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3.01 BIOSAFETY PROGRAM

The purpose of this program is to protect laboratory employees from the health hazards associated with biohazardous agents and ensure that all biohazardous activities are conducted in accordance with the standards established by the CDC, NIH and other regulatory requirements. The requirements of this program are based on the CDC/NIH Guidelines Biosafety in Microbiological and Biomedical Laboratories (http://www.cdc.gov/od/ohs/biosfty/bmbl/bmbl-1.htm).

A. CONTENTS

B. SCOPE

This program applies to all laboratories at the University that are involved in research with biohazardous agents or recombinant DNA.

C. DEFINITIONS

Aerosols - colloids of liquid or solid particles suspended in air.

Biohazardous Agents - Infectious/pathogenic agents classified in the following categories: Class 2, 3, 4 and 5 bacterial, fungal, parasitic, viral, rickettsial or chlamydial agents and other agents that have the potential for causing disease in healthy individuals, animals, or plants. A list of infectious agents and their assigned biosafety level can be found in Attachment A.

Biosafety Level 1 (BL1) - work involving minimal or no known hazard to laboratory personnel and the environment.

Biosafety Level 2 (BL2) - work involving agents of moderate potential hazard to personnel and the environment. The recommendations for handling human blood or body fluid specimens is covered in the UNM Bloodborne Pathogen Program (SHEA Manual Section 3.02).

Biosafety Level 3 (BL3) - applicable to clinical, diagnostic, teaching, research, or production facilities in which work is done with indigenous or exotic agents which may cause serious or potentially lethal disease as a result of exposure by the inhalation route. Analytical procedures with open vessels involving Class 3 agents or Class 2 agents which must be handled at a BL3 facility (concentrated or high volumes of Class 2 agents such as an HBV/HIV Research and Production Facility as defined by OSHA) MUST NOT BE PERFORMED ON THE OPEN BENCH.

Biosafety Level 4 (BL4) - work involving agents that require the most stringent conditions for their containment because they are extremely hazardous to laboratory personnel or may cause serious epidemic disease.

Biosafety Level 5 (BL5) - work with foreign animal pathogens that are excluded from the United States by law or whose entry is restricted by USDA administrative policy.

Bloodborne Pathogens - pathogenic microorganisms that are present in human or animal blood and can cause disease in humans. This includes, but is not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).

CDC - Centers for Disease Control and Prevention.

Committee - UNM’s Biosafety Committee.

Decontamination - the removal or neutralization of toxic agents or the use of physical or chemical means to remove, inactivate, or destroy living organisms on a surface so that the organisms are no longer capable of transmitting infectious particles.

Disinfection - a process by which viable biohazardous agents are reduced to a level unlikely to produce disease in healthy people, plants or animals.

NIH - National Institutes of Health.

ORDA – Office of Recombinant DNA Activities. The office within the NIH that is responsible for reviewing and coordinating all activities relating to the NIH Guidelines and other duties as outlined in the Guidelines.

RAC - Recombinant DNA Advisory Committee. The committee that advises the Director of the NIH on recombinant DNA matters.

Recombinant DNA Molecules - Molecules which are constructed outside living cells by joining natural or synthetic DNA segments to DNA molecules that can replicate in a living cell or DNA molecules that result from the replication of those described above.

Responsible Facility Official – Person authorized to transfer and receive select agents on behalf of the transferor’s and/or requestor’s facility. This person cannot be an individual who actually transfers or receives select agents at a facility. The Responsible Facility Official for UNM is Marc Gomez, Director of Safety, Health and Environmental Affairs.

Select Agents – The agents listed in Attachment C.

Sharps - any object or device having rigid corners, edges or protuberances capable of cutting or piercing including, but not limited to: needles/syringes, blades, broken glass and plastic items.

Sterilize - the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

D. RESPONSIBILITIES

1. The UNM Biosafety Committee is responsible for:

• reviewing new and existing protocols involving recombinant DNA research
• reviewing the biosafety aspects of research involving select agents and Level 3 biohazardous agents
• developing and implementing policies for this type of research and ensuring that it is conducted safely here at UNM
• assessing suspected or alleged violations of protocols, external regulations or University Policies which involve biosafety activities.
• recommending, in consultation with a physician, a program of medical surveillance, including the collection of specimens from laboratory personnel engaged in a project when applicable.

2. Safety, Health and Environmental Affairs (SHEA) is responsible for:

• developing and implementing a University-wide program;
• monitoring compliance with this program;
• providing general biosafety training;
• coordinating Biosafety Committee meetings;
• evaluating control measures as necessary;
• coordinating emergency response for biohazard spills;
• investigating laboratory accidents;
• developing a laboratory self-audit form;
• conducting periodic audits of laboratories;
• maintaining inventory of select biohazardous agents;
• maintaining database of laboratories using select agents;
• maintaining copies of EA-101 (select agent transfer) forms.

3. Deans, Directors and Department Heads responsibilities include:

• ensuring departmental compliance with all the procedures outlined in this program.

4. The Principal Investigator/Director/Supervisor of the laboratory is responsible for:

• ensuring compliance with this program in the laboratories;
• developing and implementing a specific biosafety procedures in their laboratory;
• developing Standard Operating Procedures that address the specific safety procedures used in the laboratory to protect employees;
• arranging for immediate emergency response, if necessary, for biohazard spills, injuries and overexposures;
• Instructing and training staff in the practices and techniques required to ensure safety and in the procedures for dealing with accidents and maintaining written documentation for all training activities, which includes the review of protocols by all laboratory personnel;
• Supervising the safety performance of the staff to ensure that the required safety practices and techniques are employed;
• Informing the staff of the reasons and provisions for any precautionary medical practices advised or requested, such as vaccination or serum collection and coordinating the provision of medical examinations, as required;
• Investigating and reporting in writing (when applicable) to the Office of Recombinant DNA Activities (ORDA), the Biosafety Officer, and the UNM Biosafety Committee any significant problems or incidents pertaining to the operation and implementation of containment practices and procedures;
• Correcting conditions that may result in the release of biohazardous agents;
• Ensuring the integrity of the physical containment (e.g., biological safety cabinets) and the biological containment (e.g., purity and genotypic and phenotypic characteristics);
• Sending SHEA copies of the EA-101 form upon transfer of select agents;
• Notifying SHEA of select agent transfers between UNM locations.

5. Laboratory personnel are required to:

• know the provisions of this program and of the laboratory specific Standard Operating Procedures;
• report accidents, possible overexposures or unsafe conditions to their supervisor; and
• use personal protective equipment and engineering controls when recommended and provided.

E. BIOSAFETY COMMITTEE APPROVAL

The Biosafety Committee at UNM will be responsible for reviewing and approving protocols involving the use of :

1. Biohazardous Agents

Information involving Class 2 and Class 3 biohazardous agents is catalogued and maintained by the Committee. The use of Class 3 biohazardous agents is reviewed by the Biosafety Committee.

Protocols involving Class 1 agents that do not involve recombinant DNA, are not reviewed by the Committee.

Research using Class 4 and Class 5 agents is not allowed at UNM.

2. Recombinant DNA

The National Institutes of Health (NIH) establishes guidelines for recombinant DNA research. These Guidelines are applicable to all recombinant DNA research in the US that is conducted at or sponsored by an institution that receives any support for recombinant DNA research from NIH. We feel that it is our responsibility to ensure that research conducted at or sponsored by UNM, irrespective of the source of funding, complies with NIH Guidelines. Non-compliance with NIH Guidelines may result in suspension, limitation or termination of NIH funds for recombinant DNA research at UNM.

Recombinant DNA experiments involving certain Class 1 and Class 2 agents and all Class 3 agents require Committee approval before initiation. In addition, Committee approval is required prior to the commencement of any proposed recombinant DNA project which involves pathogenic agents, human subjects, live animals, plants, and/or planned release of recombinant DNA organisms into the environment.

Experiments classified as "Exempt" in the NIH Guidelines do not require Committee review. A list of all exempt and non-exempt experiments are listed in Attachment B.

3. Select Agents

The new CDC standard, Additional Requirements for Facilities Transferring or Receiving Select Agents is designed to minimize the potential illegitimate use of certain biological agents/toxins whose inadvertent or deliberate release may have severe and adverse public health consequences. The purpose of this standard is to collect and provide information concerning the usage of potentially hazardous agents/toxins on campus, track the acquisition and transfer of these specific agents/toxins, and establish a process for alerting appropriate authorities if an unauthorized attempt is made to acquire these agents/toxins.

The University of New Mexico is required to register and track the use of these agents in order to meet the CDC Standard. The UNM Biosafety Committee will review the proposed use, storage disposal and transfer of any of the agents/toxins PRIOR to possession and use at UNM. It is essential that you inform the Committee of your agent/toxin work so that our registration form to the CDC covers the intended uses on campus. Failure to account for agent and toxin usage will jeopardize our research privileges to use these materials.

Prior to transferring select agents to and/or from a location outside of UNM, a CDC EA-101 form must be completed. These forms can be obtained through SHEA. This form must be signed by both the transferror and requestor. Principal Investigators must also list the Responsible Facility Official on this form. The Responsible Facility Official for UNM is Marc Gomez, Director of Safety, Health and Environmental Affairs. As required by the CDC, a copy of the completed form must be sent to SHEA immediately for record keeping purposes. In addition, transfers between facilities/labs at UNM must be reported to SHEA.

The use and transfer of select agents will be tracked in a database maintained by SHEA.

A list of select agents covered in this program and the CDC requirements for transferring these agents can be found in Attachment C.

F. APPLICATION PROCESS

For all contract and grant applications involving the use of biohazardous agents or recombinant DNA, the principal investigator will check the appropriate box on the UNM internal cover sheets. A Biosafety Committee Request for Information form (Attachment D) will also be completed and submitted to the Biosafety Committee unless the research is exempt from the NIH Guidelines.

If approval is required (See section D), the committee will request further information from the principal investigator and review the protocol. In addition, the Biosafety Officer may conduct a detailed review of the proposed project, which may include a personal interview with the applicant and an inspection of the proposed laboratory facilities. The Biosafety Officer will present any findings to the Committee for review and approval.

If the protocol is approved, an approval letter will be sent to the principal investigator.

G. BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN

Employees that handle or may come into contact with human blood and blood products must follow the requirements of UNM’s Bloodborne Pathogen Program (SHEA Manual Section 3.02).

H. ROUTES OF EXPOSURE IN OCCUPATIONAL INFECTIONS

1. Ingestion. To avoid an occupational exposure through ingestion:

1. Use mechanical pipettes. Mouth pipetting is not permitted.
2. Wash your hands with a disinfectant hand soap after removing your gloves at the conclusion of work.
3. Do not eat, drink, smoke or apply cosmetics in the lab. Food and beverages must not be stored in freezers, refrigerators, or cold rooms that are used to store laboratory specimens. Never heat food in a microwave oven that is used for laboratory specimens.
4. Always use a biosafety cabinet when conducting procedures which have a potential for creating aerosols or splash hazards.

2. Injection. Injection is the penetration of a sharp object through the skin and tissue. To minimize the potential of an occupational exposure through injection:

DO NOT RECAP, SHEAR, OR BEND USED NEEDLES.

1. Have overfilled sharps containers removed immediately. Never fill a sharps container over 2/3 full.
2. Dispose of sharps immediately after use. Razors, scalpels, and needles left unattended may cause injury.
3. Avoid using sharps or glass whenever possible. Some procedures can be modified to minimize the handling of sharp objects. Needles and syringes should be used only where there is no feasible alternative. Substitute plasticware for glassware in the laboratory whenever possible.
4. Never clean up broken glass with bare or gloved hands. Use mechanical means such as tong, forceps or dust pan and broom. Put the broken glass into a hard sided container such as a cardboard box lined with a plastic bag. If the broken glass is contaminated with biohazardous materials, follow the spill clean-up procedures outlined in Section O.
5. Check animal cages carefully before handling. Cuts or scratches from contaminated animal cages may result in the acquisition of zoonotic disease or tetanus.

3. Skin and Mucous Membrane Contact. To reduce the hazards of exposure through the contact route:

1. Vortex, blend, mix, sonicate or grind within a biosafety cabinet. This will confine the aerosol droplets to a device which will be easier to clean. If a centrifuge must be used, limit the spread of contamination by using a sealed centrifuge cone or vial. Do not centrifuge with an open vial.
2. Wear personal protective equipment when handling specimens or cleaning contaminated surfaces. If your reusable personal protective equipment becomes contaminated remove the contaminated clothing into an unused red bag and remove your gloves into a red bag used for biohazardous waste, wash the contaminated area with a suitable disinfectant and your hands with a disinfectant hand soap.
3. Work surfaces should be cleaned with an appropriate disinfectant at the end of the experiment or after a spill of biohazardous material Be sure to wash your hands with a disinfectant hand soap prior to leaving the lab.
4. Biohazardous waste should be promptly disposed of in a red bag. Do not clutter your work area with biohazardous waste which can be readily removed into designated containers in the lab. To avoid contamination resulting from leaking red bags, promptly double bag a leaking red bag and apply disinfectant to the spill area. Clean the spilled material and dispose of it in a red bag.

4. Eye Contact. The main causes of exposure through the eyes are the aerosol and splash generating procedures caused by blending, sonicating, and centrifugation. To prevent eye exposure:

1. always use a biosafety cabinet for any of these procedures
2. use sealed vials or cones when centrifuging and then opening these vials in a biosafety cabinet
3. wear safety glasses with side shields or a face shield when working with biohazardous agents

5. Inhalation. To minimize the potential of exposure through the airborne route:

1. Use a biosafety cabinet whenever using a Class 3 agent. If you must perform an aerosol generating procedure outside of the cabinet, use a sealed vial or covered container or use respiratory protection when performing the procedure.
2. When cleaning animal cages and areas, animal handlers must wear respiratory personal protective equipment. Potentially infectious animal bedding should be carefully handled to avoid the generation of dusts and aerosols. Sweeping space of infected animals is strongly discouraged unless the animal handler is wearing respiratory personal protective equipment and has applied a disinfectant prior to cleaning.

I. MEDICAL SURVEILLANCE

All employees that work with biohazardous agents will have an initial medical history and/or physical through Employee Occupational Health Services (EOHS).

Employees must receive medical attention under the following circumstances:

• whenever an employee has developed signs or symptoms associated with exposure to a biohazardous agent;
• whenever an employee is involved in a needlestick, cut, spill or other occurrence resulting in a possible exposure to biohazardous agents.

Laboratory personnel will receive appropriate immunizations or tests for the agents handled or potentially present in the laboratory (e.g., hepatitis B vaccine or TB skin testing).

When appropriate, considering the agent(s) handled, baseline serum samples from all personnel working in the laboratory or animal facility and other at-risk personnel are collected and stored. Additional serum specimens may be collected periodically depending on the agents handled or the function of the facility. The decision to establish a serologic surveillance program must take into account the availability of methods for the assessment of antibody to the agent(s) of concern. The program should provide for the testing of serum samples at each collection interval and the communication of results to the participants.

Medical surveillance may be required for not only those workers who use biohazardous agents but also any animal handler who must tend to animals inoculated with etiologic agents. Some animals may be infected with agents not related to the research, such as sheep whose body fluid may contain Coxiella burnetii, the causative agent for Q-fever.

J. TRAINING

Every laboratory employee that handles biohazardous materials will receive a basic orientation to the UNM Biosafety program. Employees will be required to complete this training every five (5) years. It will include the following:

• requirements of this program;
• general understanding of the biosafety levels
• general guidance on the selection of protective measures to reduce exposure to infectious agents;
• information on safety resources;
• emergency procedures to be used in the event of accidental exposure or release of infectious agents, including emergency numbers;
• proper labeling/hazard communication (biohazard sign, red bag, etc.);
• Standard Precautions (blood and body fluid precautions);
• clean-up, decontamination procedures; and
• use of Biological Safety Cabinets.

In addition to the general Biosafety training, personnel must be provided with area-specific on-the-job training. This training is to be conducted by the laboratory supervisor and will inform personnel of:

• the location of the Biosafety Program in their work area;
• the potential hazards associated with the work involved;
• the signs and symptoms of exposure to the infectious agents used in the laboratory;
• the necessary precautions to prevent exposures;
• the exposure evaluation procedures;
• the location of eye washes and safety showers, to be used in the event of an accident; and
• protective measures available in the laboratory to reduce exposures.

Supervisors are responsible for ensuring that personnel with potential exposure to infectious agents receive the appropriate training before working with those agents. Employees must receive annual updates, or additional training as necessary for procedural or policy changes.

The laboratory director is responsible for insuring that, before working with organisms at Biosafety Level 3, all personnel demonstrate proficiency in standard microbiological practices and techniques, and in the practices and operations specific to the laboratory facility. This might include prior experience in handling human pathogens or cell cultures, or a specific training program provided by the laboratory director or other competent scientist proficient in safe microbiological practices and techniques.

Prior to transporting any clinical specimens or known etiologic agents, employees will receive training to include the following:

• emergency procedures in the event of a spill;
• who to notify in the event of an emergency;
• proper labeling/hazard communication (biohazard sign, red bag, etc.);
• symptoms of the disease caused by the material being carried;
• Universal Precautions (blood and body fluid precautions);
• use of barrier precautions (gloves, aprons, etc.);
• washing hands after handling;
• limiting use of sharp instruments;
• avoiding the generation of aerosols when handling containers;
• covering open cuts or wounds before work;
• decontaminating area after opening or closing packages; and
• clean-up, decontamination procedures.

K. WARNING SIGNS AND LABELS

When Biosafety Level 2 agents are present in the laboratory or animal room, the universal biohazard symbol must be posted on the access door to the laboratory. When Biosafety Level 3 agents or infected animals are present in the laboratory or animal room, a a hazard warning sign must be posted. Along with the biohazard symbol, the sign must identify the infectious agent, list the name and phone number of the lab/animal room director/supervisor and indicate the special requirements for entry.

Warning labels with the universal biohazard symbol must be affixed to containers of regulated waste, refrigerators and freezers and other objects containing or contaminated with infectious agents.

L. CONTROL MEASURES

1. Engineering Controls

Engineering controls are used to eliminate or minimize employee risk with regard to occupational hazards.

a. Class II Biological Safety Cabinet

The Class II biosafety cabinet is used as a containment device for the manipulation of infectious agents. The Class II biosafety cabinet is engineered to be safe for both personnel and product protection by the use of HEPA filtered air which provides a curtain of clean air between the user and the experiment. HEPA filtered air is also exhausted from the biosafety cabinet and is safe to be recirculated within the room provided that the biosafety cabinet is certified on an annual basis. Biosafety cabinets are used to provide primary containment in the laboratory when the investigator is using potentially infectious materials.

Class II Biosafety Cabinets shall be used in Biosafety Level 2 or 3 experiments in each of the following instances:

• Aerosols generating procedures are conducted
• A high concentration of infectious agents are used
• Large volumes of infectious agents are used

i. Types of Class II Cabinets

Class II Type A BSCs are suitable only for work with microbiological research on low to moderate risk agents in the absence of volatile or toxic chemicals and radionuclides. In these cabinets, 30% of the air is exhausted through a HEPA filter back into the laboratory and the other 70% is recirculated in the cabinet. Type A cabinets do not have to be vented, which makes them suitable for use in laboratory rooms which cannot be ducted.

Class II Type B1 BSCs exhaust 70% of the cabinet air to the outside of the building through a HEPA filter and recirculates 30% of the air in the cabinet through a HEPA filter. These cabinets should not be used with highly volatile or flammable chemicals. Type B1 biosafety cabinets must be vented

Class II Type B2 BSCs exhaust 100% of the cabinet air to the outside of the building through a HEPA filter. This feature, plus an increased face velocity of 75-100 fpm, allow work to be done with toxic chemicals and radionuclides.

Class II Type B3 BSCs exhaust 30% of the cabinet air to the outside of the building through a HEPA filter and 70% of the air is recirculated in the cabinet. These cabinets are not suitable for work with hazardous chemicals. These cabinets must be vented.

Class III BSCs are totally enclosed, ventilated cabinets of gas-tight construction and offer the highest degree of personnel and environmental protection from infectious aerosols, as well as protection of research materials. All operations in the cabinet are performed through attached rubber gloves and the supply and return air is HEPA filtered. These cabinets are most suitable for work with hazardous agents that require Biosafety Level 3 or Level 4 containment.

Biological Safety Cabinet Selection

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ii. Certification

BSCs must be certified annually. Certification of BSCs is contracted out to independent companies. Contact SHEA to have your cabinet certified.

iii Use

Please refer to UNM's Local Exhaust Ventilation Management Program (SHEA Manual Section 6.04) for information on the proper use of Biological Safety Cabinets. In addition, Attachment E contains information on the proper selection and use of Biological Safety Cabinets.

iv Laminar Flow Clean Benches

Some laboratories have purchased laminar flow clean benches for work which may have to be performed in a Class II biosafety cabinet. A la minar flow clean bench will not provide personnel protection since the air is blown across the work area into the employees breathing zone. A laminar flow clean bench MUST NOT BE USED for any work with Class 2 or 3 agents.

b. Sharps Containers

Sharps containers are rigid, hard plastic containers designed for the storage of used sharps. Such containers shall be labeled with the universal biohazard symbol and replaced frequently enough to prevent overfilling.

c. Mechanical Pipettes

Mechanical pipettes shall be used whenever possible in the handling of blood or body fluids. Mouth pipetting is strictly forbidden.

d. Splash Guards

Splash guards are used in the lab to contain the spread of potentially infectious material.

e. Sink

Sinks are required for effective hand-washing and shall be readily available in areas of infectious agent usage.

2. PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE) is used to protect the laboratory worker from contact with infectious agents, chemicals, and other physical hazards. Personal protective equipment is also critical for those experiments which involve sterile technique because the personal protective equipment may prevent inadvertent contamination.

Certain experiments involving aerosol or splash generating procedures may increase the hazard level of the experiment and warrant the use of more items of personal protective equipment. Some biological agents such as Class 3 agents increase the hazard level to the employee and require the use of more items of personal protective equipment. Sometimes personal protective equipment is necessary because the available facilities lack the necessary engineering controls which would alleviate the need to use certain items of personal protective equipment.

The following list includes the most common items of personal protective equipment used in the lab.

1. PPE shall be provided to all employees who are at risk of occupational exposure to infectious agents, at no cost to the employee.
2. PPE is considered appropriate only if it does not permit potentially infectious material to pass through to the employee's work clothes, street clothes or undergarments, skin, eyes, or other mucous membranes under normal working conditions and for the duration of time that protective equipment shall be used.
3. The PI/laboratory director/employee supervisor shall ensure that the PPE is worn by employees as needed, and that training in the proper wearing and use of such equipment is provided.
4. The PI/laboratory director/employee supervisor shall ensure that PPE in appropriate quantities is readily accessible at the work site in an appropriate range of sizes.
5. Personal protective equipment must be changed whenever contaminated and cleaned as soon as it is feasible or at the end of the experiment. PPE as required shall be cleaned, laundered, or repaired at no cost to the employee.
6. PPE shall be removed prior to leaving the immediate work area and placed in an appropriate container or location for storage, cleaning, decontamination or disposal. Gloves shall be removed prior to entering a public area such as an elevator or phone booth to avoid inadvertently contaminating such public facilities.
7. Gloves shall be worn when it is reasonably anticipated that the employee may have hand contact with potentially infectious materials.

• Disposable gloves shall be replaced when practical after contamination or whenever feasible after they are torn or otherwise rendered ineffective to provide barrier protection.
• Disposable or other single use gloves shall be disposed of immediately after use and prior to contact with the environment outside the immediate work area.
• Utility gloves may be decontaminated for re-use if the integrity of the glove has not been compromised. However, they shall be discarded if they are peeling, cracking, or exhibit any sign of deterioration which would compromise adequate barrier protection.

8. All employees shall wear shoes in the lab. Open toed sandals are not permitted.

3. GOOD LABORATORY WORK PRACTICES

a. Standard Microbiological Practices

These practices apply to all laboratories using infectious agents.

• Access to the laboratory is limited or restricted at the discretion of the laboratory director when experiments or work with cultures and specimens are in progress.
• All laboratory workers shall wash their hands immediately or as soon as feasible after removing gloves or other personal protective clothing. Employees must wash their hands after they handle viable materials and animals, after removing gloves, and before leaving the facility.
• Eating, drinking, smoking, handling contact lenses, applying cosmetics are not permitted in work areas where there is reasonable likelihood of exposure to potentially infectious materials. Prior to the consumption of any food after handling potentially infectious materials, employees shall remove potentially contaminated protective clothing, wash hands thoroughly and exit the work area. Employees who wear contact lenses in animal rooms should also wear goggles or a face shield. Food is stored outside the work area in cabinets or refrigerators designated and used for this purpose only.
• Mouth pipetting may lead to accidental ingestion of biological specimens and is strictly prohibited. Mechanical pipetting devices must be used.
• Any procedures which could potentially generate aerosols or other inhalation hazards, shall be performed in a manner that will minimize airborne pathogen transmission. These procedures include sonicating, grinding, vortexing, blending, slicing or cutting and centrifuging.
• Personal protective equipment, such as gloves and a lab coat should be worn whenever biological work is conducted in the lab. Additional items of personal protective equipment, such as a face shield for splash hazards should be considered whenever hazards cannot be abated by good work practice or engineering controls.
• Work surfaces are decontaminated at least once a day and after any spill of viable materials.
• All laboratories should minimize any procedures involving the use of sharps, especially needles and syringes. If sharps must be used then sharps containers shall be readily available in all areas where sharps waste may be generated (Containers should be no more than 2/3 filled prior to disposal). Contaminated needles shall not be recapped, bent or sheared; dispose of such units directly into a sharps container. Broken glassware which may be contaminated shall not be directly handled with a gloved or bare hand. It shall be handled with mechanical means such as tongs and/or dust pans and broom.
• Only needle-locking syringes or disposable syringe-needle units (i.e., needle is integral to the syringe) are used for injection or aspiration of infectious materials. Used disposable needles must not be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand before disposal. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving.
• Syringes which re-sheathe the needle, needle-less systems, and other safe devices should be used when appropriate.
• Broken glassware must not be handled directly by hand, but must be removed by mechanical means such as a brush and dustpan, tongs, or forceps. Containers of contaminated needles, sharp equipment, and broken glass should be decontaminated before disposal, according to any local, state, or federal regulations.
• All cultures, stocks, and other regulated wastes are decontaminated before disposal by an approved decontamination method, such as autoclaving. Materials to be decontaminated outside of the immediate laboratory are to be placed in a durable, leakproof container and closed for transport from the laboratory. Materials to be decontaminated at off-site from the laboratory are packaged in accordance with applicable local, state, and federal regulations, before removal from the facility.
• Specimens of blood or other potentially infectious materials shall be placed inside a leak proof, unbreakable container during handling, processing, storage, transport or shipping. Universal Precautions shall be observed at all times.
• Place a color-coded label incorporating the universal biohazard label on the work surface of any potentially contaminated equipment or work surface to warn others of biohazard contamination which may not be visible. Freezers, refrigerators and incubators which contain Class 2 or Class 3 biological agent specimens should have a biohazard label prominently visible on the door.
• An insect and rodent control program is in effect.

b. Biosafety Level 1

1. Special Practices: None
2. Safety Equipment (Primary Barriers)

• Special containment devices or equipment such as a biological safety cabinet are generally not required for manipulations of agents assigned to Biosafety Level 1.
• It is recommended that laboratory coats, gowns, or uniforms be worn to prevent contamination or soiling of street clothes.
• Gloves should be worn if the skin on the hands is broken or if a rash exists.
• Protective eyewear should be worn for anticipated splashes of microorganisms or other hazardous materials to the face.

c. Biosafety Level 2

1. Special Practices

• Access to the laboratory is limited or restricted by the laboratory director when work with infectious agents is in progress. In general, persons who may be at increased risk of acquiring infection, or for whom infection might be unusually hazardous, are not allowed in the laboratory. For example, persons who are immunocompromised or immunosuppressed may be at risk of acquiring infections. The laboratory director has the final responsibility for assessing each circumstance and determining who may enter or work in the laboratory.
• The laboratory director establishes policies and procedures whereby only persons who have been advised of the potential hazard and meet any specific requirements (e.g., immunization) may enter the laboratory.
• Cultures, tissues, or specimens of body fluids are placed in a container that prevents leakage during collection, handling, processing, storage, transport, and shipping.
• Laboratory equipment and work surfaces should be decontaminated with an appropriate disinfectant on a routine basis, after work with infectious materials is finished, and especially after overt spills, splashes, or other contamination by infectious materials. Contaminated equipment must be decontaminated according to any local, state, or federal regulations before it is sent for repair or maintenance or packaged for transport in accordance with applicable local, state, or federal regulations, before removal from the facility.
• Spills and accidents which result in overt exposures to infectious material are immediately reported to the laboratory director. Medical evaluation, surveillance, and treatment are provided as appropriate and written records are maintained.
• Animals not involved in the work being performed are not permitted in the lab.

2. Safety Equipment (Primary Barriers)

• Properly maintained biological safety cabinets, preferably Class II, or other appropriate personal protective equipment or physical containment devices are used whenever:
• Procedures with a potential for creating infectious aerosols or splashes are conducted. These may include centrifuging, grinding, blending, vigorous shaking or mixing, sonic disruption, opening containers of infectious materials whose internal pressures may be different from ambient pressures, inoculating animals intranasally, and harvesting infected tissues from animals or eggs.
• High concentrations or large volumes of infectious agents are used. Such materials may be centrifuged in the open laboratory if sealed rotor heads or centrifuge safety cups are used, and if these rotors or safety cups are opened only in a biological safety cabinet.
• Face protection (goggles, mask, faceshield, or other splatter guards) is used for anticipated splashes or sprays of infectious or other hazardous materials to the face, when the microorganisms must be manipulated outside the BSC.
• Protective laboratory coats, gowns, smocks, or uniforms are worn while in the laboratory. This protective clothing is removed and left in the laboratory before leaving for non-laboratory areas (e.g., cafeteria, library, administrative offices). All protective clothing is either disposed of in the laboratory or laundered by the institution; it should never be taken home by personnel.
• Gloves are worn when handling infected animals and when hands may contact infectious materials, contaminated surfaces or equipment. Wearing two pairs of gloves may be appropriate; if a spill or splatter occurs, the hand will be protected after the contaminated glove is removed. Gloves are disposed of when contaminated, removed when work with infectious materials is completed, and are not worn outside the laboratory. Disposable gloves are not washed or reused.

c. Biosafety Level 3

1. Special Practices

• Laboratory doors are kept closed when experiments are in progress.
• The laboratory director or other responsible person controls access to the laboratory and restricts access to persons whose presence is required for program or support purposes. For example, persons who are immunodeficient or immunosuppressed may be at risk of acquiring infection. Persons who are at increased risk of acquiring infection, or for whom infection might be unusually hazardous, are not allowed in the laboratory or animal rooms. The director has the final responsibility for assessing each circumstance and determining who may enter or work in the facility.
• The laboratory director or other responsible person establishes policies and procedures whereby only persons who have been advised of the potential hazard and meet any specific requirements (e.g., for immunization), and who comply with all entry and exit procedures, may enter the laboratory or animal rooms.
• All manipulations involving infectious materials are conducted in biological safety cabinets or other physical containment devices within the containment module. No work in open vessels is conducted on the open bench.
• Laboratory equipment and work surfaces should be decontaminated with an appropriate disinfectant on a routine basis, after work with infectious materials is finished, and especially after overt spills, splashes, or other contamination with infectious materials. Contaminated equipment should also be decontaminated before it is sent for repair or maintenance or package for transport in accordance with applicable local, state, or federal regulations, before removal from the facility. Plastic-backed paper toweling used on non-perforated work surfaces within biological safety cabinets facilitates clean-up.
• Cultures, tissues, or specimens of body fluids are placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping.
• All potentially contaminated waste materials (e.g., gloves, lab coats, etc.) from laboratories or animal rooms are decontaminated before disposal or reuse.
• Spills of infectious materials are decontaminated, contained and cleaned up by appropriate professional staff, or others properly trained and equipped to work with concentrated infectious material.
• Spills and accidents which result in overt or potential exposures to infectious materials are immediately reported to the laboratory director. Appropriate medical evaluation, surveillance, and treatment are provided and written records are maintained.
• Animals and plants not related to the work being conducted are not permitted in the laboratory.

2. Safety Equipment (Primary Barriers)

• Properly maintained biological safety cabinets are used for all manipulation of infectious materials.
• Outside of a BSC, appropriate combinations of personal protective equipment are used (e.g., special protective clothing, masks, gloves, face protection, or respirators), in combination with physical containment devices (e.g., centrifuge safety cups, sealed centrifuge rotors, or containment caging for animals).
• This equipment must be used for manipulations of cultures and of those clinical or environmental materials which may be a source of infectious aerosols; the aerosol challenge of experimental animals; harvesting of tissues or fluids from infected animals and embryonated eggs, and necropsy of infected animals.
• Face protection (goggles and mask, or faceshield) is worn for manipulations of infectious materials outside of a biological safety cabinet.
• Respiratory protection is worn when aerosols cannot be safely contained (i.e, outside of a biological safety cabinet), and in rooms containing infected animals.
• Protective laboratory clothing such as solid-front or wrap-around gowns, scrub suits, or coveralls must be worn in, and not worn outside, the laboratory. Reusable laboratory clothing is to be decontaminated before being laundered.
• Gloves must be worn when handling infected animals and when hands may contact infectious materials and contaminated surfaces and equipment. Disposable gloves should be discarded when contaminated, and never washed for reuse.
• Continuous flow centrifuges or other equipment that may produce aerosols are contained in devices that exhaust air through HEPA filters before discharge into the laboratory.

d. Biosafety Level 4

The use of these agents is not allowed at UNM. If you would like further information about Biosafety Level 4 practices, please contact SHEA.

M. LAB DESIGN

Microbiological laboratory design criteria for each Biosafety Level can be found in Attachment F.

N. DISINFECTION AND STERILIZATION

Chemical disinfectants are used to decontaminate surfaces used for biological experiments. Chemical disinfectants must not be used to treat medical waste for several reasons. Medical waste is not rendered unrecognizable by the application of a disinfectant; sharps waste will still be sharps waste after the addition of bleach. Medical waste often consists of cultures which are internally contaminated and would not be inactivated by treatment (such as agar gels). Chemical disinfectants are used to clean contaminated equipment surfaces such as freezers, work surfaces such as biosafety cabinets and for spill clean up procedures in an emergency.

When using a chemical disinfectant, remember that you are using a potentially toxic chemical that may be a corrosive, flammable solvent and/or a carcinogen. Wear personal protective equipment to include a lab coat, gloves, safety glasses with side shield and possibly a face mask. If you must prepare a dilution of your disinfectant, do so whenever possible in a chemical fume hood or in a well ventilated area. Read the material safety data sheet (MSDS) to familiarize yourself with the special precautions needed when handling the disinfectant. If you are working with mixed solutions of chemical-biohazardous materials, check the MSDS to insure that an incompatible chemical reaction will not result.

Allow sufficient contact time after applying the disinfectant. Do not apply a disinfectant and immediately remove it from the contaminated surface. The contact time will be too brief to ensure that the surface has been thoroughly disinfected. When cleaning a spill of concentrated material or if the disinfectant must act on an uneven surface, allow extra time for the disinfectant to act.

Avoid using concentrated or undiluted solutions of your disinfectant to "speed up" the inactivation process. The surface which is being cleaned may be adversely affected by strong chemicals. This is especially significant when working with bleach which is a very strong corrosive. Some disinfectants will leave a residue of chemicals behind. Rinse the cleaned area with distilled water to avoid adverse effects on your experiment. This is especially important in tissue culture rooms where a cell line can be wiped out by disinfectant residue left on equipment.

A list of chemical disinfectants can be found in Attachment G.

O. SPILL CLEANUP/ACCIDENTS

All biohazard laboratories must establish internal emergency procedures based on the hazardous materials used in the room. In many cases, the biological materials are not as hazardous as other substances also used in the room so overall emergency planning must take into consideration the use of radioactive materials and chemicals as well as biohazardous materials.

Depending on the incident, it may be necessary to prevent entry into the building or vicinity where the biohazard incident occurred. UNM Police Department and/or UH Security will handle all security issues upon advisement of emergency response personnel. UNM SHEA, UNM Biohazard IAP Manager or Incident Responder and/or Albuquerque HazMat will determine Reentry criteria in conjunction with the laboratory principal investigator. Appropriate Personal Protective Equipment (PPE) may be required for reentry.

The following procedures should be followed for minor spills in a laboratory:

1. Biological Laboratory Spills:

1. Spill In A Biological Safety Cabinet

• Keep the biological safety cabinet running.
• Don personal protective clothing including: gloves, goggles and lab coat.
• Put absorbent paper down on the spill area.
• Apply a suitable disinfectant along the walls, work surfaces and trough. Avoid splashing the agent while applying the disinfectant. Do not attempt to clean the HEPA filters or other internal parts!
• Allow 20 minutes for the disinfectant to work.
• Wipe or absorb all excess disinfectant and place the absorbent material into a red bag or autoclave bag. This waste must be handled as infectious waste.
• Reapply a detergent solution to all exposed surfaces.
• In the event of liquid spillage into the catch basin, add an equal volume of disinfectant and wait for 20 minutes to clean up the sterilized material. Process the absorbed material as infectious waste.
• Disinfect all materials used in the biosafety cabinet by wiping the surface with a disinfectant. Do not attempt to disinfect contaminated cardboard or other items which absorb liquid. Dispose of as infectious waste.
• If the biosafety cabinet was exposed to excessive amounts of biological contamination, STOP. Call SHEA, 277-2753 to coordinate further clean up.

2. Spills In A Laboratory

1. For BL1 research laboratories/Class 1 Agents:

• Post signs on entrances to alert others of a biohazard spill.
• Wear disposable gloves, lab coat, and water-resistant shoes.
• Lay down paper towels to contain the spill. Then pour disinfectant over the spill area. (Note: If sharps are present, use tongs or forceps to lift the sharps into an appropriate sharps container before placing absorbent material. NEVER handle sharps with a gloved hand alone.) Next pour an appropriate disinfectant over the spill area. Allow disinfectant to act for 20 minutes before cleaning up with more paper towels (Note: If sharps were involved, be very careful for shards of sharp material that may not have been recovered during the initial sharps recovery and pick up absorbent material with tongs.)
• Clean spill area with fresh towels soaked in disinfectant.
• Place paper towels in a red bag for disposal.
• Reapply disinfectant and place more paper towels on the spill area.
• Dispose of paper towels into the red bag.

2. For BL2 research laboratories/Class 2 Agents:

• Insure that the room is evacuated, all personnel are accounted for, and that the doors are closed. Post signs on entrances to alert others of a biohazard spill.
• Contact UNM Police Department and state that there is a biohazard spill outside containment. The emergency response personnel will evaluate if special considerations such as evacuation of the adjoining areas must occur.
• Wait 30 minutes to allow aerosols to settle.
• Don appropriate protective clothing. The protective clothing recommended includes a lab coat, waterproof apron, shoe covers, rubber gloves, and goggles or face shield and a respirator, if necessary.
• Enter the room and place paper towels or other absorbent material over the spill area. (Note: If sharps are present, use tongs or forceps to lift the sharps into an appropriate sharps container before placing absorbent material. NEVER handle sharps with a gloved hand alone.)
• Carefully pour disinfectant (e.g., 1:10 dilution of bleach unless the area is stainless steel and capable of being corroded or Amphyl (78.5% ethanol and 13.6% phenyl phenol))around the edges of the spill and then onto the spill. Avoid splashing or generating aerosols.
• Allow disinfectant to remain in contact with spill for 20 minutes.
• Apply more paper towels or absorbent material to wipe up spill. Note: If sharps were involved, be very careful for shards of sharp material that may not have been recovered during the initial sharps recovery and pick up absorbent material with tongs.)
• Clean spill area with fresh towels soaked in disinfectant.
• Place all towels or absorbent materials into a red bag.
• Remove protective clothing and segregate for disposal or cleaning.
• Ensure prior to leaving that your hands and exposed skin have been washed thoroughly and that you shower at the first opportunity.

c. BL3 spill procedures:

• Attend to any injured personnel and insure that such individuals are evacuated. Dial 911 for UNM Police Department.
• Ensure that all laboratory personnel are evacuated and accounted for and that the front doors of the laboratory are closed. Post signs on entrances to alert others of a biohazard spill.
• Wait 30 minutes prior to entering to allow droplets and aerosols to settle.
• The response personnel will contact the Principal Investigator to obtain any vital information for response/cleanup.
• Don appropriate protective clothing. The protective clothing includes a Tyvek suit with tight-fitting cuffs, shoe covers, rubber gloves, and goggles or face shield and a respirator. Be advised that the definition of BL3 is hazard by the inhalation route so WEAR APPROPRIATE RESPIRATORY PROTECTION! If the appropriate respiratory protection is not available or you have not been fit-tested and trained in respirator use, leave clean up coordination to emergency response personnel.
• Enter the room and place paper towels or other absorbent material over the spill area. (Note: If sharps are present, use tongs or forceps to lift the sharps into an appropriate sharps container before placing absorbent material. NEVER handle sharps with a gloved hand alone.)
• Carefully pour an appropriate disinfectant (e.g., 1:10 dilution of bleach unless the area is stainless steel and capable of being corroded or Amphyl (78.5% ethanol and 13.6% phenyl phenol)) around the edges of the spill and then onto the spill. Avoid splashing or generating aerosols.
• Allow disinfectant to remain in contact with spill for 20 minutes.
• Apply more paper towels or absorbent material to wipe up spill. (Note: If sharps were involved, be very careful for shards of sharp material that may not have been recovered during the initial sharps recovery and pick up absorbent material with tongs.)
• Clean spill area with fresh towels soaked in disinfectant.
• Place all towels or absorbent materials into a red bag.
• Remove protective clothing and segregate for disposal or cleaning.
• Ensure prior to leaving that your hands and exposed skin have been washed thoroughly and that you shower at the first opportunity.

d. Sharps recovery (sharp items spilled from a broken container or contaminated broken glassware):

• Obtain an empty sharps container. If you know that the sharp item to be recovered is too big for a sharps container, use a sturdy cardboard box.
• If the sharps are contaminated with biological materials such as blood, then don protective clothing (e.g. a lab coat (or preferably a long-sleeve gown with tight-fitting cuffs for BL2 labs or a Tyvek suit for a BL3 lab), goggles or face shield with facemask, shoe covers and rubber gloves lined with leather work gloves. Respiratory protection may also be needed if a class 2 or 3 biohazardous agent is involved.
• NEVER pick up the sharp item with gloved hand alone! Use tongs or forceps to lift the sharps into the sharps container. Use a dustpan and broom as a secondary alternative remembering to minimize potential aerosolization of the biological material.
• After the sharps have been recovered, pour a small amount of disinfectant over the area. Place paper towels over the disinfectant and allow settling for 20 minutes.
• Using tongs, remove the absorbent material and place into a biohazard bag. Be very careful for shards of sharp material which may not have been recovered during the initial sharps pick up.

2. Exposure Incidents

Needle sticks, cuts, splashes to the eyes or mucous membranes or other exposures to biohazardous agents must be reported to Employee Occupational Health Services (EOHS). In the event of exposure to the skin (including needle sticks and cuts), wash the exposed area immediately with soap and water. If it is an exposure to the eyes or mucous membranes, rinse the area with water for 15 minutes. Notify your supervisor and seek medical attention immediately. Employees should go to EOHS during normal business hours and to the Emergency room at University Hospital after hours.

P. INFECTIOUS WASTE DISPOSAL

All infectious waste must be handled and disposed of in accordance with UNM’s Infectious Waste Disposal Program (SHEA Manual Section 5.07.03).

Q. BIOSAFETY LABORATORY CLOSE OUT PROCEDURES

Laboratories which utilize biological materials must notify SHEA prior to terminating work to ensure that the laboratory has been decontaminated and that the biological material has been secured or properly disposed of. If the Principal Investigator intends to cease work, he or she must notify SHEA at least 60 days prior to the set departure date. During the final Lab Close Out Inspection, SHEA will personally verify that the following has been accomplished prior to the inspection:

• Biosafety cabinets must be decontaminated with paraformaldehyde and the outer surfaces cleaned with a suitable disinfectant. The Principal Investigator should present a receipt verifying that the paraformaldehyde decontamination procedure has been completed by the contracted biosafety cabinet certifier.
• Storage freezers should be emptied and the surfaces should be decontaminated with a suitable disinfectant. Cryostats and liquid nitrogen storage equipment must also be emptied.
• Account for all specimens stored outside the lab room. Specimens stored in a cold room or an incubator in an adjacent tissue culture room should be disposed of in a red bag.
• Medical waste such as used sharps containers or red bags must be disposed of and the storage areas for the medical waste cleaned with a suitable disinfectant.
• Any biohazard labels must be removed from surfaces. The outer surface of all equipment and any work surface must be decontaminated with a suitable disinfectant.
• The Biohazard sign must be removed from door.

R. DISPOSITION OF USED LAB EQUIPMENT

Used laboratory equipment, such as incubators, refrigerators and freezers must be thoroughly decontaminated prior to disposal or release to surplus property. Laboratory equipment which was used in conjunction with biological research may have residual contamination resulting from chemicals and/or radioactive materials.

Prior to disposing of any used laboratory equipment:

• wear appropriate personal protective equipment. At a minimum wear gloves, lab coat, and safety glasses with side shields or goggles
• remove all specimens and/or laboratory materials
• remove all labels or stickers from the front of the equipment
• clean the surface of the equipment for any radioactive contamination, if applicable. Schedule a wipe test with Radiation Safety to ensure that the equipment is free from residual radioactive contamination. Call Radiation Safety for more information.
• be sure that the equipment surface can be safely cleaned with a chemical disinfectant. Make sure that the equipment was not used to store water reactive chemicals, corrosives or strong oxidizers which may incompatibly react during the decontamination process.
• apply a chemical disinfectant to the surface of the equipment and allow the disinfectant time to inactivate potential contamination
• insure that the surface is rinsed to remove the disinfectant
• put the cleaning waste (paper towel, sponge) in a red bag and treat as infectious waste

Do not open internal compartments of equipment for decontamination. If the internal compartments of a piece of equipment are grossly contaminated with biohazardous material, label or tag the equipment as potentially biohazardous. Notify the Biosafety Officer and a decision will be made whether the equipment is safe for disposal.

When the equipment is ready for pick up, complete a form stating that you have decontaminated the equipment designated for removal in accordance with these guidelines.

S. SHIPPING AND TRANSPORT

Requirements for shipping and transport can be found in Attachment H.

T. IMPORTING ETIOLOGIC AGENTS

It is important to obtain a CDC permit PRIOR to requesting an etiologic specimen from a source outside the United States. Procedures for importing etiologic agents are in Attachment I.