Biosafety Containment Level 2 · 2016-10-20 · Biosafety Containment Level 2 Standard Operating...
Transcript of Biosafety Containment Level 2 · 2016-10-20 · Biosafety Containment Level 2 Standard Operating...
RED DEER COLLEGE, SCIENCE DEPARTMENT
Biosafety Containment Level 2
Standard Operating Procedures
10/7/2011
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Contents
HANDLING OF PATHOGENS IN A CONTAINMENT LEVEL 2 LABORATORY ............................. 3
1. INTENT................................................................................................................................................ 3
2. DEFINITIONS ...................................................................................................................................... 3
3. ROLES AND RESPONSIBILITIES ......................................................................................................... 4
3.1 Faculty members/Laboratory Supervisors ..................................................................... 4
3.2 Waste Generators ............................................................................................................... 4
3.3 Staff/Students .................................................................................................................... 4
4. LABORATORY BIOSAFETY GUIDELINES ........................................................................................... 5
4.1 Working in a Biological Containment Level 2 Laboratory ............................................... 5
4.2 Guidelines of CL2 Laboratories ............................................................................................ 5
5. PROCEDURES....................................................................................................................................... 6
5.1 Personal Protective Equipment (PPE) ............................................................................... 6
5.2 Working in a Biological Safety Cabinet (BSC) .................................................................... 6
5.3 Avoiding the Production of Aerosols ................................................................................... 7
5.4 Decontamination And Disposal Of Biohazardous Waste .................................................. 8
5.5 Spill Procedures ...................................................................................................................... 9
6. EXPOSURE CONTROL PLAN ............................................................................................................ 10
APPENDICES ................................................................................................ 11
Application Form for a Biosafety Operating Permit ....................................................................... 12
Biosafety Resume for Authorized Workers ...................................................................................... 13
Inventory ................................................................................................................................................ 14
Guidelines for Cleaning Equipment or Area Destined for Release .............................................. 15
Equipment / Area Release Form ....................................................................................................... 16
Culture Tracking Form ........................................................................................................................ 17
Autoclave Efficiency Monitoring ........................................................................................................ 18
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HANDLING OF PATHOGENS IN A CONTAINMENT LEVEL 2 LABORATORY
1. INTENT
This Biosafety Standard Operating Procedure (SOP) applies to all faculty, staff, and students
at Red Deer College. The standards and practices listed in this SOP apply to all containment
level 2 biological laboratories. It was developed to ensure that work with biohazardous
materials is conducted in a safe manner reflecting best practices and adheres to the
Laboratory Biosafety Guidelines published by the Public Health Agency of Canada.
2. DEFINITIONS
Containment Level 2 (CL2) Laboratory
A laboratory that handles Risk Group 2 agents. The primary exposure hazards associated with
organisms requiring the CL2 are through the ingestion, inoculation and mucous membrane
route. Level 2 agents are not generally transmitted by airborne routes, but care must be
taken to avoid the production of aerosols or splashes. Primary containment devices such as
Biological Safety Cabinets are to be used, as well as appropriate Person Protective
Equipment. All persons entering the facility must be informed of the hazards present.
Notifiable Biological Substances: Genetically modified micro-organisms or genetic
combinations which are not known to occur naturally
Permit Holder: A Principal Investigator or Faculty Member or Laboratory Supervisor who is authorized to work with Biological Substances and/or Biohazardous Materials by the Biosafety Advisory Committee
Risk Group 1 Organisms
Any biological agent that is unlikely to cause disease in healthy workers or animals. These
organisms are referred to as low individual and community risk as they are unlikely to cause
disease in healthy workers or animals.
Risk Group 2 Organisms
Any pathogen that can cause human 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 preventive measures are available, and the risk of spread is limited. They are referred to
as moderate individual risk, low community risk.
* For a list of organisms and their Risk Group go to http://lois-laws.justice.gc.ca/eng/acts/H-
5.67/page-20.html#h-24
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3. ROLES AND RESPONSIBILITIES
3.1 Faculty members/Laboratory Supervisors
Faculty members and lab supervisors are responsible for ensuring that:
their work areas are compliant at all times with this SOP, RDC Biosafety and Health,
Safety and Wellness policies, and applicable federal and provincial health, safety, and
environmental regulations.
they register and/or obtain the required permits for any activities that use Risk Group
2 substances, biohazardous material, and notifiable substances
staff and students have been given adequate safety orientation, site specific training
for the work assigned, and instruction on the potential hazards associated with
working with biological agents
staff and students are competently supervised and have reviewed the department
policies and procedures for safety
staff and students have access to any hazard information on the substances being used
staff and students are provided with the appropriate safety equipment and personal
protective equipment necessary to protect their health and safety, and that they know
how to use and maintain the equipment
biohazardous agents have been disposed of properly
3.2 Waste Generators
Waste generators are any persons who generate biohazardous waste as a result of work
conducted, including laboratory supervisors, faculty members, technologists, and students.
They are responsible for:
collecting the waste in accordance with RDC’s disposal procedures (see 5.4.3)
ensuring that waste is properly segregated, identified, and labelled for disposal
keeping an inventory of the waste
3.3 Staff/Students
Staff and students working in labs are responsible for ensuring that they:
conduct their work in a safe and responsible manner in order to protect their health
and safety as well as that of others who may be affected by their acts or negligence
are familiar with the potential hazards and this SOP as it relates to working with
biohazardous agents
promptly report any known accidents/incidents, spills, or unsafe conditions to their
supervisor
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4. LABORATORY BIOSAFETY GUIDELINES
4.1 Working in a Biological Containment Level 2 Laboratory
The most important element of containment is strict adherence to standard microbiological
practices and techniques. Persons working with infectious agents or infected materials shall
be aware of potential hazards and shall be trained and proficient in the practices and
techniques required for safely handling such material.
A CL2 laboratory is suitable for work involving agents of moderate potential hazard to
personnel and the environment. Working in a CL2 laboratory involves:
working under the supervision of personnel that have training in handling pathogenic
agents
having controlled and limited access to the laboratory
taking extreme precautions with contaminated sharp items
special procedures when there is a possibility of infectious aerosols or splashes being
created
Persons who are at increased risk of acquiring infection, or for whom infection may have
serious consequences are not allowed in the laboratory. The laboratory instructor/supervisor
has the final responsibility for assessing each circumstance and determining who may enter or
work in the laboratory.
4.2 Guidelines of CL2 Laboratories
all guidelines of general laboratory safety must be followed (see Biology Laboratory
Safety Procedures)
all personnel must be trained and understand the hazards
appropriate personal protective equipment must be worn
personal items (e.g. coats, purses, backpacks) must remain outside the laboratory
doors to the laboratory must be closed at all times, and locked when the lab is not
occupied
hands must be washed after removing gloves and before leaving the lab
work surfaces must be disinfected before work begins and after it is completed
all mobile equipment must be decontaminated before being removed from the area
aerosol production is to be minimized
all contaminated or infectious material must be decontaminated before leaving the
area
use of cell phones is prohibited
access to laboratories is limited to authorized personnel only
hazard warning signs must be posted
efficacy monitoring of autoclaves using biological indicators must be done regularly
and records of those results and cycle logs must be kept on file
all accidents/incidents, spills, or unsafe conditions must be reported in writing
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leak proof containers are to be used for the transport of infectious materials within
the facility
in order to release a laboratory from CL2, complete decontamination of work surfaces,
fridges, incubators, and equipment must be completed
5. PROCEDURES
5.1 Personal Protective Equipment (PPE)
a lab coat, long pants, and shoes that cover the entire foot are to be worn at all times
while working in the laboratory
gloves must be worn at all times while working with biohazardous materials. Under no
circumstance should they be worn outside the lab, and must be disposed of in the
appropriate biohazard waste container
lab coats must remain in the lab. Under no circumstance should they be worn outside
the lab, until they have been properly decontaminated
5.2 Working in a Biological Safety Cabinet (BSC)
Biological Safety Cabinets (BSCs) are among the most effective and the most commonly used
primary containment devices in laboratories working with infectious agents. They provide
protection to the worker as well as to the work being performed.
All procedures must be performed carefully to minimize the creation of aerosols. Procedures
that create aerosols must be conducted in a Biological Safety Cabinet.
Operation of a BSC:
Before using the cabinet:
if the room is occupied, do not turn on the UV light. If the UV light is used, ensure
that it is turned off before continuing.
disinfect work surfaces with Oxivir Tb.
place required items inside the cabinet
turn on the blower and allow to run 5 minutes
use of an open flame in the BSC should be kept to a minimum.
After completion of work:
allow the blower to run for 5 minutes in order to purge the BSC
remove and decontaminate materials and equipment
disinfect work surfaces
turn off the blower and fluorescent light, and turn on the UV light if room is not
occupied
For more detailed instructions on using a BSC, refer to Operation and Maintenance Manual
(located in drawer 1430-31).
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5.3 Avoiding the Production of Aerosols
5.3.1 Centrifuge Operation
If a microorganism is not contained within a centrifuge, aerosols can be produced during the
centrifugation process. This could occur with uncapped samples, or when a leak, spill or
breakage of the tube occurs. Minimize the risks when centrifuging by following the guidelines
below:
use unbreakable tubes
avoid overfilling the tubes
use caps or stoppers on centrifuge tubes
use outer, sealable safety cups that can be loaded and unloaded in a BSC
decontaminate the outside of the cups or buckets before and after use and inspect
seals regularly for deterioration
ensure that the centrifuge is properly balanced
do not open the lid during or immediately after operation
allow the centrifuge to come to a complete stop before opening
5.3.2 Mixing Operations
Sonicators, shakers and homogenizers can generate aerosols during operation. Minimize the
risks when mixing by following the guidelines below:
use sealed vessels during mixing and allow the vessels to settle before opening
open mixing vessels inside a BSC
check the condition of the mixing equipment routinely for deterioration
disinfect all exposed surfaces before and after use
5.3.3. Vacuum and Aspirating Equipment
Minimize the risk of generating aerosols during vacuum and aspiration operations by following
the guidelines below:
use non-breakable equipment (i.e. do not use glass)
ensure that vacuum equipment is fitted with a HEPA filter
place a disinfectant in the overflow flask of the aspirating equipment
5.3.4 Needles and Syringes
Minimize risk while using needles and syringes by following the guidelines below:
perform all operations with needles and syringes in a BSC
fill syringes carefully to avoid frothing or introducing air bubbles
use blunt-end needles for removal or introduction of fluids through small apertures in
equipment
dispose of needles and syringes into appropriate sharps container
5.3.5 Pipettes
Minimize risk while using pipettes by following the guidelines below:
use cotton-plugged pipettes
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keep pipettes upright while in use and between steps to prevent contamination of the
mechanical suction device and work surface
gently expel the contents of the pipette close to the surface of the liquid to allow to
flow down the side of the container
do not mix contents of a container by alternating suction and expulsion with the
pipette
“to deliver” (TD) pipettes are recommended vs. “to contain” (TC) pipettes so the last
drops do not need to be expelled for an accurate measurement
TC pipettes are to be used in the BSC due to the potential for aerosol production
submerge used non-disposable pipettes horizontally in disinfectant solution to avoid
forcing out the any liquid remaining in the pipette
5.3.6 Transfer Loop
Minimize risk while using transfer loops by following the guidelines below:
when disinfecting the loop between inoculations, hold the loop close to, but not in the
flame until the material has charred and then fully insert into the flame
substitute an enclosed micro-incinerator for an open flame burner or disposable loops
where possible
5.4 Decontamination And Disposal Of Biohazardous Waste
5.4.1 Chemical Disinfection
Chemical disinfectants are used for the decontamination of surfaces and equipment that
cannot be autoclaved, any item for which heat treatment is not feasible, and for cleanup of
spills of infectious materials. Oxivir Tb may be used for disinfection.
5.4.2 Autoclave
Infectious laboratory wastes (Petri dishes, pipettes, culture tubes, glassware) can be
effectively decontaminated in an autoclave.
Operation of an Autoclave
turn the autoclave on and allow to warm up for ½ hour
place items in the chamber. Bags must be unsealed and must be placed in leak proof
autoclavable trays
place an indicator strip in appropriate area of the autoclave chamber
close door
choose the appropriate cycle depending on the items and the size of the load
press start
when the cycle is finished, open the door carefully to avoid escaping steam
wearing heat resistant gloves, remove items and place “decontaminated “ labels on
any items to be placed for general garbage pick-up
Efficiency testing must be performed on the autoclave on an on-going basis. See the
Autoclave Efficiency Monitoring form in the appendix.
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For more detailed information on the operation of the autoclave refer to Operator Manual
(located in instructors’ desk, room 1430).
5.4.3 Disposal
All biohazardous wastes must be disposed of in the appropriate labelled containers.
contaminated sharps (needles and syringes, broken glass, microscope slides)
must be placed in rigid, puncture resistant, leak-proof, closable sharps
containers labelled with WHMIS approved biohazard symbol
contaminated disposable non-sharps (Petri plates, culture tubes, gloves, paper
towels) must be placed in bags labelled with WHMIS approved biohazard symbol
contaminated non-disposable items (instruments, glassware) must be placed
into appropriately labelled containers
After proper disposal, contaminated items must be autoclaved or otherwise
decontaminated in a timely manner.
5.5 Spill Procedures
5.5.1 Inside a BSC
remove gloves inside the BSC and leave the area for at least 5 minutes
wear lab coat, safety glasses, and gloves during clean-up
place contaminated reusable items in autoclave bags or trays
cover spill with absorbent paper towels and soak with disinfectant (Oxivir Tb). Allow
at least 10 minutes contact time
place towels and any other disposable items in autoclave bag
wipe down work surfaces, walls, and equipment in the BSC with disinfectant (Oxivir
Tb)
allow the BSC to run 10 minutes before resuming work or turning it off
5.5.2 Outside a BSC
clear area of all personnel, and wait at least 30 minutes for the aerosol to settle
remove contaminated clothing and shoes and place in a biohazard bag
put on a lab coat, safety glasses, and gloves
cover spill with absorbent paper towels and soak with disinfectant (Oxivir Tb). Allow
at least 10 minutes contact time
decontaminate all items within the spill area
place paper towels and any other disposable items in an autoclave bag
5.5.3 Reporting
all spills must be reported on an Incident/Injury Report Form. This form can be found
on the Red Deer College website, www.rdc.ab.ca, Log in to the Loop, click on Quick
Access and then Forms Index.
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6. EXPOSURE CONTROL PLAN
The Permit Holder shall develop a written Exposure Control Plan (ECP) for situations where
any student or worker is required to handle, use, or produce hazardous or infectious
materials. This plan shall:
identify any student or worker at the place of employment who could be exposed to
hazards in the workplace
describe the ways in which material can enter the body and the risks associated with
that entry
describe the signs and symptoms of any illness that may arise from exposure
describe (referencing this SOP) the safety control measures and their limitations,
including:
o administrative safety procedures
o procedural safety controls and training
o engineering safety controls and training
o PPE (include training & maintenance)
o immunization in accordance with the University Immunization Policy and
o the use of Universal Precautions when handling blood and body fluids.
describe (referencing this SOP) emergency response procedures for:
o spills or leaks of hazardous materials
o when a worker has been or believes they have been exposed to a hazardous
material
describe (referencing this SOP) methods of cleaning, disinfecting, or disposing of
clothing, PPE or other equipment if contaminated with hazardous materials, and
indicate who is responsible for carrying out those activities
describe the training that will be provided to students or workers and the means by
which this training will be provided
require the investigation and documentation of any work-related exposure incident,
including the route of exposure and the circumstances under which the exposure
occurred
require the investigation of any occurrence of an occupationally acquired illness or an
occupationally transmitted infectious disease in order to identify the route of
exposure and to implement measures to prevent further illnesses
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APPENDICES
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Application Form for a Biosafety Operating Permit
Name of Applicant:
Position:
Department:
Office Phone #:
E-mail :
Project Description:
Attach a brief summary of the experimental procedures including an inventory of the names of any biohazardous materials or notifiable biological substances used indicating their Risk Group Level.
Identify what species the agent could infect, comment on its virulence, hosts, vectors, routes of infection, etc.
State what potential impact the biohazardous materials or notifiable biological substances may have on the health and safety of personnel, the public and the environment. Develop a written Exposure Control Plan for situations where a student or worker is required to handle, use, or produce biohazardous or infectious materials.
( ) Check this box to confirm that you will be working in an appropriate containment facility and using the appropriate microbiological procedures as set forth in the "Laboratory Biosafety Guidelines" (Health Canada). If NOT applicable, check ( ).
Attach any permit (import/export) restrictions or conditions associated with this work.
Work Location and Containment Level:
Room #s:
Outdoor locations identified if applicable:
Agent Storage Locations (i.e. freezers etc):
Containment Level Assigned to area: Level 1 ( ) Level 2 ( ) Level 3 ( ) Level 4 ( )
Do you have a BSC: Yes ( ) No ( ) Other Containment Required: Yes ( ) No ( )
Cabinet Model Number: Serial Number: Date Last Tested:
Is there controlled access to the work area?: Yes ( ) No ( )
Authorized Workers: Attach a resume form for each worker and permit holder.
I accept responsibility for the accuracy of the information in this application and ensure that
this project will be performed in accordance with the RDC Biosafety Standard Operating
Procedures.
Signature of Applicant: _______________________________ Date: __________________
Approval of the Biosafety Officer: ______________________ Date: __________________
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Biosafety Resume for Authorized Workers
(PLEASE PRINT OR TYPE ALL OF THE FOLLOWING INFORMATION)
Personal Information:
Name: ________________________________ Department: _________________________
E-mail: ______________________________ __ Room: _____________
Phone: ________________________________
Education and Experience:
Degree(s), Diploma(s) & Position: ___________________________________________________
_________________________________________________________________________________
Number of years worked with biohazardous materials or notifiable biological substances:
_____
Training:
List any formal Biosafety courses taken (Date, Length, Location):_________________________
_____________________________________________________________________________________
Please verify the following:
have attended the RDC biosafety course
principles and practices of biological exposure/infection controls are followed
have read the Laboratory Biosafety Guidelines (Health Canada) or watched the Lab Biosafety 101 DVD
know the biological effects of exposure (signs & symptoms) and the ways it can occur
information (or PSDS) is available on the biohazardous materials or notifiable biological substances used understand the function/use and maintenance of biosafety cabinets and personal protective equipment (PPE) understand the emergency procedures that are in place for exposure, accidents, incidents, and spills with a written recording and follow up system
will not remove Risk Group 2 organisms from the Containment Level 2 labs
have read the Red Deer College Biosafety Policy and the SOP on Level 2 Containment
understand the Right to Know the hazards in the workplace under the Health and Safety Legislation
understand the Right to Refuse unsafe acts under the Health and Safety Legislation
I have read the Biosafety Standard Operating Procedures and understand and accept my duties
and responsibilities in accordance with the Biosafety Standard Operating Procedures.
Signature of Authorized Worker: ________________________________________
Date: _______________________________________
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Inventory
Biological Material or Agent Host Ranges Containment/ Risk Group Level
2.
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Guidelines for Cleaning Equipment or Area Destined for Release
Objective
The objective of the Equipment or Area Release guidelines are to protect the health and
safety of all staff, students, and the public at large from being exposed unnecessarily to
equipment or areas that may contain hazardous biological substances. It is hoped that the
person requesting service in an area or on a piece of equipment will take the time to evaluate
the associated risks from the point of view of the service technician who will be completing
the work.
Biological Substances
The minimum for cleaning any area or equipment contaminated with biological agents is for
the technical staff in the laboratory to wipe down the area or equipment with a disinfectant
that is effective on that biological substance (Oxivir TB). Equipment shall be autoclaved if
this is a feasible option.
Personal Protective Equipment and Precautions
Personal protective equipment and precautions shall be taken in handling equipment or upon
entering a certain area. Ask technical staff what you should wear when handling or entering
the designated area to work. Always protect your eyes and hands. Wash your hands and tools
upon completion of the work.
Consultation
The Office of Health, Safety and Wellness will provide consultation if there is any unresolved
safety concerns.
Examples
Equipment that may require decontamination and the use of personal protective equipment
are:
biosafety cabinets
fume hoods
autoclaves
incubators
refrigerators
water baths
spectrophotometers
vortex mixers
sonicators
shaker units
centrifuges
pipette pumps
lab coats
Areas that may require decontamination and the use of personal protective equipment are:
laboratories
prep rooms
fume hood /BSC discharge areas
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Equipment / Area Release Form
Supervisors, Technologists, and Faculty members releasing equipment or areas for service
work, relocation, disposal, or resale which may contain biohazardous residue within or on the
surface are required to complete an Equipment /Area Release Form. This form may be
attached to the equipment or given to the service employee.
Room #: __________________________
Description of Area /Equipment: ___________________________________________________
Model #: _________________________
Serial #: (attach list if necessary) __________________________________________________
Destination:
( ) Service ( ) Relocation ( ) Disposal ( ) Area turnover
Comments: ______________________________________________________________________
I declare that the equipment /area specified above has been cleaned and decontaminated so
that it does not present any hazard associated with biohazardous substances.
Signature: __________________________________________
Date: ______________________________________________
Phone #: ___________________________________________
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Culture Tracking Form
Culture:
Date Acquired:
Subculture Date Batch # Purpose Initials Disposal Date Initials
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Autoclave Efficiency Monitoring
Daily: Clean sediment screens; blow down boiler; Bowie-Dick Test
If Bowie Dick Test fails, perform Vacuum Leak Test
Weekly: Biological Control testing
Bowie-Dick Test (SMART
Pack)
Biological (Biosign
Biological Indicators)
Bowie-Dick Test (SMART
Pack)
Biological (Biosign
Biological Indicators)
Date Date