Working with blood and human tissues Code of Practice Hatchcroft Laboratories - Middlesex University Introduction All University staff, students and visitors who work with biological materials in the Hatchcroft Laboratories (whether in taught classes, research, or in any other manner) are expected to read and follow this code of practice in order to follow best practice for Health and Safety and legal obligations under the Human Tissue Act. Human Tissue Act The Human Tissue Act requires that all tissues and fluids of human origin are logged, detailed, stored and handled in a very prescribed manner. For full information on how this is dealt with in the Hatchcroft Laboratories, please refer to the HTA Quality Manual and HTA SOPs. Health and Safety Blood-Borne Viruses All human tissues will be contaminated with blood. Therefore they should be regarded as potentially infectious for blood-borne viruses (the more common BBVs found in the UK are HIV, Hepatitis B (HBV) and Hepatitis C (HCV)). HIV has been detected in blood and blood products, in serum, plasma, breast milk, semen, vaginal and cervical secretions, urine, saliva, tears, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, amniotic fluid and both cerebrospinal fluid (CSF) and brain tissue. There is also evidence that certain specialised cells lining the gut support the multiplication of HIV. Possible HIV contamination should therefore be risk assessed before considering handling materials of these types in the laboratory. Other specimens such as faeces and urine are not regarded as posing HBV or HIV infection risk as long as they are not contaminated with blood. However, faeces in particular will contain various other pathogens. Sputum samples and specimens of lung tissues may contain Mycobacterium tuberculosis. Samples of neurological origin may contain disease-form prion proteins. 1
Several factors should be taken into account when assessing likely incidence of BBVs. These include known medical history of a patient or donor, whether the samples are from individuals showing clinical symptoms of infectious disease, and the incidence of any pathogens that are endemic in the local population. Any samples that have not been screened should be regarded as potentially infectious. The following provides some guideline examples:. The National Blood Service (NBS) will usually release out-of-date or surplus transfusion blood for non-clinical purposes. Since it has rigorous exclusion criteria for at risk donors and the blood is screened prior to release, blood obtained from the National Blood Transfusion Service may be regarded as one of the lowest risk sources (although this does not guarantee the sample is HIV negative because of the window between infection and seroconversion).. Some commercial companies supply screened blood products and derivatives of human tissues which may be more suitable than using unscreened human blood/tissues. Samples from the general population in the UK would be regarded as low risk for BBVs whereas those from areas of the world where hepatitis and HIV are endemic would be regarded as higher risk. If samples are from a specific group in the UK in which the incidence of BBVs was known to be significantly increased, such as intravenous drug users, then these too would be regarded as higher risk. If samples are from individuals known to be, or because of clinical indications suspected to be, infected with BBVs or other pathogens from Hazard Group 3 or 4, these would be regarded as high risk and under no circumstances may they be used, stored or brought into the Hatchcroft laboratories. It is a requirement under the Control of Substances Hazardous to Health (COSHH) Regulations to always consider whether a less hazardous substance, or form of the substance, can be used instead. If it can, then it should be used or justification be 2
given as to why it is not being used. In many cases there will be good reasons for using samples from specific sources since these are the subject of the research. However if material is needed for control purposes or a specific source is not required, then the least hazardous should be used. NB Staff and students should not work with their own cells or those from others sharing the laboratory, due to the risks from inoculation with autologous cells that may have become infected or transformed. Any blood taking (venesection) must be done within the designated area and must be mindful of potential for inducing anaemia and appropriately considered within the risk assessment. HTA and ethics considerations must also be applied When cultivating primary cells "permissive" to infection by HIV (e.g. T-cells, whole blood etc.) there is an upper limit of 4 days for cultivation. Cultivation beyond this time period increases the chance of propogation of unknown HIV viruses. COSHH The basis of current legislation pertaining to working safely with human blood and tissues is to assess the risks to health before work begins to allow appropriate precautions to be put in place. Specific legislation is The Control of Substances Hazardous to Health Regulations of 1999, which make sensible measures to ensure safe working with blood and tissues legally enforceable. In essence, these are: i. Assessing the risk to health before starting work; ii. Selecting appropriate precautions to eliminate or minimise risk to health; iii. Ensuring precautions are used through adequate supervision; iv. Ensuring precautions are effective through maintenance, inspection and testing; v. Ensuring staff and students are working safely through provision of information, instruction and training; vi. Providing health surveillance and vaccination where appropriate. For work involving human blood or tissues with potential for presence of lethal pathogens, the Regulations require: 1. Where there is no intention to work with pathogens but there is a possiblility that they may be unknowingly present in samples, work must be carried out at Containment Level 2 (see Appendix-4). 3
2. Effective implementation of this Code of Practice will ensure the safest possible working with human blood and tissues, and compliance with COSHH regulations. Risk assessment An assessment of health risks before starting work with human blood or tissues must be completed and documented in the LabRAT format. The risk assessment must be specific for procedures involved in the practical class or research proposed, and must take account of the nature and source of any samples to be handled. Completed forms must be lodged within the LabWiki. Consistent application of good working practice and avoidance of sharps should eliminate (or greatly reduce) the risk of pathogen infection. Blood product and human tissue reception and storage Packages containing human blood or tissues may only be opened in a laboratory by suitably trained and competent staff. Receipt of such samples should be prearranged with the originator, packages should be clearly identified as containing human samples with pathogenic potential (as per UK postal regulations). Samples must be securely stored in designated fridges or freezers in a laboratory, and be clearly labelled. No food must be stored in fridges or freezers containing human blood or tissues. Waste disposal The disposal of human tissue falls within the Human Tissue Authority s statutory remit. The HT Act permits disposal of surplus tissue as waste. Where practical, identifiable human tissue should be bagged and labelled separately from other clinical waste bags, but disposed of within the same way as the clinical waste. All waste from practical classes or research projects involving human blood or tissues must be placed in autoclave bags and, rendered non-infectious by autoclaving before being placed into yellow clinical waste bags and removed for disposal. Any sharp implements or broken glass that has been in contact with human blood or tissue should be placed in a Sharps bin. 4
Spillage procedure Each lab must display the spillage procedure for use by all staff and students (see Appendix -2). Induction, training and supervision for safe handling of human tissues Induction into each lab must be conducted by the nominated person for that lab before any access permission may be granted. ALL staff and post graduate students must be inducted (laboratory competence (eg arising from external training, previous experience, rank etc). must not be assumed) and any further training requirements should be identified during induction and arrangements put into place by the inductor. Swipe card access to the West wing laboratories may only be granted by Lucy Ghali (HTA Designated Individual). All signed records of induction must be kept and maintained by the nominated individual for each lab. All undergrad students will be inducted during classes. Induction must provide sufficient grounding in the activities of each lab, such that the inductee is capable of working safely and unaccompanied from that point on. Further training in non-critical issues can be ongoing but further training requirements should be elucidated during induction. Induction/training should provide: i. information regarding hazards and safeguards to prevent exposure or infection; ii. knowledge and understanding of local rules; iii. knowledge and understanding of disinfection policy; iv. knowledge and understanding of waste disposal arrangements; v. knowledge and understanding of emergency spillage procedures; vi. technical competence for all aspects of the work e.g. use, maintenance and testing of microbiological safety cabinets, centrifuges (with sealed buckets) and automatic pipette aids. vii. Awareness and understanding of the CL2 Air Handling Unit alarm for those working in the CL2 area. 5
viii. Confirmation that the member of staff or student has completed all the relevant on-line H&S training. Staff and students working with blood, tissue and samples should be competent to work safely. For a new member of staff competence should not be assumed but must be verified and, if necessary, further training should be provided (this is the responsibility of the nominated person). Training programmes should be tailored for each individual taking into account their level of experience and the type of work undertaken. Written records of training should be kept. A high standard of supervision of the work of undergraduate students should be maintained at all times to ensure control measures to minimise exposure are used. Undergraduates may not work with unscreened samples unless they receive a very high level of training and supervision (e.g. students who have been out on block placement in NHS laboratories) and then only by special arrangements following discussion with lab personnel including the lab manager / safety officer. Children (under 16) or young persons (under 18) may not work with human blood or other potentially infectious materials and may not work within the CL2 area due to presence of such materials and vaccination requirements.. Health surveillance and vaccination Elaborate health surveillance is not required, but all laboratory staff and students working at CL2, Must be vaccinated against Hepatitis B, and have their positive response to the vaccine proven. Occupational Health provision is being provided for staff in this area by Dr. Lubin at Derwent Crescent Medical Practice in Finchley; staff and students may similarly see their own GP for vaccination if that is their preference, but should be screened for antibody levels at the University. For non-lab staff who need to enter CL2 (eg cleaners, maintenance staff etc) Hepatitis B vaccination is not routinely recommended but adequate induction is essential and a Lab-Permit-to-Work must be completed whenever undertaking work during operational hours. 6
Appendix 1 Accident procedure Following an accident that results in: i. superficial contamination of unbroken skin The affected area should be washed immediately with soap and running water ii. contamination of the eyes The eye(s) should be irrigated with eye wash iii. contamination of the nose or mouth The nose or mouth should be washed out with copious amounts of tap water iv. breakage of the skin The wound should be encouraged to bleed, and the area washed with soap and water but without scrubbing. The wound should be covered with a waterproof dressing. Any injury involving exposure to foreign human blood or tissue will require a professional medical opinion. If a significant risk of infection is judged to be present, the injured person is to attend the local Accident and Emergency department (The Royal Free Hospital, Barnet General Hospital and The Whittington Hospital are closest to Hendon Campus) immediately for further advice and any necessary treatment. The hospital may deem it necessary to obtain a baseline blood sample, and start treatment with anti-retroviral drugs. The injured person will be given all reasonably available information about the blood or human tissue they have been exposed to, and will be accompanied by a member of University staff if necessary. Accidents should be reported immediately to the staff supervising a practical class or research project, and to the technician assisting. An accident report must be completed and submitted via the technical manager. Any source of potential contamination (e.g. a blood or tissue source) should be immediately identified and retained for testing if possible. Staff involved in clean-up and disinfection of any spills must be informed of specific risks from any blood or tissue involved, and must not place themselves at risk (particularly if the accident involves glass or other sharp objects). 7
The right to confidentiality of people potentially infected with pathogens should be respected and reasonable steps taken to safeguard this. 8
Appendix 2 - Spillage procedure for human bloods, fluids and tissues i. Spills onto working surfaces Move away from the area for a few minutes to allow aerosols to disperse, and keep other people away until clean-up is complete. If lab coat is contaminated, remove and place into autoclave bag prior to autoclaving. Don new coat and gloves before proceeding. (For small spills <10mls) - Spray spill with 2% Virkon solution, or cover with Presept granules (do not use Presept on metal) - leave 10 mins (For large spills >10mls) Cover spill with Virkon powder, or Presept granules (do not use Presept on metal) - leave 10 mins Mop up spill with disposable paper towels place in clinical waste bin. Place contaminated gloves in clinical waste bin. Spray surface with 2% Virkon, leave for 10 minutes and then dry with paper towels (place these in clinical waste bin) If footwear is contaminated, clean with 2% Virkon ii. Spills inside Safety Cabinets or incubators Treat as i. above (DO NOT use Presept or other chlorine based disinfectant) Remove baseplate / shelves and decontaminate base and sides of cabinet / incubator also. iii. Spills inside centrifuge Stop centrifuge and leave 30 minutes to permit aerosols to settle. Open centrifuge and transfer sealed buckets to safety cabinet for decontamination as per ii. above (DO NOT use Presept or other chlorine based disinfectant) If sealed buckets are compromised, the centrifuge bowl will also require decontamination s per ii. above. 9
Appendix 3 - Responsibilities The Dean of the School of Science and Technology is ultimately responsible for the health and safety of staff and students who are working in the School. However, this responsibility may typically be delegated to various individuals as indicated below. There must be arrangements in place to ensure: Risk assessments are conducted Lab facilities are adequate Local rules are drawn up and implemented Appropriate waste disposal procedures are used Microbiological safety cabinets and autoclaves are tested at least annually by a competent engineer Appropriate training is in place Accidents are recorded, investigated and reported to the Technical Manager for Biosciences and Health in the first instance Accident report recommendations are implemented Competent technicians are appointed Arrangements are reviewed annually Principle investigators/academic staff leading practical classes Are responsible for: Carrying out a risk assessment for each practical class, and completing the LabRAT Risk Assessment form, storing this on the lab wiki and sharing this with technical staff in order that they may complete their own LabRAT Informing staff and students of risks when working with human blood or tissues, and control measures to minimise risks Formulating local rules appropriate for the work being undertaken and facilities available Ensuring staff and students comply with local rules Report any accidents /near misses to the Lab Manager Research staff, supervisors and students Are responsible for: 10
Carrying out a risk assessment for all lab activities undertaken and completing the LabRAT form as above (supervisors must oversee and approve any risk assessments by research students) Following local rules as instructed Using control measures put in place to minimise risk Disposing of waste as instructed Reporting all accidents to supervising academic and the Lab Manager Reporting any potential dangers to supervising (academic and technical) staff Technical staff Are responsible for: Advising on risk assessments Advising on local rules Advising on disinfection and waste disposal Ensuring safety cabinets and autoclaves are tested at least annually Investigating accidents reported, and notifying the Lab Manager of findings and recommendations 11
Appendix 4 - LABORATORY CONTAINMENT LEVEL 2 1. Management Measures 1. Personnel must receive induction, instruction and training in working safely with human blood, tissues and other specimens potentially infected with lethal biological agents. 2. A high standard of supervision of the work should be maintained. 3. Ensure control measures to minimise exposure are used. 4. Accidents and incidents should be reported immediately to, and recorded by, the Principal Investigator and Lab Manager. 2. Physical/Engineering Measures 1. Access to each laboratory is to be restricted to suitably inducted and authorised laboratory personnel and other specified persons. 2. A biohazard sign must be displayed on the laboratory entrance door. 3. There should be adequate space in the laboratory for each worker. 4. The laboratory should be easy to clean. Bench surfaces must be impervious to water, easy to clean and resistant to acids, alkalis, solvents and disinfectants. 5. The laboratory must contain a wash basin located near the laboratory exit. Taps should be of a type that can be operated without being touched by hand. 6. All Hatchcroft laboratories are mechanically ventilated with an inward flow of air from corridor to laboratory There are warning lights showing the operating state of the CL2 Air-Handling Units adjacent to the lift. 7. In Hatchcroft laboratories, al microbiological safety cabinets are of Class-II recirculation type. 8. An autoclave for the sterilisation of waste materials is readily accessible in H223, with a back-up autoclave present in the same laboratory. 1. Operating Procedures 1. The laboratory door must be closed when work is in progress. 12
2. Laboratory coats, which should be side or back fastening, must be worn and removed when leaving the laboratory suite. 3. Laboratory coats must be stored on the dedicated hooks, apart from personnel clothing and be cleaned at suitable intervals. 4. Laboratory coats contaminated by biological agents must be removed immediately and placed inside an autoclave bag for subsequent decontamination. 5. Eating, chewing, drinking, smoking, taking medication, using mobile phones, storing food and application of cosmetics in the laboratory must not take place in the laboratory. 6. Mouth pipetting must not take place. 7. Lesions on exposed skin should be covered with waterproof dressings. 8. A single pair of single use (disposable) nitrile gloves should be worn (latex gloves are prohibited). If during use the glove is punctured or grossly contaminated it should be removed and disposed of. Gloves must be removed before handling items likely to be touched by others (e.g. telephones). On completion of work, gloves should be removed and discarded, and hands should be washed. 8. In general, work can be carried out on the open bench but care must be taken to minimise the production of aerosols. Laboratory procedures likely to create infectious aerosols must be conducted in a microbiological safety cabinet, isolator or be otherwise suitably contained. 9. Bench surfaces should be regularly decontaminated according to the pattern of work. 10. There must be safe storage of biological agents. 11. The prescribed disinfectants must be available for routine disinfection, and for immediate use in event of a spill according to the disinfection policy. 12. There should be a means for the safe collection, secure storage and disposal of contaminated waste prior to collection/autoclaving. 13. Materials for autoclaving should be transported to the autoclave in robust containers without spillage. 14. Used laboratory glassware and other materials awaiting sterilisation before recycling should be stored in a safe manner. Pipettes, if placed in disinfectant, should be totally immersed. 15. Samples should be centrifuged in sealed buckets ideally with transparent lids or sealed rotors. These should be cleaned and disinfected regularly and immediately 13
following leakage. If a sample has been known to leak during centrifugation then the bucket or rotor must be opened in a microbiological safety cabinet. Seals on buckets and rotors should be checked before use for wear and damage and replaced if damaged. 14
Appendix 5 - LOCAL RULES FOR HANDLING HUMAN BLOOD, TISSUES AND OTHER SPECIMENS IN THE LABORATORY 1. Work cannot commence unless you have received induction and training from PI, supervising member of academic staff, or other competent person. 2. The laboratory door should be kept closed. 3. Samples arriving in the laboratory must be stored securely in a designated fridge or freezer. 4. Eating, chewing, drinking, smoking, applying cosmetics, using phones (or anything else involving hand/face contact) is forbidden. 5. Howie style laboratory coats must be worn at all times in the laboratory and removed before leaving, storing them on designated coat hooks. 6. Nitrile gloves must be worn at all times and removed before leaving the laboratory or touching items used by others (e.g. telephone). In the event of gloves becoming damaged or grossly contaminated the gloves must be discarded, hands washed and new gloves put on. 7. Hands should be washed regularly and always before leaving the laboratory. 8. Mouth pipetting is forbidden. 9. All procedures must be performed so as to minimise production of aerosols: rapid pouring of liquids must be avoided; pipettes used slowly; bottles opened carefully. 10. All workers in the laboratory must cover cuts and abrasions to exposed skin with a waterproof dressing. 11. On completion of work, bench tops must be cleaned with 2% Virkon. 12. Waste materials are to be placed in autoclave bags and autoclaved prior to disposal. 13. Following spillages contaminated surfaces must be disinfected immediately following the prescribed procedures 14. Accidents must be reported to PI, supervising member of academic staff and technician, and an accident report form completed and submitted via the Lab Manager. If the accident results in contamination, the accident procedure must be followed (appendix-1). 15