFORM BIOSAFETY CONTAINMENT LEVEL 3 OR 4 WORK AT THE UNIVERSITY.

14 Page: 14 of GENERAL SAFETY PRACTICES AND PROCEDURES 4.1 General Laboratory Safety Practices Employees must be advised of potential hazards before entering the work area. Laboratory doors should be kept closed. Safety glasses must be worn in all designated laboratory areas. Lab coats must be worn in the laboratory areas by all personnel, including visitors, trainees and others entering or working in the laboratory. (Refer to Section ). Contaminated clothing must be disinfected by appropriate means. Mouth pipetting is strictly prohibited. Eating, drinking, smoking, chewing gum and/or storing food is not permitted in the laboratory areas. The lab should be kept clean and free of materials not pertinent to the work. Work surfaces shall be decontaminated at least once a day and after any spill. Employees must wash their hands after handling infectious materials and before leaving the laboratory. Gloves must be worn for all procedures that involve contact with body fluids, infectious materials, or infected animals. Gloves must be autoclaved. All spills, accidents and possible exposures to infectious materials must be reported immediately to the PI and the BSO. The BSO will ensure that training in laboratory safety for infectious materials is provided. All procedures shall be performed carefully to minimize the creation of aerosols. All contaminated or infectious liquid or solid materials must be decontaminated before disposal or re- use. Where infectious agents are used in a laboratory, a biohazard warning sign incorporating the universal biohazard symbol must be posted on the access door to the work area. 4.2 Cultivation of Bacteria on Laboratory Media For microbiological investigations it is essential to learn the skills of inoculating specimens onto culture media: Always practice aseptic technique Clean benchtop with supplied disinfectant before beginning your work and upon completion Ensure loops and picks are flamed upon completion of you work Discard any waste biohazardous material in the appropriate area, to ensure adequate disinfection is completed

15 4. 3 Working with Laboratory Animals By definition, all work involving animals is considered biohazardous. Animals can harbour infectious organisms that can be transmitted to humans. Laboratory facilities must provide containment for laboratory animals exposed to or harbouring infectious agents that is appropriate to the risk level of the infectious agents involved. Page: 15 of 47 Requirements for the maintenance of animals may differ in scale and degree, but the basic principles for microbiological safety will be similar to those outlined in Section 3 and shall include the following precautions: 1. Infected animals and insects shallbe segregated from uninfected animals and is preferable to separate any handling area from the holding area. 2. Animals or insects in use in an experiment must be maintained at a level of containment that is at least equivalent to the containment level for the biological agent with which it has been infected or treated. 3. Provision must be made to ensure that inoculated animals or insects cannot escape. 4. Dead animals or insects and the refuse from the animal room and cages (e.g. bedding, faeces and food) must be placed in a leak- proof container and autoclaved or incinerated. 5. All cages must be properly labelled, and procedures in the holding area must minimize the dispersal of dander and dust from the animals and cage refuse. 6. Animal care providers while feeding and watering animals or cleaning cages shall wear gloves and eye protection. 7. Gloves, boots, floors, walls and cage racks shall be disinfected as defined by Standard Operating Procedures (SOPs) In addition to the preceding: 8. All aspects of the proposed use of animals in research must satisfy all the standards and regulations of the Canadian Council on Animal Care (CCAC), and the Animals for Research Act. All work involving animals must receive prior approval from the TRU Animal Care Committee. 9. The appropriate species must be selected for animal experiments. 10. The investigator and/or person(s) responsible for an animal experiment must ensure that all those having contact with the animals and waste materials are aware of and familiar with any special precautions and procedures that may be required. Where possible and warranted, personnel should be protected by immunization with appropriate vaccines. 11. All incidents, including animal bites and scratches or cuts from cages or other equipment must be documented and reported by the employee to the Lab Supervisor. 4.4 Working with Human Pathogens (Infectious Agents) Some microorganisms (viruses, bacteria, fungi, etc.) are species- specific, selectively infecting and causing disease in one or a limited number of host species. Unrelated and distantly related species may not be similarly affected by the same infectious microorganism due to differences in physiology, metabolism, biochemistry, etc. In general, the risk to laboratory personnel working with a virus that only infects and

16 Page: 16 of 47 causes disease in rodents is lower than the risk to laboratory personnel working with tissues and cells from humans or other primates. If the human material contains a viable pathogen, it will likely be a human pathogen, with the potential to infect and cause disease in another human. Although a single mode of transmission may predominate, disease- causing microorganisms can be spread or transmitted from one host to the next, directly or indirectly, by a number of methods, including aerosol generation and inhalation, ingestion of contaminated food and water, skin and mucous membrane contact with contaminated surfaces, contact contamination of an open wound or lesion, and autoinoculation via a cut, laceration or puncture with a contaminated instrument. 4.5 Human Bloodborne Pathogens Human blood is recognized as a potential source of pathogenic microorganisms that may present a risk to workers who are exposed during the performance of their duties. Although the hepatitis B virus (HBV) and the human immunodeficiency virus (HIV) are often cited as examples, a "bloodborne pathogen" is any pathogenic microorganism that is present in human blood or other potentially infectious materials and that can infect and cause disease in persons who are exposed to blood or other potentially infectious materials containing this pathogen. "Other potentially infectious materials" means material that has the potential to transmit bloodborne pathogens. This includes infected human tissues and the following body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, saliva in dental procedures, and any other body fluid that is visibly contaminated with blood Universal Blood and Body Fluid Precautions The possibility of undiagnosed infection combined with the increasing prevalence of HBV and HIV led the Center for Disease Control to recommend that blood and certain other body fluids from all humans be considered potentially infectious and that precautions be taken to minimize the risk of exposure. This approach, called "Universal Precautions", is a method of infection control, intended to prevent parenteral, mucous membrane, and non- intact skin exposure of workers to bloodborne pathogens. All human blood, certain human body fluids, and other materials are considered potentially infectious for hepatitis B virus (HBV), human immunodeficiency virus (HIV), and other bloodborne pathogens. Precautions must be consistently used. Body fluids to which universal precautions apply include blood, body fluids containing visible blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. Universal precautions generally do not apply to faeces, breast milk, nasal secretions, sputum and saliva, sweat, tears, urine, and vomitus unless they contain visible blood. Although these materials are not implicated in the transmission of bloodborne pathogens, it is prudent to minimize non- intact skin and mucous membrane contact with these materials. Hepatitis B immunization is recommended as an adjunct to universal precautions for workers who have occupational exposure to human blood or other potentially infectious materials. This immunization is provided to employees at risk, free of charge General Precautions 1. All workers should routinely use appropriate barrier precautions to prevent skin and mucous

17 membrane exposure when contact with human blood or other body fluids is anticipated. Page: 17 of Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited. 3. Gloves shall be worn when touching blood and body fluids, mucous membranes, or non- intact skin, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. If a glove is torn or damaged during use, it shall be removed and a new glove used as promptly as safety permits. Disposable gloves shall not be washed or disinfected for reuse. Washing with surfactants may enhance penetration of liquids through undetected holes in the glove. Disinfecting agents may cause deterioration of the glove material. 4. Masks and protective eyewear or face shields shall be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. 5. Gowns or aprons shall be worn during procedures that are likely to generate splashes of blood or other body fluids. Protective clothing should be removed before leaving the area. 6. Hands and other skin surfaces shall be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands shall be washed immediately after gloves are removed since no barrier is 100% effective. 7. Workers shall take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures, when cleaning used instruments, during disposal of used needles, and when handling sharp instruments after procedures. Needles and syringes should be used only in those situations when there is no alternative. To prevent needlestick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items shall be placed in puncture- resistant containers for disposal. The puncture- resistant container shall be located as close to the use area as practical. 8. Workers who have exudative lesions, weeping dermatitis, cuts, open wounds or other breaks in the skin shall either refrain from all direct contact with blood and other body fluids until the condition resolves, or utilize protective barriers to reduce the risk of exposure. 9. Pregnant workers shall be especially familiar with and strictly adhere to precautions to minimize the risk of perinatal transmission of bloodborne pathogens. 4.6 Biosafety Signs and Labels The Public Health Agency of Canada and the Medical Research Council (MRC) require that warning signs and/or symbols be used to inform personnel and visitors of the potential of hazards in the workplace. Specifically, with regard to biohazards, the universal biohazard warning sign must be used to "signify the actual or potential presence of a biohazard and to identify equipment, containers, rooms, materials, experimental animals or combinations thereof, which contain and/or are contaminated with, viable hazardous agents." 1. TRU requires that the universal biohazard symbol be used to designate the presence of agents/substances that are believed to be biohazardous. 2. All laboratories and work areas utilizing and/or storing biohazardous substances must have the appropriate biohazardous caution sign posted prominently. If infectious agents are used, a

18 Page: 18 of 47 biohazard sign must be located outside the laboratory door to indicate the nature of the hazard, the biohazard level, special provisions for entry and contact information for the Principal Investigator and/or other responsible person(s). 3. Principal Investigators/Supervisors are responsible for ensuring that all hazard signs are current and accurate. Notify the Biosafety Officer if changes are necessary in laboratory door signage and/or equipment labeling. 4.7 Access/Security Controls Doors must be locked when laboratories are unoccupied and only authorized persons are permitted to enter laboratory working areas. Children under the age of 14 years must not be permitted to enter laboratory working areas. 4.8 Cell Culture All new cell lines introduced into TRU must be registered with the Biosafety Officer. Storage and retrieval of frozen cell cultures from liquid nitrogen require appropriate personal protective equipment. There are three major risks associated with liquid nitrogen (- 196 C): frostbite, asphyxiation and exposure. Gloves shall be worn that are thick enough to provide insulation, but flexible enough to allow manipulation of ampoules. When ampoules are submerged in liquid nitrogen, a high- pressure differential results between the outside and the inside of the ampoule. If the ampoule is not perfectly sealed, the pressure differential may result in inspiration of liquid nitrogen, which may cause the ampoule to explode violently when thawed. Wear eye protection, a face shield and earplugs are recommended Biological safety cabinets shall be kept clean and free of unnecessary equipment and material to ensure proper functioning of the cabinet. Liquid waste shall be decontaminated by chemical disinfectant (e.g., 10% hypochlorite). Vacuum collection flasks for liquid waste shall be kept outside the cabinet in a secure place and should contain an appropriate disinfectant.the collection flask shall also have a back- up trap to protect the central vacuum line. Decanting shall be done to minimize splashing. All flasks should be properly labelled. Decontamination of the biological safety cabinet shall be done with a liberal spray with supplied disinfectant followed by a wipe with 70% ethanol at the end of the procedure. Solid waste shallbe placed in biological waste bags and the bags then sealed for autoclaving. Biohazard

19 Page: 19 of 47 disposal containers with lids shall be used for primary disposal. Glass pipets shalld be placed in a pipet container with an appropriate disinfectant. Plastic disposable pipets must be disposed of in an appropriate container. Contaminated sharps shall be placed in the yellow biohazardous sharps containers 4.9 Training Requirements Biosafety training is mandatory for all new Principal Investigators, supervisors, research staff and students who work with microorganisms, cell cultures and human blood and body fluids. Principal Investigators are responsible for ensuring new employees have received training appropriate to the specific biological materials and/or processes in the lab. This training is to be provided prior to initiation of work and shall be documented by the Biosafety Officer. On completion of Biosafety training, the participant will: demonstrate an understanding of the process of risk assessment for work with microorganisms and cell lines. demonstrate an understanding of the concept of containment level as it applies to biohazard laboratories. describe how a biological safety cabinet works and its role in a biohazard laboratory. describe the procedures for accidental exposure or spills of biohazardous materials. describe the risks associated with human blood and body fluids. demonstrate how to apply precautions when working with human blood and body fluids. THOSE INVOLVED IN BLOODBORNE PATHOGENS RESEARCH HAVE ADDITIONAL TRAINING REQUIREMENTS Personal Protective Equipment (PPE) The type and extent of clothing and equipment to be selected for any particular procedure depend on the research operations and levels of risk associated with them. At a minimum, a lab coat, closed- toe shoes, and gloves must be worn in any microbiology laboratory. Lab coats, closed- toe shoes, and gloves prevent biohazardous materials from contact with the skin, including areas where there might be cuts, abrasions, or dermatitis. The legs are a vulnerable area if uncovered, so it is inappropriate to wear skirts or shorts. Closed- toe shoes protect the feet from spills as well as injuries from dropped sharps. Soles must be non slip to avoid slips and falls, Lab Coats The lab coat protects street clothing from contamination and prevents possible cross- contamination from any normal flora present on the skin. Lab coats must be worn by all personnel, including visitors, trainees and others entering or working in the laboratory. Coats must be properly fastened. If contaminated, lab coats shall be decontaminated by autoclaving before being placed in the laundry. If decontamination is not possible, any contaminated coat shall be placed in the biohazard waste container Gloves Appropriate gloves must be worn for all procedures that might involve direct or accidental skin contact

20 Page: 20 of 47 with biohazardous materials. Latex or vinyl gloves offer a high level of dexterity and a higher level of sensitivity; however, they don t offer a great deal of protection from needle sticks, animal bites or sharps. All gloves will eventually permeate and shall therefore be changed periodically. If gloves become contaminated or torn, remove immediately and wash hands with soap. Some procedures may require double gloving. Gloves should overwrap the cuff and lower sleeve of the lab coat if double gloving is practiced Gloves must be removed prior to leaving the laboratory and decontaminated with other laboratory wastes before disposal. The following chart lists preferential gloves for different products. TYPE ADVANTAGES DISADVANTAGES FOR USE WITH: Natural rubber latex Natural rubber blends Polyvinyl chloride (PVC) Neoprene Nitrile Butyl Polyvinyl alcohol (PVA) Fluro- elastomer (Vitron ) Norfoil, Silver Shield, 4H Low cost, good physical properties, dexterity Low cost, dexterity, generally better chemical resistance than natural rubber. Low cost, very good physical properties, average chemical resistance. Average cost, average chemical resistance, average physical properties, high tensile strength, high heat resistance. Low cost, excellent physical properties, dexterity Good resistance to polar organics, high resistance to gas and water vapour Resists broad range of organics, good physical properties. Good resistance to organic and aromatic solvents. Flexible. Excellent chemical resistance. Poor against oils, greases, organic solvents, ethidium bromide. May cause allergic reactions. Physical properties often inferior to natural rubber. May cause allergic reaction. Plasticizers can be stripped. Poor vs. chlorinated hydrocarbons Poor vs. chlorinated organic solvents Expensive, poor vs. hydrocarbons, chlorinated solvents Very expensive. Water sensitive, poor vs. light alcohols, acids and bases. Extremely expensive. Poor physical properties. Poor vs. some ketones, esters, amines Poor fit, stiff, easily punctures, poor grip. Bases, acids, alcohols, dilute aqueous solutions. Fair vs. aldehydes, ketones. Bases, acids, alcohols, dilute aqueous solutions. Fair vs. aldehydes, ketones. Strong acids and bases, salts, aqueous solutions, alcohols, oils, greases and petroleum products. Oxidizing acids, alcohols, anilines, phenol, glycol ethers, solvents, oils, mild corrosives Oils, greases, xylene, aliphatic hydrocarbons, perchloroethylene, trichloroethane, ethidium bromide. Fair vs. toluene. Glycol ethers, ketones, esters, aldehydes, polar organic solvents Aliphatic and aromatic hydrocarbons, chlorinated solvents, ketones (except acetone), esters, ethers Aromatics and aliphatic hydrocarbons, chlorinated solvents, oils, lubricants, mineral acids, alcohols. Use for Hazmat work. Good for range of solvents, acids and bases.

21 5. BIOLOGICAL SAFETY CABINETS (BSCs) Page: 21 of 47 Protection of the respiratory system is of major concern in any biological safety program because infectious organisms can readily enter the human body through the respiratory tract. Engineering controls (biological safety cabinets) are the primary barrier for inhalation of biohazard and should be use whenever possible. Respirators should only be used as secondary means of control. Any individual needing respiratory protection will be required to participate in the Respiratory Protection Program. The BSO will contact the Dean of Science who will ensure respirators will be made to individuals who require such. A biological safety cabinet is a ventilated cabinet that uses a combination of HEPA (high efficiency particulate air) filtration, laminar air flow and containment to provide personnel, product and environmental protection from particulates or aerosols involving biohazardous materials. It is distinguished from a chemical fume hood by the presence of HEPA filtration and the laminar nature of the air flow. The following is a basic description of the two classes of biological safety cabinets, their capabilities and the limitations of each class. 5.1 Class I Biological Safety Cabinet This is a ventilated cabinet which provides partial protection to the worker and environment but no protection to the work. These cabinets have unrecirculated airflow away from the operator that is discharged to the atmosphere after filtration through a HEPA filter. Chemical carcinogens and low level of radioactive materials and volatile solvents can be used in a Class I safety cabinet. 5.2 Class II Biological Safety Cabinet This is a ventilated cabinet that provides personnel, product and environmental protection. These

22 cabinets have an inward airflow and HEPA- filtered supply and exhaust air. Page: 22 of 47 A class II biological safety cabinet shall be used whenever there is a risk of creating potentially infectious aerosols or droplets. Examples of processes that may create aerosols are: centrifuging, grinding, blending, vigorous shaking or mixing, opening containers of infectious materials that are at other than ambient pressure. Use of a centrifuge in the open laboratory may be carried out safely only if the samples have sealed heads or centrifuge safety caps are used. However, it is strongly recommended that centrifuging gets done in a contaminant hood at all times. Class II BSCs are the most commonly used BSC on campus. These cabinets provide personnel, environmental and product protection. (See Figure 3). Only BSCs that have hard ducts to the outside and provide a face velocity of 80 to 125 feet per minute should be used when working with volatile chemicals. Note: these cabinets are not designed to prevent ignition of volatile flammable chemicals 5.3 Working in a Biological Safety Cabinet Turn the cabinet on for at least minutes prior to use, if the cabinet is not always operating. Disinfect work surface with suitable disinfectant followed by 70% alcohol. Consider the materials necessary for the work to be conducted in the cabinet. Place all required materials on an absorbent pad to avoid aerosol generation Place items into the cabinet so they can be used efficiently without unnecessary disruption of the air flow, working with materials from the clean to the dirty side.

23 Page: 23 of 47 Wear appropriate personal protective equipment. At a minimum, this will include a buttoned laboratory coat and gloves. Delay manipulation of materials for approximately one minute after placing the hands/arms inside the cabinet. Minimize the frequency of hand movements in and out of the cabinet. If it is required to move out of the BSC pull hands slowly and horizonatally from the cabinet. Allow time for the air flow disruption to diminish before putting hands back into the BSC Do not disturb the airflow by covering any grillwork with materials. Work at a moderate pace to prevent the air flow disruption that occurs with rapid movements. Wipe the bottom and side of the hood surfaces with disinfectant when work is completed. Leave the hood running for several minutes following the procedures before turning off the blower NOTE: BE VERY CAREFUL WHEN USING SMALL PIECES OF MATERIAL SUCH AS KIMWIPES IN THE HOOD. THESE CAN BE BLOWN INTO THE HOOD AND DISRUPT THE MOTOR OPERATIONS. ** THE BSC IN S365C IS T USE FOR STERILITY ONLY. FOR USE WITH POTENTIAL PATHOGENS USE THE BSC IN S367. NO CHEMICAL USE IS ALLOWED IN EITHER OF THESE BSCs. THE BSC IN S363 MAY BE USED WHEN VOLATILE CHEMICALS ARE REQUIRED TO BE USED IN THE BSC 5.4 Certification of BSC All biological safety cabinets must be certified on installation, when the filters are changed, before and after a move or transfer and annually. Cabinets must not be moved without first undergoing a decontamination process. The Biosafety Officer must approve any modifications to any biological safety cabinets. Cabinets must undergo certification following modification. The certification process is arranged for annually by the BSO. If problems are encountered in operating a biological safety cabinet, do not continue to use it; contact the BSO immediately. The certification of the biological safety cabinets is essential to their safe and effective use.

24 Page: 24 of LABORATORY EQUIPMENT SAFE OPERATING PROCEDURES 6.1 Sonicators When used with infectious agents sonicators can release significant amounts of hazardous aerosols, and shall be operated inside a biological safety cabinet whenever possible. Sonicators are devices commonly used for disrupting cells and mixing samples. Vortexers are also used for mixing samples. The following safety measures should be used with a sonicator to reduce the chance of aerosol formation. Safe Operating Procedures include: Loosely cap all samples. Make sure there is enough water in the sonicator. Avoid prolonged sonication. Inspect all glassware to be used in the sonicator. Do not use chipped or cracked glassware. Routinely replace the sonicator liquid. Avoid sonicating volatile compounds. When possible, use secondary containment (container within container within the sonicator). Perform sonicating in isolated rooms and areas. Make sure you have adequate ear protection. Allow aerosols to settle for at least one minute before opening containers. 6.2 Centrifuges Safe use of centrifuges requires proper maintenance and operation. Failed mechanical parts or improper operation can result in release of projectiles, hazardous chemicals and biohazardous aerosols. Maintenance and repairs must be performed only by trained, qualified personnel. Centrifuges are a source of potential biological contamination due to the rapid speeds and relatively high pressure exerted by such devices. The following safety measures shall be used when using any centrifuge: Safe Operating Procedure includes: Prior to starting, make sure the centrifuge is clean. Do not operate with any material spills in either the body or the rotor. Ensure that the interlocking device prevents the lid from being opened when the rotor is in motion and the centrifuge from starting when the lid is open.

25 6.3 Vacuum Page: 25 of 47 Make sure the centrifuge is level. If a portable model, make sure it is secure on the bench top before starting. Inspect all equipment to be placed in centrifuge for cracks or weak areas. Ensure that the tube material provides the necessary chemical resistance and speed rating. Use the lowest speed and time setting that will accomplish the job. Avoid over- filling tubes. Balance all loads. Do not open the lid until it comes to a complete stop. Wait for at least one minute before opening the lid to remove your sample. Should a spill occur, disinfect immediately and dry completely before the next run. Periodically inspect centrifuge. Check seal around top, baskets, rotors and wiring. Avoid use of volatile materials when possible. Plastic centrifuge tubes with seal- forming screw tops should be used whenever possible. Centrifuges should not be placed into a biological safety cabinet if the motor produces strong air current because the air turbulence generated may disrupt the laminar airflow. If there is a vacuum system serving multiple areas, care should be taken that there are filters in the system, and that there is an overflow trap containing an appropriate disinfectant to prevent entry of contaminated material into the piping system and pumps. It is often best to use either a stand- alone pump- type vacuum system, or to use a water siphon vacuum system that is attached to a faucet (provided that measures are taken to prevent back- siphonage). 6.4 Gas Chromatograph Gas chromatography (GC) procedures involve the use of compressed gas cylinders and may involve the use of flammable solvents and toxic chemicals. Be familiar with the use and handling of compressed gas cylinders, and with hazardous properties, precautionary measures, and handling instructions for any hazardous materials being used. Refer to MSDSs (found on- line use the MSDS icon on the desktop) or other reliable reference material. The following guidelines will assist in the safe operation of GCs: Wear proper eye protection. GC columns are fragile and breakage could result in small projectiles during handling. As well, samples are prepared in various hazardous solvents that could damage the eyes upon contact. When cutting a GC column, be sure that the cut is made away from the body. Ensure that GC column cutters are capped or otherwise stored to prevent injury when not in use.