Approver(s):

Executive Council

Authorizes Release:

Vice President for Administration and Finance

Responsible Area:

Administration - Risk Management

Review Cycle:

Annually or as required

Last Review:

February 2020

Related Policies and Additional References:

None

Purpose

The reasons for developing and implementing a biosafety program are twofold; (1) protecting workers and students from potential hazards; and (2) protecting the surrounding community from those same potential hazards.

Responsibilities and Functions

Biosafety Committee

A biohazard is a microbiological, radiological or chemical agent of a nature hazardous to humans (this includes flammable material). The Biosafety Committee formulates and formalizes biosafety rules and regulations. The Biosafety Committee shall consist of three faculty members from the School of Science, Engineering and Technology. One of these individuals will serve as chair of the committee. The dean of School of Science, Engineering and Technology (SET) has the responsibility for approving the composition of this committee. If deemed necessary by the chair of the Biosafety Committee, a committee member may be recruited from outside of the University on an ad hoc basis. The Biosafety Committee will meet once a year to review the Biosafety Plan and at other times at the discretion of the committee chair. The Biosafety Committee may collaborate with the Chemical Hygiene Officer (CHO) to advise the Office of Administration and Finance in the area of biosafety and seek ways to eliminate potential biohazards with a minimum of interference to the working effectiveness of the University. This committee will review university projects and, when appropriate, approve all safety plans prepared by the principal investigator/instructor for the use of biohazards (except radioisotopes) and recombinant DNA not specified in these guidelines. In exercising this responsibility, the Biosafety Committee shall make an independent evaluation of the proposed use and determine if the proposed controls are appropriate to assure the protection of the staff, students and the environment.

Department Chairperson

Within each department, the department chairperson is responsible for the management of the safety program for work involving biohazards and establishing procedures for the proper disposal of such materials. Records of work areas where biohazards are used (doors leading to these areas should be properly labeled), and an inventory of such chemicals and their storage location shall be maintained and made available to the San Antonio Fire Marshal. These records shall be updated at least annually. It is essential that safe practices be taught in academic courses to prepare students for future responsibilities in their chosen field. This, and other biosafety-related responsibilities, may be delegated to the department’s faculty and staff, but the responsibility for safety management still resides with the department chairperson.

The departmental chairperson, in consultation with the chair of the Biosafety Committee, the Chemical Hygiene Officer, and the Office of EHS shall investigate all accidents that result in the exposure of staff, students or the environment to a biohazard.

Principal Investigator/Instructor

The principal investigator/instructor has the primary responsibility for:

  • Selecting the appropriate control practices for handling any biohazardous material used under his/her direction or stored in laboratories or otherwise under his/her control.
  • Prior to beginning work, the principal investigator/instructor shall establish, in consultation with the department’s chair, a procedure for the disposal of all biohazardous waste that is within the guideline.
  • Reporting to the department chair the current location of work areas where biohazards will be used, and a current inventory of stock quantities of such materials that will be kept in these areas.
  • Instructing students, student employees, and other course instructors of potential biohazards, available safety apparatus, safety procedures, and the proper disposed of biohazardous waste.
  • Securing approval from the Biosafety Committee of the safety plan before using alternative controls that are not specified in these guidelines.
  • Supervising the students to ensure that the required safety practices and techniques are employed.
  • Arranging for immediate medical attention and for reporting to the department chairperson, Biosafety Committee chairperson, Chemical Hygiene Officer, and Office of EHS any accident involving a biohazard in which a person is injured or there is released to the immediate environment biohazards or danger of fire and/or explosion. Evacuation of the area is best accomplished by use of the fire alarm pull stations.
  • Assisting the department chairperson, Biosafety Committee chairperson, Chemical Hygiene Officer, and the Office of EHS in investigating an accident.
  • Investigating and reporting in writing to the department chairperson, Biosafety Committee chairperson, Chemical Hygiene Officer, and Office of EHS any problems pertaining to operation and implementation of control practices, equipment or facility failure.
  • Proactively correcting any conditions that could result in the accidental release of any potentially biohazardous agent and result in any human exposure.

All Faculty and Staff (including paid and unpaid student workers)

Each employee is responsible for:

  • Reading at least once a year, understanding and complying with written biosafety rules, regulations and procedures contained in this Biosafety Plan and waste disposal requirements contained in the Waste Disposal Management Plan relevant to the task assigned.
  • Reporting unsafe conditions to the principal investigator/instructor, the department chairperson and to the Chemical Hygiene Officer.
  • Reporting to the principal investigator/instructor and investigating committee all facts pertaining to any accident resulting in human exposure or environmental release.
  • Making every effort to inform his/her co-workers with special procedure of safe storage and disposal of those hazardous chemicals that he/she works with and informing fellow employees of his/her actions so that they are not put at risk. Refer to Waste Disposal Management Plan for disposal requirements of hazardous chemicals.

Employment and Other Personnel Considerations

Biohazards Safety Briefing

New employees should receive a safety briefing of information relevant to their job responsibilities as determined by the Vice-President of the Functional Area or Dean of the School; for example, those involved in housekeeping or maintenance work, should be apprised by persons qualified by training and experience about (i) the possible sources of exposure on campus, (ii) adverse health effects associated with exposure, (iii) work practice, safety labeling and engineering controls in use and being planned to limit exposure, and (iv) the responsibility of the employees for following proper work practices to help protect their health and provide for the safety of themselves and fellow employees. All employees and students working with, or whom may be exposed to known or potential biohazards shall receive sufficient information that will enable them to work safely and to make informed decisions as to the relative significance to potential hazards as they relate to them personally. Safety practices should be reviewed by the employee at least annually to insure awareness of their responsibilities. Students should receive written and oral warning of potential hazards, and how to eliminate risks.

Immunization Requirements

Individuals working with animals are required to refer to the Animal Use Committee Guidelines for Information concerning required immunizations. Hepatitis B vaccine and vaccination series shall be made available to all employees with reasonably anticipated exposure to blood, as outlined in the University’s Faculty Handbook (Section 2.12.6.1.2).

Administrative Requirements

Appropriate written information describing the relevant toxic, physical and chemical properties of the particular hazardous chemicals used or stored in the laboratory must be kept in a file that is continuously and readily available to employees and students. Each chemical shall include a Safety Data Sheet that is retained in hardcopy form in the MSDS (Material Safety Data Sheet) binders located in the Biology stockroom and/or specific laboratory that uses the chemical. The department chairperson, Biosafety Committee chairperson, Chemical Hygiene Officer, Office of EHS, and all staff and students working with the hazardous chemicals shall be aware of and have access to the Safety Data Sheets. The department chairperson is responsible for ensuring the Safety Data Sheets and the accompanying chemical inventory list is updated at least annually and when new chemicals are purchased.

NOTE: Available in the Administration and Finance Office is the Hazard Communication Plan.

University-wide Biosafety Regulations

General Work Practices and Engineering Controls

The work practices and engineering controls specified in this section shall be used by all laboratories in which work involving biohazards is carried out regularly. Section 3.2 gives examples of controls treated to the use of chemicals and section 3.3 details guidelines for using biological material.

Personal Requirements for General Biosafety

  • Protective Clothing: Protective clothing such as shoes, a fully fastened laboratory coat or a chemically resistant apron must be worn in any area in which biohazards are being used. Any laboratory coat that is worn in working with biohazards shall not be worn outside the work area. Gloves that are appropriate to the specific situation shall be used when handling hazardous chemicals. Disposable gloves shall be discarded appropriately after each use and immediately after known contact with such chemicals.
  • Eye Protection: Devices to provide appropriate eye protection shall be worn in any laboratory work area where there is a danger of splashing biohazardous liquids.
  • Eating, Drinking and Smoking: There shall be no eating, drinking, smoking, chewing of gum or tobacco, preparation of food or beverages, application of cosmetics or storage of food in designated laboratory areas.
  • Pipetting: Mechanical pipetting aids shall be used for all pipetting procedures. Mouth pipetting is prohibited without exception.
  • Behavior: There shall be no horseplay or other forms of distracting behavior in a room in which chemicals are used or stored. Experiments not authorized by the instructor or investigator are prohibited.
  • Personnel Hygiene: All personnel shall wash hands immediately after completion of any procedures in which biohazards have been used and before leaving the laboratory area. Immediately after an accidental and obvious exposure to a biohazard, personnel shall wash or shower the affected area.

Facility Requirements for General Biosafety

  • Work Area Identification: Entrances to all work areas where biohazards are being used shall be posted with permanent type signs which shall be easily read and understood by a person with a minimum of special training and marked with NFPA code (see Appendix E).
  • Access Control: Work areas where biohazards are being used or stored shall be entered only by persons authorized by the principal investigator/instructor. Access doors to work or storage areas shall be kept closed and locked when work is not in progress.

Practices for Working with Chemicals

Personal Requirements for Working with Chemicals

  • Work Surfaces: All work surfaces (bench tops, hood floors, etc.) on which biohazards are used or stored shall consist of material impervious to attack by the chemical expected to be used and shall be non-porous and easily cleaned. The protective surfaces shall be examined for possible contamination immediately after each laboratory session involving a biohazard has been completed. Contaminated surfaces shall be decontaminated or disposed of as is appropriate.
  • Use of Primary Containment Devices: Procedures that involve the use of biohazardous chemicals shall be conducted in an open face laboratory-type hood or a glove box when: (i) procedures involve the use of volatile chemicals, or (ii) procedures involving the use of solid or liquid chemicals may result in the generation of aerosols. Such procedures include: the opening of closed vessels, transfer operations, weighing, preparation of feed mixtures and the application, injection and intubation of a chemical into experimental animals.
  • Use of Shared Analytical Instrumentation: Instruments which produce vapors or aerosols of chemicals shall be vented through local exhaust ventilation at the site of their production. Whenever possible, these instruments should be placed in an open face laboratory-type hood. In the event of contamination the equipment shall be labeled appropriately until it has been completely decontaminated. These guidelines apply to shared analytical equipment even when only infrequently used for chemicals.
  • Storage Inventory and Identification: Stock quantities of chemicals shall be stored in a properly ventilated specific storage area that is secured at all times. An inventory of stock quantities shall be maintained by the principal investigator/instructor that shall provide copies to the department chairperson. The inventory records shall include the quantities of chemicals acquired and dates of acquisition and disposition. Storage vessels containing stock quantities shall be appropriately labeled.
  • Working Quantities: Quantities of chemicals present in the work area shall not exceed the amounts required for use in one week unless it is a regularly used reagent present in quantities of 1 gallon or less. Storage vessels containing working quantities shall be appropriately labeled.
  • Flammable Liquids: The use of an open flame to heat any flammable liquid is expressly prohibited.
  • Dispensing and Transporting Potentially Hazardous Material within the School: Section 3.2.C.
  • Housekeeping: General housekeeping procedures which suppress the formation of aerosols, such as the use of a wet mop may be used to remove particulates. Dry sweeping and dry mopping are prohibited in laboratories because of the hazard of aerosol formation. In those instances where the chemical or contaminated material is spilled, special procedures developed for the individual compounds shall be followed.
  • Protection of Vacuum Lines: Each vacuum service, including water aspirators, if used with hazards chemicals shall be protected with a gaseous or liquid trap, as required, to prevent entry of any chemical into the system or public water supply.
  • Chemical Packaging and Shipping: Chemicals shall be packaged to withstand shocks, pressure changes, and any other conditions incident to ordinary handling in transportation which might cause the leakage of contents. Shipments shall be in accordance with DOT regulations.
  • Chemical Decontamination: Contaminated materials shall be decontaminated by procedures that either react with the chemical to produce a safe product or remove them for subsequent disposal. Chemicals that have spilled out of a primary container so as to constitute a hazard shall be inactivated in situ or shall be absorbed by appropriate means for subsequent disposal. A means for assuring adequacy of cleanup should be provided.
  • Disposal: The method selected for handling, storage and ultimate disposal of contaminated waste shall be approved by the Biosafety Committee, departmental chairperson and EHS Office. Proper containers used for the collection of biohazardous waste generated during a laboratory session must be maintained in the laboratory where the waste is generated.

Generators of Medical Waste that ship their waste off-site for treatment are required to properly package and label as specified in 30 TAC330.1207(c). Generators are required to list the weight of each Medical Waste container on the generator label per 30 TAC330.1207(c) (5) prior to transportation offsite to allow for complete tracking.

Containers used for disposal of biohazard waste shall be approved containers with lid and labeling indicating “Biohazard Waste” or “Medical Waste”. The container will be lined with a red bag.

Biology will accumulate their Medical Waste in a designated HW Accumulation area. Autoclaving of medical waste is acceptable but only as a method of destroying the bacteria to minimize biological growth and odor concerns. Autoclaved waste must then be disposed of as Medical Waste through a certified Medical Waste disposal service.

Facilities Service (Housekeeping Division) will contact the Biology Lab Supervisor every quarter to schedule pickup of the departmental Medical Waste. Refer to Medical Waste Disposal – Chain of Custody SOP.

Facility Requirements for Working with Biohazardous Chemicals

  • Handwashing Facility: A handwashing facility shall be available within the work area.
  • Shower Facility: An emergency drench shower or eyewash shall be located in each room in which biohazardous chemicals are being used.
  • Exhaust Air from Primary Containment Devices: The air exhaust laboratory-type hoods and other ventilated containment devices shall be discharged to the outdoors so that it is dispersed clear of occupied buildings and air intakes. Treatment shall be provided by filtration, reaction, absorption, adsorption, electrostatic precipitators or incineration as appropriate. The appropriate method of treatment shall be determined by the department chairperson, Biosafety Committee and safety officer. Exhaust air treatment systems that remove chemicals from the exhaust air by collection mechanisms such as filtration, absorption and adsorption shall be operated in a manner that permits maintenance so as to avoid direct contact with the collection medium.
  • Gas Cylinders: Gas cylinders must be stored securely so that they cannot tip over.

Dispensing and Transporting Chemicals within the University

  • An acid pail shall be used to transport single glass containers of acids as well as other highly reactive material. An acid pail shall be any container impervious to attack by the material being transported, but not made of glass, and being large enough to contain all of the material, in case of breakage of original container. The shipping carton may be used to transport quantities greater than one primary container.
  • Liquid nitrogen as well as other liquefied gases shall be dispensed into and transported in approved cryogenic containers only. Cryogenic containers shall be designed to hold low temperature, liquefied gases and made of materials that can withstand the rapid changes and extreme differences in temperature encountered in working with liquefied gases. They shall be built to withstand normal operating pressures sand shall be either open or protected by a vent or other pressure relieving device that permits vapors to escape. Only vent tubes and stoppers supplied with these containers shall be used.
  • Flammable liquids shall be dispensed into and transported in approved safety cans only. Glass containers with manufacturers seal unbroken may be used to transport flammable liquids.
  • Compressed gas cylinders (filled, partially filled, and empty) shall be transported using a cylinder dolly designed expressly for that purpose. The cylinders must be securely capped and fastened to the transport equipment.
  • Transfer from one container to another of material (flammable or non-flammable) that, at normal temperatures, gives off toxic vapors, shall be performed inside a vent hood. Quantities greater than one pint shall be transferred only with leak-proof systems in well-ventilated areas.
  • If a package of material is damaged so that there is probability of escape of the contents, the Lab Supervisor and Dept. Chair shall be notified by the discoverer of the condition prior to acceptance or disposal of the material.

General Guidelines for the Storage of Chemicals in Laboratories

  • Good lab practice requires that storage be accomplished in a certain manner to insure safety and to eliminate mistakes which may prove costly in terms of time, money and loss of valuable resources. Whereas plastic ware and/or paper goods may be stored on high shelves without concern for breakage or spillage, care must be taken to prevent accidental contact with fragile or hazardous material in case of a fall (See Appendix A).
  • 2 Biohazards should never be stored in glass containers on high shelves. The dangers of leaking as well as the consequences of a fall are too drastic to allow this practice to occur. Because lids do corrode and stop cocks do leak, it is imperative that chemicals that are not compatible be separated so that the likelihood of an unplanned reaction becomes as remote as possible.
  • Glassware that is dirty must be separated from clean so that there is very little opportunity to mix them up.
  • Flammable chemicals must be stored in a ventilated cabinet with a self-closing door and enough pan room to contain a reasonable amount of the chemical if a spill should occur.
  • The area beneath the fume hood may be used for storage of flammable liquids in small quantities (1 gal. each) if that area is vented through the fume hood. Acids may be stored in the same area under the same conditions but not without a separation between flammables and acids. Perhaps the safest method is accomplished by storing acids in the area under the fume hood and storing flammables in an especially designed flammable storage cabinet (available on the market).
  • Generally, strong alkaline agents are non-fuming and may be stored in areas under sinks, etc.
  • Great care must be taken with labeling, especially if chemicals are mixed into an unmarked container. Refer to Hazard Communication Plan for labelling requirements.
  • The entranceways to rooms where chemicals are used or stored should be marked with the NFPA code (See Appendix E) that represents the most hazardous chemical in the room.

Guidelines for Working Safely with Microorganisms and Other Biohazards

Microbiology laboratories are special work environments that may pose an identifiable infectious disease risk to persons in or near them. The majority of documented infections have been related, historically, to mouth pipetting. Working with infectious agents has not been shown to represent a threat to the community. Of the 109 laboratory-associated infections recorded at the Centers for Disease Control and Prevention from 1947–19734, no secondary cases were found in family members or community contacts. Moreover, no laboratory-acquired infections of students or staff have been recorded at St. Mary’s in more than 60 years of using microorganisms in the laboratory classroom.

In the United States, however, no single code of practice, standards, guidelines, exists for work with infectious agents. The descriptions of Biosafety Levels 1-4 given below parallel those in the NIH Guidelines for Research Involving Recombinant DNA,5, 6, 7 and are consistent with the general criteria originally used in assigning agents to Classes 1-4 in Classification of Etiologic Agents on the Basis of Hazards.2 Recommendations for Biosafety levels for specific agents are made on the basis of the potential hazard of the agent and of the laboratory function or activity.

Since the early 1980’s, laboratories have applied these fundamental guidelines in activities associated with manipulations involving the human immunodeficiency virus (HIV). Guidelines were also promulgated for health care workers under the rubric of Universal Precautions.3 Indeed, Universal Precautions and the BMBL have become the basis for safe handling blood and body fluids, as described in the recent OSHA publication Bloodborne Pathogen Standard.9

In the late 1980’s, considerable public concern was expressed about medical wastes, which led to the promulgation of the Medical Waste Tracking Act of 1988.8 The principles established in the earlier volumes of the BMBL for handling potentially infectious wastes as an occupational hazard were reinforced by the National Research Council’s Biosafety in the Laboratory: Prudent Practices for the Handling and Disposal of Infectious Materials.1

Experience has demonstrated the prudence of the Biosafety Level 1-4 practices, procedures and facilities described for manipulations of etiologic agents in laboratory settings and animal facilities. Although no national reporting system exists for reporting laboratory-associated infections, anecdotal information compiled by the CDC suggests that strict adherence to these guidelines does contribute to a healthier and safer work environment for laboratorians, their co-workers and the surrounding community.

Principles for Safely Using Microorganisms in the Laboratory

  • Instructor Qualifications: A scientist trained and knowledgeable in appropriate laboratory techniques, safety procedures, and hazards associated with handling infectious agents must direct laboratory activities involving any microorganisms.
  • Containment: The term “containment” is used in describing safe methods for managing infectious agents in the laboratory environment where they are being handled or maintained. The purpose of containment is to reduce or eliminate exposure of laboratory workers, other persons, and the outside environment to potentially hazardous agents. Primary containment, the protection of personnel at the immediate laboratory environment from exposure to infectious agents, is provided by both good microbiological technique and the use of appropriate safety equipment. Secondary containment, the protection of the environment external to the laboratory from exposure to infectious materials, is provided by a combination of facility design and operational practices. Therefore, the three elements of containment include laboratory practice and technique, safety equipment, and facility design.
  • Laboratory Practice and Technique. The most important element of containment is strict adherence to standard microbiological practices and techniques. Persons working with infectious agents or potentially infected materials must be aware of potential hazards, and must be trained and proficient in the practices and techniques required for handling such material safely. The principle investigator or person in charge of the laboratory is responsible for providing or arranging for appropriate training of personnel and students. Personnel and students should be advised of special hazards and should be required to read and to follow the required practices and procedures.

Facility Requirements for Working with Microorganisms

The risk assessment of the work to be done with a specific agent will determine the appropriate combination of the following elements:

  • Safety Equipment: (Primary Barriers): For general work with microorganisms, safety equipment shall include as a minimum, such items for personal protection as lab coats, safety glasses and shoes. But, if aerosol transmission is possible, then use of the agent should be restricted at St. Mary’s, as appropriate safety equipment (e.g., biological safety cabinets [BSCs], enclosed containers, and other engineering controls designed to remove or minimize exposures) may not be available. The biological safety cabinet (BSC) is the principal device used to provide containment of infectious splashes or aerosols generated by many microbiological procedures. An example of another primary barrier is the safety centrifuge cup, an enclosed container designed to prevent aerosols from being released during centrifugation.
  • Facility Design (Secondary Barriers): The design of the facility is important in providing a barrier to protect persons working inside and outside of the laboratory within the facility, and to protect persons or animals in the community from infectious agents which may be accidentally released from the laboratory. The recommended secondary barrier(s) will depend on the risk of transmission of specific agents. For example, the exposure risks for most laboratory work in Biosafety Level 1 and 2 facilities will be direct contact with the agents, or inadvertent contact exposures through contaminated work environments. Secondary barriers in these laboratories may include separation of the laboratory work area from public access, availability of a decontamination facility (e.g., autoclave), and handwashing facilities.
  • As the risk for aerosol transmission increases, higher levels of primary containment and multiple secondary barriers may become necessary to prevent infectious agents from escaping into the environment. Such design features could require specialized ventilation systems to assure directional airflow, air treatment systems to decontaminate or remove agents from exhaust air, etc. Such facilities do not exist at St. Mary’s and investigators are, therefore, limited to using agents requiring Biosafety Level 1 and 2 facilities.

Infectious Waste Treatment and Disposal and the Handling of Infectious Wastes

Hands should be washed after handling infectious waste and eating, drinking, and smoking is prohibited. Workers using an autoclave should wear a rubber apron, sturdy shoes, asbestos-free heat-resistant gloves, and a face shield, to protect against accidents that may occur while loading or unloading the autoclave.

  • Chemical Decontamination: The addition of liquid chlorine bleach, iodophors or phenolic disinfectants may be added to pipette discard containers at workstations, etc. The concentration of the disinfectant should be such that the addition of liquid waste will not interfere with its effectiveness (follow manufacturer’s recommendations).
  • Steam Autoclaving: A technically proven method for disinfection and can be used for decontaminating cultures, laboratory glassware, pipettes, syringes or other small contaminated items used in the lab. Autoclaving will not be used as the primary method for treatment of biohazardous waste generated in Biology. Autoclaving can be used as a means to destroy biological growth and reduce odors while waste is in storage. But this biohazardous /medical waste will then need to be disposed of as Medical Waste through the waste stream for Medical Waste disposal and treatment off-site. Refer to Section 3.2.A.12 of this document.
  • Incineration: The method of choice for disinfecting large volumes of infectious waste, and animal carcasses and bedding. However, an incinerator is not available at St. Mary’s. St. Mary’s uses a Medical Waste Disposal service to pick up and transport the Medical Waste generated in the Biology department to a treatment and disposal facility for incineration.

Description of Biosafety Levels 1-4:

Four biosafety levels (BSLs) are described which consist of combinations of laboratory practices and techniques, safety equipment, and laboratory facilities. Each combination is specifically appropriate for the operations performed, the documented or suspected routes of transmission of the infectious agents, and for the laboratory function or activity. The laboratory instructor or principle investigator is specifically and primarily responsible for assessing risks and for appropriately applying the recommended biosafety levels. Only agents requiring BSL 1 or 2 may be used at St. Mary’s University.

Generally, work with known BSL 2 agents shall be prohibited, but permission to use such agents may be granted by the Biosafety Committee after review of the investigator’s written proposal (see list of restricted agents below in Appendix C). However, when specific information is available to suggest that virulence, pathogenicity, antibiotic resistance patterns, vaccine and treatment availability, or other factors are significantly altered, more (or less) stringent practices may be specified.

  • Biosafety Level 1: Biosafety Level 1 represents a basic level of containment that relies on standard microbiological practices with no special primary or secondary barriers recommended, other than a sink for handwashing. Safety equipment and facilities are appropriate for undergraduate and secondary educational training and teaching laboratories, and for other facilities in which work is done with defined and characterized strains of viable microorganisms not known to cause disease in healthy adult humans. Bacillus subtilis, Naegleria gruberi, and infectious canine hepatitis virus are representative of those microorganisms meeting these criteria. Many agents not ordinarily associated with disease processes in humans are, however, opportunistic pathogens and may cause infection in the young, the aged, and immunodeficient or immunosuppressed individuals. Vaccine strains which have undergone multiple in vitro passages should not be considered avirulent simply because they are vaccine strains.
  • Biosafety Level 2: Equipment and facilities are applicable to clinical, diagnostic, teaching and other facilities in which work is done with the broad spectrum of indigenous moderate-risk agents present in the community and associated with human disease of varying severity. With good microbiological techniques, these agents can be used safely in activities conducted on the open bench, provided the potential for producing splashes or aerosols is low. Hepatitis B virus, the salmonellae, and Toxoplasma are representative of microorganisms assigned to this containment level. BSL 2 is appropriate when work is done with any human or animal-derived blood, body fluids, or tissues where the presence of an infectious agent may be unknown. University personnel working with human-derived materials should refer to Policy Controlling Exposure to Bloodborne Pathogens in the University’s Faculty Handbook (Section 2.12.6) and the Bloodborne Pathogen Standard9 for specific, required precautions. Investigators must submit a written proposal, which must be approved by the Biosafety Committee, before BSL 2 agents may be used on campus.
  • Primary hazards to personnel working with these agents relate to accidental cutaneous or mucous membrane exposures, or ingestion of infectious materials. Extreme precaution with contaminated needles or sharp instruments must be emphasized. Even though BSL 2 organisms are not known to be transmissible by the aerosol route, procedures with high splash potential may increase the risk of creating aerosols and suitable precautions should be taken (e.g., face shields, safety centrifuge cups, lab gowns, gloves, etc.).
  • Secondary barriers such as handwashing and waste decontamination facilities must be available to reduce potential environmental contamination.
  • Biosafety Level 3: Safety equipment and facilities are applicable to clinical, diagnostic, teaching, research, or production facilities in which work is done with indigenous or exotic agents with a potential for respiratory transmission, and which may cause serious and potentially lethal infection. BSL 3 containment facilities are not present on campus and, therefore, the use of BSL 3 agents at St. Mary’s is prohibited.
  • Biosafety Level 4: Safety equipment and facilities are applicable for work with dangerous and exotic agents which pose a high individual risk of life-threatening disease, which may be transmitted via the aerosol route, and for which there is no available vaccine or therapy. BSL 4 containment facilities are not present on campus and, therefore, the use of BSL 4 agents at St. Mary’s University is prohibited.
  • Biosafety Levels Appropriate for use with Animals: The four biosafety levels also appropriately describe activities involving infectious disease work with experimental mammals. These four combinations of practices, safety equipment, and facilities are designated Animal Biosafety Levels 1, 2, 3, and 4, and provide increasing levels of protection to personnel and the environment. A written proposal must be submitted and approved by the Biosafety Committee and the Animal Use Committee before a researcher/instructor may use any infectious agent to infect mammalian animals.

Personal and Facility Requirements for Working with Biosafety Level 1 Agents: Biosafety Level I is suitable for work involving well-characterized agents not known to cause disease in healthy adult humans, and of minimal potential hazard to laboratory personnel and the environment. The laboratory is not necessarily separated from the general traffic patterns in the building. Work is generally conducted on open bench tops using standard microbiological practices. Special containment equipment or facility design is not required generally. Laboratory personnel have specific training in the procedures conducted in the laboratory and are supervised by a scientist with general training in microbiology or a related science.

The following standard and special practices, safety equipment and facilities apply to agents assigned to Biosafety Level 1:

Standard Microbiological Practices

  • Access to the laboratory is limited or restricted at the discretion of the laboratory instructor or principle investigator when experiments or work with cultures and specimens are in progress.
  • Persons wash their hands after they handle viable materials and animals, after removing gloves, and before leaving the laboratory.
  • Eating, drinking, smoking, handling contact lenses, and applying cosmetics are not permitted in the work areas where there is reasonable likelihood of exposure to potentially infectious materials. Persons who wear contact lenses in laboratories should also wear safety glasses/ 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 is prohibited; mechanical pipetting devices are used.
  • All procedures are performed carefully to minimize the creation of splashes or aerosols.
  • Work surfaces are always decontaminated before and after use and after any spill of viable microorganisms.
  • All cultures, stocks, or other biohazardous wastes can undergo preliminary decontamination such as autoclaving before disposal to reduce biological growth and odor. All biohazardous materials once treated by the autoclave shall be placed in a durable, leak-proof container and closed for transport from the laboratory. All biohazardous materials will be packaged in accordance with applicable local, state, and federal regulations, and shipped off-site for disposal using a certified Medical Waste disposal service provider. Refer to Section 3.2.A.12 of this document.
  • An insect and rodent control program is in effect. No dry sweeping, mopping and vacuuming of floors is allowed, to prevent aerosol formation; wet mopping with a disinfectant cleaner must be used instead.

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 (required for students) that safety goggles/ glasses and laboratory coats, gowns, or uniforms be worn to prevent contamination or soiling of street clothes; closed toe shoes must be worn.
  • Gloves should be worn if the skin on the hands is broken or if a rash exists.

Laboratory Facilities (Secondary Barriers)

  • Each laboratory contains a sink for handwashing.
  • The laboratory is designed so that it can be easily cleaned. Rugs in laboratories are not appropriate, and should not be used because proper decontamination following a spill extremely difficult to achieve.
  • Bench tops are impervious to water and resistant to acids, alkalis, organic solvents, and moderate heat.
  • Laboratory furniture is sturdy. Spaces between benches, cabinets, and equipment are accessible for cleaning.
  • If the laboratory has windows that open, they must be fitted with fly screens.

Personal and Facility Requirements for Working with Biosafety Level 2 Agents

Biosafety Level 2 is similar to Level 1 and is suitable for work involving agents of moderate potential hazard to personnel and the environment. It differs in that (1) laboratory personnel have specific training in handling pathogenic agents and are directed by competent scientists, (2) access to the laboratory is limited when work is being conducted, (3) extreme precautions are taken with contaminated sharp items, and (4) certain procedures in which infectious aerosols or splashes may be created are conducted in biological safety cabinets or other physical containment equipment.

The following standard and special practices, safety equipment, and facilities apply to agents assigned to Biosafety Level 2:

Standard Microbiological Practices

  • Access to the laboratory is limited or restricted at the discretion of the laboratory principle investigator when experiments are in progress.
  • Persons wash their hands after they handle viable materials and animals, after removing gloves, and before leaving the laboratory.
  • Eating, drinking, smoking, handling contact lenses, and applying cosmetics are not permitted in the work areas. Persons who wear contact lenses in laboratories should also wear safety goggles/ glasses or a face shield. Food is stored outside the work area in cabinets or refrigerators designated for this purpose only.
  • Mouth pipetting is prohibited; mechanical pipetting devices are used.
  • All procedures are performed carefully to minimize the creation of splashes or aerosols.
  • Work surfaces are always decontaminated before and after use and after any spill of viable material.
  • All cultures, stocks, or other biohazardous wastes can undergo preliminary decontamination such as autoclaving before disposal to reduce biological growth and odor. All biohazardous materials once treated by the autoclave shall be placed in a durable, leak-proof container and closed for transport from the laboratory. All biohazardous materials will be packaged in accordance with applicable local, state, and federal regulations, and shipped off-site for disposal using a certified Medical Waste disposal service provider. Refer to Section 3.2.A.12 of this document.
  • An insect and rodent control program is in effect.
  • No dry sweeping, mopping and vacuuming of floors is allowed, to prevent aerosol formation, wet mopping with a disinfectant cleaner must be used instead.

Special Practices

  • Access to the laboratory is limited or restricted by the laboratory principle investigator when work with infectious agents is in progress. In general, persons who are at increased risk of acquiring infection or for whom infection may be unusually hazardous are not allowed in the laboratory or animal rooms. For example, persons who are immunocompromised or immunosuppressed may be at risk of acquiring infections. The laboratory principle investigator has the final responsibility for assessing each circumstance and determining who may enter or work in the laboratory.
  • The laboratory principle investigator establishes policies and procedures whereby only persons who have been advised of the potential hazard and meet specific entry requirements (e.g., immunization) enter the laboratory or animal rooms.
  • When the infectious agent(s) in use in the laboratory require special provisions for entry (e.g., immunization), a hazard warning sign incorporating the universal biohazard symbol is posted on the access door to the laboratory work area. The hazard warning sign identifies the infectious agent, lists the name and telephone number of the laboratory principle investigator or other responsible person(s), and indicates the special requirement(s) for entering the laboratory.
  • University personnel receive appropriate immunizations or tests for the agents handled or potentially present in the laboratory (e.g., hepatitis B vaccine or TB skin testing, see the University’s Faculty Handbook Section 2.12.6.1.2).
  • When appropriate, considering the agent(s) handled, baseline serum samples for laboratory 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.
  • A biosafety manual is prepared or adopted. Personnel are advised of special hazards and are required to read and to follow instructions on practices and procedures.
  • Laboratory personnel receive appropriate training on the potential hazards associated with the work involved, the necessary precautions to prevent exposures, and the exposure evaluation procedures. Personnel receive annual updates, or additional training as necessary for procedural or policy changes.
  • A high degree of precaution must always be taken with any contaminated sharp items, including needles and syringes, slides, pipettes, capillary tubes, and scalpels. Needles and syringes or other sharp instruments should be restricted in the laboratory for use only when there is no alternative. Plastic ware should be substituted for glassware whenever possible.
  • 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; rather, they must be carefully placed in conveniently located puncture-resistant containers used for sharps disposal. Non-disposable sharps must be placed in a hard-walled container. The sharps container can be transported to a processing area for preliminary decontamination (i.e. autoclaving) before adding it to the Medical Waste stream for off-site disposal. Whether or not the sharps are autoclaved the sharps container must be disposed of in an approved Medical Waste container for disposal off-site using a certified Medical Waste disposal service. Refer to Section 3.2.A.12 in this document.
  • Syringes which re-sheathe the needle, needle-less systems, and other safe devices should be used when appropriate.
  • Broken glass 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 broken glass shall be treated and disposed similar to the requirements of sharps according to all applicable local, state, or federal regulations. Refer to preceding Section G.2.i and Section 3.2.A.12 in this document.
  • Cultures, tissues, or specimens of body fluids are placed in a container that prevents leakage during collection, handling, processing, storage, transport, or 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 materials are immediately reported to the laboratory principle investigator. 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.

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, face shield 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, or uniforms designated for lab use 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.

Laboratory Facilities (Secondary Barriers)

  • Each laboratory contains a sink for handwashing.
  • The laboratory is designed so that it can be easily cleaned. Rugs in laboratories are not appropriate, and should not be used because proper decontamination following a spill is extremely difficult to achieve.
  • Bench tops are impervious to water and resistant to acids, alkalis, organic solvents, and moderate heat.
  • Laboratory furniture is sturdy, and spaces between benches, cabinets, and equipment are accessible for cleaning.
  • If the laboratory has windows that open, they are fitted with fly screens.
  • A method for decontamination of infectious or regulated laboratory wastes is available (e.g., autoclave, chemical disinfection, incinerator, or other approved decontamination system).
  • An eyewash facility is readily available.

Selection of an appropriate biosafety level for work with a particular agent or animal study depends upon a number of factors. Some of the most important are: the virulence, pathogenicity, biological stability, route of spread, and communicability of the agent; the nature or function of the laboratory; the procedures and manipulations involving the agent, and the availability of effective vaccines or therapeutic measures.

The assessment of risks associated with laboratory activities involving the use of infectious microorganisms is ultimately a subjective process. The risks associated with the agent, as well as with the activity to be conducted, must be considered in the assessment. Agents are listed in the prohibited category (Appendix C) based on the following criteria: the agent is a proven hazard to laboratory personnel working with infectious materials (e.g., hepatitis B virus, M. tuberculosis); the potential for laboratory associated infections is high, even in the absence of previously documented laboratory-associated infections (e.g., exotic arboviruses); or, the consequences of infection are grave.

Risk assessments and biosafety levels recommended here presuppose a population of immunocompetent individuals. Persons with altered immunocompetence may be at increased risk when exposed to infectious agents. Immunodeficiency may be hereditary, congenital, or induced by a number of neoplastic or infectious diseases, by therapy, or by radiation. The risk of becoming infected or the consequence of infection may also be influenced by such factors as age, sex, race, pregnancy, surgery (e.g., splenectomy, gastrectomy), predisposing diseases (e.g., diabetes, lupus erythematosus) or altered physiological function. These and other variables must be considered in applying generic risk assessments of agents to specific activities of selected individuals.

The laboratory principle investigator must make an assessment of the activities conducted and select practices, containment equipment, and facilities appropriate to the risk, irrespective of the volume or concentration of agent involved. The laboratory principle investigator should also give special consideration to selecting appropriate safeguards for materials that may contain a suspected agent. For example, sera of human origin may contain hepatitis B virus, and therefore, all blood or blood-derived fluids should be handled under conditions which reasonably preclude cutaneous, mucous membrane or parenteral exposure of personnel. The laboratory principle investigator is also responsible for appropriate risk assessment and for utilization of appropriate practices, containment equipment, and facilities for agents not included in the agent summary statements.

The infectious agents (including bodily fluids) that meet the previously stated criteria are listed by category of agent in Appendix B.

Guidelines for the Use of Recombinant DNA Molecules

The National Institutes of Health (NIH) has established recombinant DNA guidelines concerning research involving interspecific DNA transfer. The subject of recombinant DNA guidelines cannot be adequately covered in this manual. Since the NIH continuously revises the guidelines, any detailed discussion in this manual would rapidly become obsolete. The trend has been to deregulate general cloning procedures in approved vectors. Most experiments have been placed in the Biosafety Level 1 category that, in essence, refers to bench work using standard microbiological practices. It is, however, advisable to perform such procedures in a class II BSC.

The principal investigator must review the current NIH publication, NIH Guidelines for Research Involving Recombinant DNA Molecules, to determine whether special containment is required for a project. Copies of the revised guidelines (October, 2011) are available for reference from the chairperson of the Biosafety Committee. Certain experiments are exempt from NIH regulation and may be performed at St. Mary’s University using BSL 1 practices.

As stated in provision III-F-6 of the Guidelines (NIH 2011):

The following recombinant DNA molecules are exempt from the NIH Guidelines and registration with the Institutional Biosafety Committee is not required:

Section III-F-1. Those that are not in organisms or viruses.

Section III F-2. Those that consist entirely of DNA segments from a single nonchromosomal or viral DNA source, though one or more of the segments may be a synthetic equivalent

Section III-F-3. Those that consist entirely of DNA from a prokaryotic host including its indigenous plasmids or viruses when propagated only in that host (or a closely related strain of the same species), or when transferred to another host by well-established physiological means

Section III-F-4. Those that consist entirely of DNA from a eukaryotic host including its chloroplasts, mitochondria, or plasmids (but excluding viruses) when propagated only in that host (or a closely related strain of the same species).

Section III-F-5. Those that consist entirely of DNA segments from different species that exchange DNA by known physiological processes, though one or more of the segments may be a synthetic equivalent. A list of such exchangers will be prepared and periodically revised by the NIH Director with advice of the RAC after appropriate notice and opportunity for public comment (see Section IV-C-1-b-(1)-(c), Major Actions). See Appendices A-I through A-VI, Exemptions under Section III-F-5–Sublists of Natural Exchangers, for a list of natural exchangers that are exempt from the NIH Guidelines

Section III-F-6. Those that do not present a significant risk to health or the environment (see Section IV-C-1-b-(1)-(c), Major Actions), as determined by the NIH Director, with the advice of the RAC, and following appropriate notice and opportunity for public comment. See Appendix C, Exemptions under Section III-F-6 for other classes of experiments which are exempt from the NIH Guidelines

The University’s Biosafety Committee does not meet the requirements laid out in the Guidelines (NIH 2011); consequently only exempt experiments may be performed on campus. If a researcher wishes to perform non-exempt experiments on campus, he/she would have to request in writing to the chair of the Biosafety Committee that an Institutional Biosafety Committee that conforms to the NIH Guidelines be established before experimentation involving interspecific mixing of DNA begins and before submission of a grant for funds for recombinant DNA research.

Guidelines for Controlling Exposure to Bloodborne Pathogens

The Policy Controlling Exposure to Bloodborne Pathogens is found in Section 2.12.6 of the University’s Faculty Handbook. These guidelines should be followed for any University personnel with an occupational exposure to human blood. However, principle investigators and/or instructors must submit a written proposal, which must be approved in writing by the Biosafety Committee, before human blood, cells, or tissue may be used in research or for instruction at the University.

Available in the Administration and Finance Office:

Appendix A: Guide to Compatibility of Chemicals

Appendix B: Notes to Compatibility Chart – Reactivity Differences (Deviations) Within Chemical Groups (General Classes of Incompatible Chemicals, Examples of Incompatible Chemicals, and Chemicals Recommended for Refrigerator Storage)

Appendix C: Restricted Agents Classified as Biosafety Level 2

Appendix D: Resources for Information on Biohazard Control

Appendix E: Biohazard Labels

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