Biosafety Protocol Written by: Diane Hagner 11-4-15 Updated: Sarah Arrowsmith 2-28-17 1 P a g e Purpose The Biodesign Institute Center for Environmental Biotechnology Biosafety Protocol is intended to serve as a resource and guide for information, guidelines, University and Institute policies and procedures that will enable our Center personnel to work safely and reduce or eliminate the potential for exposure to biological hazards. The policy reflects the requirements and guidelines established in federal, state and university regulations. This policy is applicable to all laboratory activities that may involve exposure to biohazardous agents or materials including: o Bacterial, viral, fungal and parasitic agents o Recombinant DNA o Human blood, body fluids, feces, tissues and cell cultures o Listed select agents o Exposure to research animals o Infectious waste and sludge Responsibilities ASU has instituted and maintains a Biosafety Program for employees who may be exposed to biological hazards (biohazards) during the performance of their duties and research. This Biosafety Program is designed to achieve regulatory compliance and a means to inform and protect employees from these biohazards. The Institutional Biosafety Committee (IBC) has been set up to facilitate the registration of biological research by providing materials and information to the Principal Investigators (PI). The IBC provides reviews of research involving recombinant DNA and other potentially biohazardous agents and approves those that comply with NIH and CDC guidelines and university policies. The IBC also reviews and approves all work involving select agents and toxins. The IBC adopts policies supporting the safe use of biological materials and the elimination or reduction of exposure to potentially biohazardous materials and agents. The Office of Research Integrity and Assurance (ORIA) accepts all IBC forms from the PI for any research involving recombinant DNA, biohazardous agents or select agents and toxins; the Office of Research Integrity and Assurance coordinates the review of these forms with the IBC and EH&S. The ORIA reviews biological Material Transfer Agreements (MTA) and coordinates approval with EH&S. They also accept research protocols involving the use of human subjects and coordinates their review by the Institutional Review Board (IRB). The Department of Environmental Health and Safety (EH&S) develops, implements and maintains the university s Biosafety program, the select agents and toxins program, works with the IBC and ORIA to review all registration forms for research proposals by PIs. EH&S consults
with researchers on issues of Biosafety and the safe use of biological materials in the laboratory. They assist in the development of protocols and procedures to address Biosafety and provides training in the safe use and practices for those researchers working with potentially biohazardous materials and activities. EH&S will conduct annual laboratory Biosafety audits to determine compliance status in an effort to promote regulatory compliance and a safe laboratory environment. Additionally EH&S advises researchers on proper waste disposal methods based on state and federal regulations. The Principle Investigator (PI) is defined as a scientist, trained and knowledgeable in appropriate laboratory techniques, safety procedures and hazards associated with handling infectious agents and is responsible for the work performed using any infectious agents. The PI will consult with Biosafety and EH&S with regard to any risk assessment. The PI has the direct responsibility for the health and safety of the center staff working with biological materials in the laboratory. The Center Research Laboratory Manager/Coordinator will complete required registration forms for all research projects in the center involving the use of recombinant DNA, biological materials or select agents and toxins. The Lab Manager will also work with the PI to develop specific Biosafety standard operating procedures for each biohazardous material used in the laboratory. The lab manager will monitor the training status of all center employees and ensure that this training remains current for the annual refresher trainings: Laboratory Safety, Fire Safety, Biosafety, Hazardous Waste management and Radiation Safety. The Lab manager will ensure that all individuals working with potentially infectious material receive the needed medical surveillance, are offered the opportunity to receive vaccinations or declines in writing. Additionally, the lab manager will ensure that Biosafety cabinets are maintained, PPE is provided and used by all staff and that all lab personnel complies with all relevant regulations, guidelines and policies. All Laboratory Employees will participate in the mandatory annual refresher trainings: Laboratory Safety, Fire Safety, Biosafety, Hazardous Waste management and Radiation Safety. All researchers are responsible to follow all laboratory policies, practices and procedures, comply will all associated guidelines and policies, fully comprehend the potential risks associated with exposure as well as to understand the associated emergency response procedures. The employee must elect to receive the offered vaccinations or decline in writing. All spills, contaminations, accidents, injuries or incidents must be reported by the employee to the lab manager immediately for proper steps to be taken. Biohazardous Research Project Registration and Approval The PI is ultimately responsible for the preparation of the registration documents for all research involving potentially biohazardous materials, including assignment of the required Biosafety level for the proposed research. This research includes work involving: o potentially infectious agents (bacterial, viral, fungal, or parasitic agents) o recombinant DNA including work that may be exempt under NIH Guidelines 2 P a g e
o human blood, body fluid and tissue, including human cell lines These registration documents will be prepared by the Center Laboratory Manager who will work with the PI and the researchers involved in the project to prepare the documents and submit them for the center to the IBC. Registration and approval process If any project involves recombinant DNA, infectious agents, human blood, tissue or cell cultures the center must submit a Form 112AB to the Office of Research Integrity and Assurance (ORIA) in advance of beginning work with these materials. The PI will indicate what Biosafety Level this work requires. This document must include a complete description of the project goals, detailed description of the methods being used, the organism or tissue involved, and the genes being used with the recombinant DNA. The Form 112AB will identify any potential hazards in this research project and also must include information as to how the safety of the lab will be maintained: how spills and waste is handled, what PPE will be used, if the work must be done in a Biosafety cabinet. The document will provide the location in which the work in the project will be performed, where the biohazardous material will be stored. The personnel actively working on this project will be listed with their Biosafety training records. The ORIA will submit the Form 112AB to the IBC for review. The IBC will review the document at their regularly scheduled meeting and if necessary request corrections or additional information as needed in order for the protocol to be approved. The center is required to have a representative attend the IBC meeting when a protocol is submitted for approval in order to answer any questions the IBC may pose. The ORIA will notify the center of the status of any application under review, stipulations, corrections required. When protocols are due for renewal a Continuing Review to Original 112AB disclosure Form 112CR will be sent to the center to be processed. In any research involving the use and/or exposure to human blood, body fluids or unfixed human tissue including human cell cultures there is the danger of exposure to bloodborne pathogens that may be found in this material. Research working with any of these materials must follow all ASU EH&S procedures for Biosafety. Additionally, when human blood or tissue donors are involved, the PI must contact the ORIA to determine whether a human subject Institutional Review Board (IRB) application is required in addition to the Form 112AB documentation. Training for Working Safely with Biohazardous Agents The Center Director, the Principle Investigator and the Center Laboratory Manager/Coordinator are jointly responsible for maintaining a safe working environment for the researchers in the center. They will provide or arrange for site-specific training for all personnel. The researchers are required to attend the annual Biosafety Training and Laboratory Chemical Safety Training provided by ASU EH&S. This annual training must be documented by the Center Laboratory Manager/Coordinator. 3 P a g e
Measures to reduce exposure to Biohazardous Materials Exposure Control Measures or Containment are used to describe using safe methods for handling, maintaining or managing biohazardous agents in the laboratory environment. The intention is to reduce or eliminate exposure risks for laboratory workers, other people in the lab and the outside environment to potentially hazardous materials. There are three elements to containment including proper laboratory practices, use of safety equipment and facilities design. Risk assessment of the work being done will determine the appropriate combination of these three elements. 1. Laboratory Practices or Technique: The most important element of containment is strict adherence to standard microbiological practices and techniques. Individuals working with potentially infectious agents or materials must be aware of the potential hazards associated with this work. All individuals working with potentially infectious agents or materials must be trained and proficient in the practices and techniques required for handling such material safely. Specific hazards for the research must be identified and procedures developed to minimize potential risk. Individuals working adjacent to areas where work using potentially infectious material must be made aware of this and provided with proper protection. 2. Safety Equipment (Primary Barriers): Primary Barrier Safety Equipment includes biological safety cabinets (BSC), enclosed biohazardous containers and other engineering controls designed to minimize or eliminate exposures to biohazardous materials. They are used to provide containment of infectious splashes and aerosols unavoidably generated by many microbiological procedures. Primary Barriers may also include personal protective equipment (PPE) which includes gloves, lab coats, safety glasses or goggles and face shields. PPE is frequently used in combination with use of the BSC and other containment devices. 3. Facilities Design (Secondary Barriers): Engineering or Facility Design Barriers include physically separating the work with biohazardous materials for the rest of the laboratory, restricting public access to the laboratory, nearby hand washing facilities and available decontamination facilities such as an autoclave. Biosafety Levels The CDC and NIH have established four Levels of Biosafety, each is based on the degree of hazard associate with the material used, to describe the combination of laboratory techniques and practices, safety equipment and facilities design modifications required to safely do the research intended. Each of the four Biosafety Levels is successively more restrictive than the preceding Level. o BSL1 Biosafety Level 1: Agents used not associated with disease in healthy adult humans. o BSL2 Biosafety Level 2: Agents used associated with human disease, which is rarely serious, and for which vaccines or treatment are often available. 4 P a g e
5 P a g e o BSL3 Biosafety Level 3: Agents associated with serious or lethal human diseases for which vaccines or treatment may be available- (high individual risk/low community risk) o BSL4 Biosafety Level 4: NOT PERMITTED AT ASU Agents associated with serious or lethal human disease for which there is no vaccine or treatment available (high individual risk/ high community risk) Laboratory Guidelines for Procedures and Equipment BSL1 Labs 1. Access to the laboratory is restricted to authorized personnel at all times. 2. Eating, drinking, smoking, gum chewing, handling of contact lenses or the application of cosmetics including lip balm is prohibited in the laboratory. Areas outside the lab will be provided for these purposes. 3. It is not permitted to bring food, food containers, beverages, medications, and cosmetics into the laboratory for storage or for use at any time. Areas outside the lab will be provided for these purposes. 4. Frequent hand washing is strongly recommended especially after handling viable material, removing gloves and before leaving the laboratory bench. At least one sink will be available in each laboratory with an adequate supply of disposable paper towels. An eyewash station and a Lab Safety shower are located in each lab. 5. Pipetting by mouth is forbidden mechanical pipetting devices will be provided. 6. Perform all procedures carefully and in a manner such that the creation of splashes and aerosols is kept to a minimum. 7. Sharps are to be disposed of properly after use needles are to be placed in the hard sided sharps containers, pipette tips are to be placed into the small biohazard buckets lined with a red biohazard bag or into sharps containers and serological pipettes are to be placed in the tall broken glass boxes located on the floors in the lab. No containers are to be over filled. Do not attempt to retrieve any items once placed into these containers. 8. Microscope slides should not be placed in broken glass boxes. Slides should be placed in hard-sided sharps containers. 9. Lab coats must be worn at all times when in the laboratory. The soiled lab coats are placed in the dirty laundry hamper and sent to the cleaners weekly. Fresh lab coats are obtained as needed from the cabinets located in each laboratory. 10. Protective eyewear is required when the researcher has a reasonable expectation of the existence of a splash risk this risk may be due to his or her own work or from the individual working at an adjacent bench. This includes working with chemicals and biological materials. 11. Gloves are required when working with biological agents or chemicals. 12. Lab benches, equipment and other work surfaces must be decontaminated at the completion of work, the end of the day and following any spills of biohazardous materials. The process for cleaning up spills is to soak up any spilled material and discard these towels in the biohazardous waste containers available in the lab. Follow this by
6 P a g e washing the contaminated area with a solution of 10% Chlorine Bleach in water allowing this solution to stand for at least 10 minute and the wipe up the solution with paper towels and discard in the biohazardous waste containers available in the lab. 13. Notify the Center Laboratory Manager/Coordinator in the event of a spill involving biohazardous materials. 14. Use of a BSC is not generally required work on the open laboratory bench is permitted. 15. All containers of cultures, tissues and specimens of body fluids and other potentially infectious waste must be contained to prevent leakage during collection, handling, storage, transport or shipping. All such materials must be autoclaved prior to disposal. BSL2 Labs In addition to the guidelines listed for BSL1 1. Prior approval from the Institutional Biosafety Committee is required for all BSL2 work 2. Personnel working in the lab must be informed of the special hazards involved in work requiring a BSL2 rating. All doors must be lockable and security measures in place to maintain a controlled access to the biohazardous materials. 3. Signage must be posted at the lab access doors to identify the agents in use, the Biosafety level, required immunizations, the PI s name and contact information and list the PPE required to be worn in the laboratory. 4. The Center Director, PI and Center Laboratory manager must ensure that all personnel working in the BSL2 lab have had appropriate training on the hazards associated with the materials being used and that all personnel can demonstrate proficiency in the techniques required for this work. BSL3 Labs In addition to the guidelines listed for BSL1 and for BSL2 1. Access is restricted to those individuals with need to actually work with the materials in the BSL3 lab will be permitted. No visitors or guests are allowed. 2. Nothing will be allowed out of the BSL 3 lab until it is decontaminated. 3. A Biosafety manual, specific to the exact laboratory procedures used, is to be prepared and adopted by the center after review by the IBC and EH&S. Emergency Response Procedures: Biodesign EH&S is responsible for preparing and posting at the entrance for each lab the Responsible Party Information Sheets which includes the emergency contact information for that lab, the list of potential hazards in the lab and the health and safety rating of the contents of the lab. Decontamination is a process or treatment that renders an instrument or environmental surface safe to handle. It can be as simple as clean up with detergent and water or as thorough as sterilization, the manner of decontamination needed is determined by the degree of contamination. Decontamination is required whenever a surface or equipment has been contaminated with potentially hazardous agents and should be daily upon completion of
7 P a g e procedures using biohazardous materials. This should happen immediately following any spills of such materials. It is recommended to use a solution of 10% Bleach in water for this purpose. Autoclave use: the autoclave is used to rapidly destroy all forms of microbial life and involves exposure of contaminated materials to steam under pressure of approximately 15 PSI at a temperature of 250F for typically 30 min minimum. Bags and containers should be left open during the autoclave process. Biodesign Institute has biohazard trash gravity cycles preprogrammed for this purpose. Chemical Disinfectant Use: Prepare a solution of commercial quality Liquid Chlorine Bleach to provide a 1:10 dilution with tap water. Spray or pour over the surface to be decontaminated and allow to stand approximately 10-20 min and then wipe up, discarding the paper towels in the regular trash container. Exposure to a Biohazardous Agent: In the event of an exposure to a biohazardous agent or material: To intact skin: 1. Remove any contaminated clothing do no pull clothing over the face to prevent contact with the face, nose or eyes cut the shirt off. 2. Vigorously wash contaminated skin for at least one minute using soap and water. 3. Report the incident at once to the Center Lab Manager/Coordinator. 4. Contact the Biodesign Institute EH&S who will arrange for medical treatment as needed, and file required incident reports. To broken, cut, damaged skin or a puncture wound: 1. Remove any contaminated clothing do no pull clothing over the face to prevent contact with the face, nose or eyes cut the shirt off. 2. Vigorously wash contaminated skin for at least five minutes using soap and water 3. Report the incident at once to the Center Lab Manager/Coordinator. 4. Contact the Biodesign Institute EH&S who will arrange for medical treatment as needed, and file required incident reports. To the Eye: 1. Immediately flush the eyes, using the nearest eye wash station, for a minimum of 15 minutes, holding the eye lids open and away from the eyeballs so that all eye surfaces are flushed completely. 2. Remove any contaminated clothing do no pull clothing over the face to prevent contact with the face, nose or eyes cut the shirt off. 3. Report the incident at once to the Center Lab Manager/Coordinator. 4. Contact the Biodesign Institute EH&S who will arrange for medical treatment as needed, and file required incident reports. By ingestion or inhalation:
8 P a g e 1. Move to an area of fresh air immediately. 2. Report the incident at once to the Center Lab Manager/Coordinator. 3. Contact the Biodesign Institute EH&S who will arrange for medical treatment as needed, and file required incident reports. 4. Do not induce vomiting unless directed by a health care provider. Biological Material Spills Incidents Neither ASU nor the Biodesign Institute has a centralized Biological Spill Response Team. Therefore, it is the responsibility of each laboratory working with potentially hazardous biological materials to be prepared for and handle any biological spills in the lab. EH&S will be available for assistance if necessary. Absorbent spill kits are available in each of the Center s labs to assist in soaking up any spills, commercial chlorine bleach is available in all the labs (stored underneath one of the sinks in each lab). Paper towels, disposable gloves and appropriate biohazard trash bags are available in each lab to assist in cleanup of any spill. Should a spill occur inside a Biosafety cabinet alert the other people working in the area. Leave the cabinet turned on and spray the walls, work surfaces and any equipment contaminated with the disinfectant (1:10 commercial bleach in water). Make sure a sufficient amount of disinfectant has been used to flood the surface as well as the drain pans and catch basins below the work surface allow this to stand for 10-20 min. Soak up the disinfectant with paper towels, drain the catch basin, and wipe all surfaces dry. Autoclave the towels and other waste before disposal in the regular trash. Wash your hands thoroughly with soap and water for at least 1 minute. Notify the Center Lab Manager/Coordinator about the incident and the cleanup. Handling of spills outside of a Biosafety cabinet is the same regardless of the size of the spill. Alert the other people working in the area of the spill and have them vacate the area. Cover the spill with paper towels soak the area with disinfectant and allow to stand for 10-20 min. Pushing the towels towards the center of the spill remove the soaked material and autoclave this before disposal. Wipe the entire area down a second time with disinfectant. Report the spill to the Center Lab Manager/Coordinator. If the area of the spill is larger than which can be covered by a few paper towels or is on the floor Biodesign Institute Housekeeping staff will come to clean the floor following disinfection by laboratory staff. Audits and Compliance ASU EH&S and the Biodesign Institute EH&S will conduct regular inspections of the laboratory areas used in research involving biohazardous materials to ensure compliance with procedures and protocols. Inspection reports will document any violations noted and will be directed to the PI for correction. The results of these inspections will be documented and kept on file by ASU EH&S. Recordkeeping: the Center Lab Manager will maintain records for the laboratory and be able to present these at laboratory inspections. These records will include: 1. An accurate and current list of each biological agent or toxin stored in the lab.
2. A Health Hazard Assessment for each biological agent or toxin stored in the lab. 3. The current Responsible Party Information Sheet (prepared by Biodesign EH&S). 4. All Safety and Training documentation. 5. Safety, security and emergency response plans. 6. Copies of all safety and incident report forms. 9 P a g e