Attachment_34_COBRATF_Biosafety_Manual_for_BSL_2_Areas.pdf

Training Operations and Support

Services – COBRATF

Attachment 34

COBRATF Biosafety Manual

FEMA MANUAL

Chemical, Ordnance, Biological, Radiological Training Facility

Biosafety Manual for BSL-2 Areas

APPROVAL DATE: 05/22/2013

DEPARTMENT OF HOMELAND SECURITY

CENTER FOR DOMESTIC PREPAREDNESS

Charles M. King Acting Superintendent Center for Domestic Preparedness

Date: _______________________

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Signatures

Reviewed By: ________________________________ __________________ William Cappucio Date ECBC Biosafety Committee Chairman

John Blandamer Date Biosafety Officer

Andrea J. Higgins Date Biologist

Holly S. Terrell Date Laboratory Manager

Gary L. Milner Date Assistant Director, COBRATF

Denis Campeau Date Director of Training and Education, CDP

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Foreword

The COBRATF Biosafety Manual (BSM) prescribes the technical safety requirements for the use, handling, transfer, storage, and disposal of biological materials used at the COBRATF Biosafety Level 2 (BSL-2) laboratory and toxic agent area. The BSM is a resource for information, guidelines, policies, and procedures that will enable and promote those working in the laboratory and toxic agent area to work safely and reduce or eliminate the potential for exposure to biological hazards. The information presented also reflects the requirements and guidelines of federal and state regulations.

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Table of Contents

Signatures

Foreword

CHAPTER 1: GENERAL INFORMATION

1-1. Purpose

1-2. Applicability and Scope

1-3. Supersession

1-4. Authorities/References

1-5. Policy

1-6. Definitions

1-7. Responsibilities

1-8. Reporting Requirement

1-9. Forms Prescribed

1-10. Questions

CHAPTER 2: PROCEDURES

2-1. Principles of Biosafety

2-2. Administration

2-3. Personnel Qualifications and Training

2-4. Occupational Health Program

2-5. Facility Design

2-6. Laboratory Equipment Care and Use

2-7. Personal Protective Equipment

2-8. Laboratory-Specific Biological Safety Practices

2-9. Decontamination and Disposal

2-10. Emergency Planning and Response to a Biological Incident

CHAPTER 3: APPENDICES

Appendix 1 – Laboratory Orientation Checklist (SAMPLE)

Appendix 2 – List of Training and Other Requirements to Enter Biological Laboratory

Appendix 3 – Common Laboratory Tasks in the COBRATF BSL-2 Laboratory

Appendix 4 – Agent Specific Information

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CHAPTER 1: GENERAL INFORMATION

1-1. Purpose

The purpose of the BSM is to set technical safety requirements for the use, handling, transfer, storage, and disposal of biological materials used at the COBRATF BSL-2 laboratory and toxic agent area. The BSM is a resource for information, guidelines, policies, and procedures that will enable and promote those working in the laboratory and toxic agent area to work safely and reduce or eliminate the potential for exposure to biological hazards.

1-2. Applicability and Scope

This manual applies to all COBRATF personnel using, handling, transferring, storing and disposing of biological materials.

1-3. Supersession

This is the initial document issue.

1-4. Authorities/References

A. Biosafety in Microbiology and Biomedical Laboratories, U.S. Department of Health and

Human Services

B. CDP Safety Plan

C. COBRATF Chemical Hygiene Plan

D. COBRATF Emergency Response Plan

E. 29 CFR 1910.157

1-5. Policy

It is the policy of the CDP to furnish services to Emergency Responders that meet or exceed their requirement. This is accomplished through teamwork and continuous improvement as we develop partnerships with members of the emergency response community, as well as state/local, tribal, and federal officials to provide them with world-class services delivered on time, every time, and with the utmost professionalism.

Our expressed goal is a safe, quality, professional environment.

1-6. Definitions

A. AD – Assistant Director

B. BI – Biological Indicators

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C. BMBL – Biosafety in Microbiological and Biomedical Laboratories

D. BSC – Biosafety Cabinet

E. BSM – Biosafety Manual

F. BSO – Biosafety Officer

G. BSL-2 – Biosafety Level 2

H. CDC – Centers for Disease Control and Prevention

I. CDP – Center for Domestic Preparedness

J. CFR – Code of Federal Regulations

K. CHP – Chemical Hygiene Plan

L. Cl- – Chlorine ion or free available chlorine

M. COBRATF – Chemical, Ordnance, Biological, Radiological Training Facility

N. HEPA – High Efficiency Particulate Air

O. HOT – Hands-On Training

P. IAW – In Accordance With

Q. LET – Laboratory Essentials Training

R. MA – Medical Authority

S. MSDS – Material Safety Data Sheets

T. NaOCl – Sodium Hypochlorite, Bleach

U. NaOH – Sodium Hydroxide

V. OHN – Occupational Health Nurse

W. pH – Symbol for the logarithm of the reciprocal of hydrogen ion concentration in gram atoms per liter; used to express the acidity or alkalinity of a solution on a scale of 0 to 14, where less than 7 represents acidity, 7 neutrality, and more than 7 alkalinity

X. PPE – Personal Protective Equipment

Y. ppm – Parts Per Million

Z. SOP – Standard Operating Procedure

1-7. Responsibilities

A. The COBRATF AD is responsible for:

1. Ensuring all aspects of biological program are in compliance with BSM requirements;

2. Assessing employee/contractor performance against BSM standards and contract requirements;

3. Ensuring compliance with written operating procedures during biological operations;

http://dictionary.reference.com/browse/ion

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4. Approving individuals for access to the biological laboratory;

5. In case of a potentially life threatening deficiency, contacting affected individuals and ensuring deficiencies are corrected; and

6. Ensuring employees receive medical clearance if they must wear a respirator.

B. The BSO is responsible for:

1. Preparing and implementing the BSM;

2. Ensuring BSM procedures are understood and followed by all personnel working with and in a biological area;

3. Ensuring inspections are conducted and records maintained;

4. Assisting personnel with safety matters and providing technical assistance as needed;

5. Reviewing BSM on a biennial basis and submitting necessary revisions;

6. In concert with the OHN and Laboratory Manager, recommending the level and type of required PPE for the BSL-2 tasks;

7. Ensuring personnel have received the proper training to work with biological materials;

8. Surveying the laboratory on a quarterly basis;

9. Evaluating reports of potentially life threatening deficiencies;

10. Determining, with the Laboratory Manager, Biologist and OHN, when respiratory protection is required in the laboratory;

11. With the Laboratory Manager, clearing the laboratory for re-entry after an incident where potential contamination is expected; and

12. With OHN, assessing potential and confirmed exposures to biological materials.

C. The Laboratory Manager is responsible for:

1. Providing oversight to personnel working in BSL-2 areas;

2. Reviewing SOPs/forms associated with biological materials;

3. Providing input to BSO as necessary;

4. Reviewing biological material records for accuracy;

5. Supplementing BSM with instruction and guidance regarding specific practices and procedures to be performed;

6. Ensuring stored chemicals are inspected on a routine basis;

7. Determining, with the Biologist, OHN, and BSO, when respiratory protection is required in the laboratory;

8. Ensuring laboratory workers understand physical security requirements of biological storage;

9. With the BSO, clearing laboratory for re-entry after an incident where potential contamination is expected;

10. With the Biologist, certifying personnel to work with biological materials;

11. Recommending individuals for unescorted access into the biological laboratory to the COBRATF AD; and

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12. Reviewing daily operational checklist.

D. The Biologist is responsible for:

1. Maintaining biological material laboratory records;

2. Ensuring SOPs/forms for biological laboratory reflect current procedures;

3. Providing input to Laboratory Manager as necessary;

4. With the Laboratory Manager, certifying personnel to work with biological materials

5. Validating methods for operational, testing, and decontamination of equipment to be used in the biological areas;

6. Ensuring biosafety cabinet is certified semi-annually;

7. Determining, with the Laboratory Manager, OHN, and BSO, when a respirator would need to be worn in the laboratory;

8. Enforcing compliance with housekeeping standards in the biological laboratory; and

9. Ensuring daily checklists are completed.

E. The Operators are responsible for:

1. Completing specific biological safety training and chemical hygiene plan training initially, and when changes in tasks occur;

2. Complying with entry and exit procedures for the biological laboratory;

3. Completing the pre-operational checklist prior to starting an operation in the laboratory and completing a post-operational checklist at the end of the work day;

4. Being knowledgeable of the signs, symptoms, and emergency procedures for the chemicals with which they are working;

5. Being medically cleared to work with biological materials;

6. Wearing specified PPE;

7. Ensuring the laboratory is kept clean;

8. Reporting to the OHN if injured or potentially exposed to a biological material; and

9. Reporting all mishaps to the Laboratory Manager and BSO.

F. The Supervisor is responsible for:

1. Working with the BSO and the Laboratory Manager to ensure respective personnel are authorized to work with biological materials;

2. Ensuring employees are medically cleared prior to working with biological materials;

3. Ensuring employees receive adequate training regarding biosafety and tasks to be performed prior to working with biological materials;

4. Ensuring employees who work with biological materials are evaluated by the OHN if they have had surgical procedures or injuries involving significant alteration to the skin;

and

5. Ensuring employees who have been absent for 3 or more days due to a medical condition are evaluated by the OHN or MA before resuming duties.

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G. The OHN/MA is responsible for:

1. Evaluating and medically clearing personnel who work with biological materials (initial, periodic, and termination medical evaluations);

2. Medically clearing personnel who will wear a respirator;

3. Evaluating personnel who have had surgical procedures or injuries involving significant alternation to the skin;

4. Evaluating personnel who have been absent three or more days due to a medical condition; and

5. With the BSO, assessing potential and confirmed exposures to biological materials.

1-8. Reporting Requirement Not Applicable

1-9. Forms Prescribed

1-10. Questions

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CHAPTER 2: PROCEDURES

2-1. Principles of Biosafety

A. Risk Assessment. In this context, the primary goals of risk assessments are to prevent work-associated infection and incidents from happening in areas concerning biological materials.

1. By definition, a BSL-2 material is any indigenous moderate-risk material that is present in the community and associated with human disease of varying severity.

2. In addition to the hazard analyses and risk assessments, each individual requiring access to the biological areas must be the subject of an individual risk assessment and complete a thorough training program. Individual training for the laboratory includes Laboratory Orientation (Appendix 1) and LET, and Phase 1 - 3 training prior to the actual conduct of independent work within the biological areas. Staff working in the Toxic Agent Area will be required to take General Biosafety Training and phase training to work with biological materials.

3. Factors considered in the hazard analysis and risk assessment include the pathogenicity, transmission route, material stability, infectious dose, concentration, origin, animal study data, and prophylaxis and/or treatment availability for the materials, along with the medical surveillance, and experience/skill level of personnel. These factors are considered in comparison and contrast to current policies and procedures.

4. Hazards to personnel working with biological materials are respiratory exposure to infectious aerosols, mucous membrane or broken skin exposure to infectious droplet, and autoinoculation. Manipulations of BSL-2 materials pose a moderate risk of exposure and infection to personnel. Each of these risks represents a critical point, necessitating mitigation to ensure protection of COBRATF personnel.

5. Risk Mitigation:

a. In the laboratory, risks are mitigated by ensuring that manipulation of all biological materials are only conducted within a Class II BSC or other primary barrier, utilizing proper laboratory techniques, by proficient personnel who have completed general training regarding biological safety and task specific training by experienced personnel, proper clean-up techniques and established emergency response procedures.

b. In the Toxic Agent Area, risks are mitigated by wearing proper PPE, performing operations by proficient personnel who have completed general training regarding biological safety and task specific training by experienced personnel, and utilizing established emergency response procedures.

6. Materials:

a. Bacillus anthracis delta Sterne: B. anthracis delta Sterne is an attenuated form of Bacillus anthracis, the causative agent of anthrax. See Appendix 4 for further information.

b. Ricin A chain is one subunit of the toxin Ricin. See Appendix 4 for further information.

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7. Hazard Analysis:

a. Hazard Analysis performed for biological agents are a function of severity vs.

probability.

b. There are four hazard severity categories used to classify processes. Engineering and administrative controls, human error, design inadequacies, procedural deficiencies, and system, subsystem, or component failure or malfunctions are considered in the hazard assessment. Hazard categories are assigned as follows:

(1) 1 = Category 1 - Catastrophic - May cause loss of life or loss of system.

(2) 2 = Category 2 - Critical - May cause severe injury or minor system damage.

(3) 3 = Category 3 - Marginal - May cause minor injury or minor system damage.

(4) 4 = Category 4 - Negligible - Will not result in injury or system damage.

c. Each safety hazard has been assigned a probability indicator as follows:

(1) 1(E) = Unlikely

(2) 2(D) = Remote

(3) 3(C) = Occasional

(4) 4(B) = Likely

(5) 5(A) = Frequent

d. A risk assessment level is assigned (based on the chart below) during the hazard analysis.

B. Supervision. The employees’ supervisor, Laboratory Manager, and the BSO, or qualified designee, are responsible for authorizing personnel to work with operations involving biological materials and toxins and ensuring that employees have received the training to enable them to safely execute the operations.

1. The Laboratory Manager and operations specialist contact information is located at the entrance of the biological laboratory and biological bays. The Laboratory Manager will contact the BSO for advisement when necessary. The Laboratory Manager and

HAZARD PROBABILITY

Frequent Likely Occasional Remote Unlikely

Catastrophic 1

EXTREMELY HIGH

HIGH

MODERATE

Critical 2 MODERATE

Marginal 3 HIGH MODERATE LOW

Negligible 4 MODERATE

H A

Z A

R D

S E

V E

R

IT

Y

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operations specialist will inform the COBRATF AD of any situation that arises in the biological laboratory.

2. Experience is crucial when performing tasks safely in a BSL-2 environment. Even experienced personnel must remain vigilant and cautious and always remember WHEN IN DOUBT, ASK. The employees’ supervisor, Laboratory Manager, BSO, and COBRATF AD identify a safe/workable solution to any problem/situation that may arise while working in a BSL-2 environment.

3. The COBRATF AD shall ensure employees working in the biological areas suspend their work inside the laboratory at least 14 days prior to termination of employment to ensure proper medical surveillance.

2-2. Administration

A. Laboratory Access. The Laboratory Manager will recommend individuals for unescorted access into the biological laboratory to the COBRATF AD. Once the COBRATF AD approves an individual for access, the Access Control Specialist will provide access to the individual. A list of training and other requirements for entry into the biological laboratory is listed in Appendix 2.

1. Visitors to the laboratory must be approved by the COBRATF AD. Visitors will not enter the laboratory while biological material is outside engineering controls. Visitors are required to follow established laboratory protocols while inside the laboratory, such as utilizing sticky mats and shoe covers.

2. Toxic Agent Area. Access, entry, and exit to the Toxic Agent Area will be IAW CDP COBRATF SOPs.

3. The OHN ensures personnel who have had surgical procedures or injuries involving significant alteration to the normal integrity of the skin are evaluated. The OHN will recommend to the COBRATF AD whether or not the individual may enter the biological laboratory and/or the toxic agent area after considering all aspects of the risk involved and after consulting with the MA and others as appropriate.

4. The biological laboratory has secured, locked doors with access control readers.

Authorized persons will comply with entry and exit procedures outlined in this chapter.

A card-key activated computer record will be used to indicate the date and time of both entry and exit for all personnel in the laboratory.

5. Only authorized personnel enter the biological laboratory un-escorted.

a. Personnel not cleared for access to the biological laboratory may enter the laboratory only when escorted by authorized personnel.

b. The Laboratory Manager ensures that all laboratory workers and visitors understand physical security requirements.

c. Vaccine Requirements: Administration of the B. anthracis vaccination series is not recommended for the delta Sterne strain.

d. Laboratory Entry Procedures

(1) Swipe badge, green light on badge reader will indicate access and magnetic door lock will release.

(2) Enter laboratory by stepping on sticky mat and don shoe covers and PPE.

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e. Laboratory Exit

(1) Remove PPE and wash hands thoroughly.

(2) Swipe badge, green light on badge reader will indicate access and magnetic door lock will release.

6. Emergency Situations in the Laboratory

a. In the case of a fire within the laboratory, exit the laboratory in an orderly fashion and pull the nearest fire alarm. NOTE: Only personnel trained IAW 29 CFR 1910.157(g) will use the fire extinguisher.

b. In the case of a power failure in the laboratory, safely cease work and do not panic.

If working in a BSC during the power failure, hold your breath without inhaling, remove your gloves, slowly pull your arms out of the cabinet, and slowly close the front sash. Emergency generators will activate within 10 seconds. In addition, the laboratory is equipped with an emergency rechargeable flashlight. Safely proceed to the exit. NOTE: If there is a complete power failure and if the BSC has been powered off there may be a chance of a potential exposure depending on the procedure being performed, biological materials being manipulated, and PPE being employed. Once the situation is resolved, immediately contact the Laboratory Manager and BSO to evaluate the risk of the potential exposure. If it is determined that you may have been exposed, you must meet with the on-site medical authorities for further evaluation.

c. In case of a natural disaster, terrorist incident, suspicious package, or similar event, follow the COBRATF Emergency Response Plan.

7. Emergency Laboratory Exit

a. If magnetic door lock release does not work after swiping your badge, exit the laboratory using the emergency exit push bar on the door.

b. If possible, make sure that all personnel exit the laboratory.

c. Notify safety control of the emergency.

d. Conduct emergency procedures in the Toxic Agent Area IAW CDP COBRATF Emergency Procedures.

B. Safety Communications

Material safety data sheets for hazardous chemicals and biological materials (when an MSDS is available for the biological material) used in the laboratory are readily available to all employees, while inside the laboratory. Paper copies are also available in the technical library. In addition, electronic copies are available on the Y:\\ drive for any personnel working in a biological area.

C. Surveys

1. Before beginning work, individuals working in the biological laboratory will perform a pre-operational check. At the end of the work day, perform a post-operational check.

2. The Laboratory Manager (or designated representative) conducts a weekly walk-thru of the laboratory, ensuring weekly testing of eye-wash station, and the safety shower has been completed. It will also include ensuring that walkways are free of obstacles and hazards that could impair emergency egress from the laboratory.

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3. The BSO will survey the laboratory on a quarterly basis. This survey will consist of, at a minimum, a visual inspection of the biological laboratory and select records verification.

4. Reports of deficiencies or procedures that create a potentially life threatening situation will be immediately referred to the COBRATF AD and BSO. Corrective actions will be immediately implemented. The suspect operation will not continue until every health and safety code deficiency is corrected. The Laboratory Manager or the COBRATF AD will ensure that individuals directly concerned are contacted and deficiencies remedied before operations are resumed.

5. Reports of deficiencies for other than life-threatening situations will be made as soon as possible to the Laboratory Manager and to the BSO.

6. Malfunctioning equipment will be reported to the appropriate individuals, labeled to indicate that it will not be used, and repaired promptly. This corrective action is the responsibility of the Biologist.

7. All deficiencies noted in the Toxic Agent Area shall be reported to Safety Control and a work order will be initiated to correct the deficiency.

D. Biohazard Warning Signs and Labels

1. Door placards with the universal Biohazard Symbol and BSL-2 sign shall be posted on all entrances to the biological laboratory and biological bays. Each door placard will have the name of the Laboratory Manager and operations specialist, PPE required to enter the area, exit procedures, and current immunization requirements and recommendations for the area.

2. All refrigerators, freezers and cabinets utilized for storage of biological materials in the biological laboratory will be labeled with the international biohazard symbol.

3. Primary containers of materials used in the laboratory will be labeled with information identifying or describing the material contained therein.

4. Biohazardous waste receptacles will be labeled with the international biohazard symbol on at least one side.

E. Bloodborne Pathogen Program

The COBRATF Bloodborne Pathogen Program provides policies and procedures necessary to safeguard employees while performing duties involving the handling of bloodborne pathogens. Please reference the CDP Safety Plan, Bloodborne Pathogen Program.

F. Chemical Hygiene Plan

1. Good chemical hygiene practices are included in the appropriate sections of this manual.

2. Personnel will receive initial training in the purpose, content, and requirements of the CHP. The CHP is available in the COBRATF technical library or a copy can be obtained from document control or the Y:\\ drive.

3. Personnel will also review pertinent portions of the CHP annually during Chemical Hygiene Training.

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4. Chemical Procurement and Dating

a. Personnel receiving chemicals in the laboratory will be familiar with procedures for their use and handling. The laboratory is required to contain hard copies of the MSDS information for the chemicals stored in the laboratory.

b. Undiluted disinfectants, other than bleach, will be labeled with an expiration date that is no greater than one year from the date the disinfectant is received. Diluted disinfectants, other than bleach, will be labeled with an expiration date that is no greater than one month from the date the diluted disinfectant was prepared.

c. Undiluted bleach will be labeled with an expiration date that is no greater than six months from the date the bleach is received. Diluted bleach will be labeled with an expiration date that is no greater than one day from the date the diluted bleach was prepared.

d. Deteriorated or outdated chemicals will not be used and shall be disposed of properly.

5. Chemical Storage

a. Chemicals will not be stored in glass containers on shelves that are higher than six feet six inches from the floor. Large breakable bottles (one-gallon or greater) shall be stored as close to the floor as possible in a safe and secure manner. The containers shall not protrude beyond the edge of the storage shelf.

b. The amounts of, and number of chemicals on the bench top, will be as small as practical. Storage of chemicals on a bench top or other work surface will be limited to the amount needed for one operation or daily workload. The container size will be the smallest that will allow completion of the task.

c. Stored chemicals will be inspected on an annual basis for expiration date, deterioration, and/or integrity of the container. The inspection will also determine if any corrosion, deterioration, or damage has occurred to the storage area as a result of leaking chemicals. Unnecessary, deteriorated, or outdated chemicals will be processed for disposal.

6. General Precautions for Handling and Use of Chemicals

a. If unexpected chemical odors are detected, work will be stopped until it is determined that the odor is not hazardous to employees.

b. Skin contact with all chemicals shall be kept to a minimum. Nitrile and vinyl gloves are appropriate types of gloves used for chemicals found at the COBRATF, and are located within the laboratory. Butyl gloves are used in the Toxic Agent Area.

c. Substances of unknown toxicity shall be assumed to be toxic.

d. Laboratory employees, and their supervisors, will be knowledgeable with the signs and symptoms of exposure to chemicals with which they work and with emergency spill procedures. Emergency spill procedures will be posted in the laboratory.

e. Do not smell or taste any chemicals.

f. Chemicals will only be used in areas where the ventilation (general or local) is sufficient to prevent exposure to harmful quantities of fumes or vapors.

g. Avoid unnecessary exposure to all chemicals by any route.

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7. Labeling

a. All containers that contain a material that is, or could be perceived as a chemical, shall be labeled. This labeling is necessary to distinguish hazardous from non-hazardous chemicals.

b. For chemicals from manufacturer’s or suppliers, the label will be durable and will identify contents, titer or concentration, any special storage requirements, and hazards. Labels on stock solutions will also list the date the solution was prepared.

Labels on containers of chemicals received from manufacturers or suppliers shall include the name and address of the manufacturer/supplier, date received, and date opened, if applicable.

8. Safety and Emergency Equipment

a. Telephone numbers of emergency personnel, supervisors, and essential employees are located near the telephone(s).

b. As part of the laboratory orientation, all employees will be instructed on the location and use of emergency showers, eyewashes, and fire extinguishers.

c. The emergency eyewash and emergency shower shall be flushed at least weekly and recorded on the operations and maintenance preventative maintenance schedule.

d. Fire extinguishers and emergency lights shall be routinely inspected by the COBRATF Operations and Maintenance contractor.

2-3. Personnel Qualifications and Training

A. Medical. Before assignment to work with biological materials, all personnel will be evaluated by the OHN with respect to their assignments and will be evaluated using the criteria set forth in Chapter 2-4 of this manual.

B. Training. All employees and contractors identified as working with biological materials or toxins will participate in initial and annual refresher training, as well as whenever changes in procedures or tasks occur. Training will include a description of organism being used, signs, symptoms, and information on exposure routes, worker responsibilities, and review of pertinent mishaps, handler mishaps and medical monitoring. This training will be documented by the BSO.

2-4. Occupational Health Program

A. Occupational Health and Medical Surveillance

1. General Physical Examinations: Post offer, pre-placement, periodic, and termination physical examinations are performed for employees who may be exposed to human pathogens while working at the COBRATF. The COBRATF AD ensures the employees whose job require the use of respiratory protection receive medical clearance from the MA to use a respirator as part of the COBRATF Respiratory Protection Program.

2. Medical examinations are performed by a licensed physician, a nurse practitioner, or a physician’s assistant under the supervision of a licensed physician, and are provided without cost to the employee, without loss of pay, and at a reasonable time and place.

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3. Upon completion of examinations, a written opinion is provided to the COBRATF AD and maintained in the individual’s medical record. The opinion will include:

a. The employee is FIT/UNFIT for the assigned duty position.

b. The employee IS/IS NOT able to wear respiratory protection in a safe manner.

c. The employee IS/IS NOT cleared to wear all personal protective equipment to include but not be limited to gloves, laboratory coat, eye protection, and the COBRATF chemical protective ensemble as needed.

d. Additional information (e.g.: PPE limitations, accommodations for medical conditions that may be affected by the biological laboratory).

e. The individual was informed of the results of the evaluation.

4. Pre-placement examinations: Workers who may be exposed to human pathogens will receive a pre-placement examination. The pre-placement examination will include:

a. History: The medical history will include a review of the employee’s previous and ongoing medical problems, current medications, and indications of the individual’s immune system’s status.

b. Occupational Health History: The occupational health history places emphasis on prior exposures and previous job activities.

c. Respiratory protection use clearance.

5. Periodic Examination: Individuals working with biological materials will have an annual examination. The examination will include updating the employee’s medical and occupational health history from the previous year and an updated respiratory protection use clearance.

6. Termination Examinations: The MA provides employee termination examinations which include reviewing the medical and occupational history with a written opinion.

7. Personnel who are enrolled in the medical surveillance program will be required to be evaluated and medically cleared by the MA or OHN prior to resuming duties once returning to work from being absent three or more days due to a medical condition.

8. Students are not placed in medical surveillance program. Upon arrival, students complete an OSHA respiratory questionnaire with questions about their immune status included.

B. Potential Exposures

1. Employees who sustain a potential exposure to human pathogens in the workplace will receive medical attention, including an examination, whenever any of the following occurs:

a. When an incident occurs in the work area resulting in the likelihood of an exposure such as ingestion, percutaneous, or mucous membrane exposure.

b. When a person develops signs and/or symptoms consistent with an exposure to the human pathogen.

2. The MA’s or OHN’s description of the potential exposure includes:

a. The potential infectious material.

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b. The mechanism and route of exposure (percutaneous, splash to mucous membranes or skin, ingestion).

c. Time and place of the incident.

d. The PPE used at the time of the potential exposure.

2-5. Facility Design

A. General

The biological laboratory at the COBRATF is designed to meet and exceed guidelines and regulatory requirements established in the BMBL and was commissioned by an independent agent. The Toxic Agent Area is designed to contain chemical agent(s) and associated vapors to include a 5-stage chemical biological and radiological air filtration system. Additionally, knock-down HEPA filters are installed at each bay’s exhaust. These filters will be changed out on a quarterly basis.

B. Equipment System Safety

All equipment used in the biological areas shall be evaluated prior to installation and operation by analyzing and documenting the methods for operation, alarming, testing and decontamination of the equipment. An initial assessment analysis of the potential hazards associated with the equipment and the appropriate means for mitigating the risk, including personal protective equipment, shall be conducted. Additional tests and certifications are conducted based on regulatory requirements and manufacturer’s recommendations.

2-6. Laboratory Equipment Care and Use

A. Biological Safety Cabinets

1. A BSC will be used in the biological laboratory while working with biological materials when procedures may create infectious aerosols or splashes and when these procedures are not being conducted in other physical containment devices.

2. BSCs will be inspected and certified semi-annually.

3. Laboratory personnel will set the sash (viewing window) to the height used for certification. Before beginning work, laboratory personnel will adjust the stool height so that the operator will be seated with armpits level with the bottom of the view screen sash and their head above the front opening. Personnel shall never place his/her head inside the BSC.

4. Personnel will not place equipment or supplies over the front or rear ventilation grilles (within or on top of the cabinet), since this action will interfere with the laminar flow effect of the cabinet, and could potentially compromise safety and cause product contamination.

5. Only the materials and equipment required for the immediate work will be placed in the cabinet.

6. To avoid interference with the airflow of the cabinet, which could potentially compromise safety, personnel will avoid:

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a. Rapid and sweeping motions of a worker’s arms into and out of the cabinet. The arms will be moved in and out, slowly, and perpendicular to the face opening of the cabinet.

b. Pedestrian traffic in front of the cabinet.

7. Personnel will perform all operations as far back in the cabinet, as possible, at least four inches from the front grille on the work surface, but preferably beyond the halfway point between the front and rear grilles, if possible. Potentially contaminated materials will be placed downstream of the product.

8. Potentially contaminated materials will not be brought out of the cabinet until they have been surface decontaminated. The exception to this general rule is removal of tubes, flasks, plates or dishes containing viable biological materials and having loose fitting lids whereby disinfectant vapors from surface decontamination of the primary container could degrade viability of the material contained therein. These primary vessels are to be contained within a secondary container which has been surface decontaminated before transfer of the contained biological materials in their primary containers to an incubator, centrifuge, refrigerator, freezer, or other storage location. This operation will be performed while wearing gloves and shall be followed by thorough surface decontamination of any surface(s) that may have been touched by gloved hands and using a disinfectant appropriate for decontamination of the biological material in use.

B. Autoclaves

1. Biological waste generated in the laboratory will be autoclaved. It will be transported to the autoclave in a durable leak-proof container that is secured for movement and steam sterilized at 121°C for at least 30 minutes. Items being sterilized will include autoclave indicator tape per run.

2. Proper Use of Autoclave

a. Biohazardous materials will not be placed in autoclaves overnight in anticipation of autoclaving the next day.

b. Wrap packages to allow for steam penetration.

c. Do not overload the chamber.

d. Avoid over packing of autoclave bags.

e. Do not seal bags or close bottles and other containers tightly.

f. Do not stack containers in an unsafe manner.

3. Safe work practices when using an autoclave include the following:

a. Ensure you have been trained or instructed by a knowledgeable individual on how to use the autoclave. Only trained personnel will operate the autoclaves.

b. Never autoclave hazardous chemicals.

c. Dry hypochlorites (other than small amounts of bleach residue), or any other strong oxidizing material must not be autoclaved with organic materials such as paper, cloth or oil: oxidizer + organic material + heat = potential explosion.

d. Each run should be visually checked to ensure the autoclave cycle was completed to prevent accidental removal of material from an autoclave before it has been sterilized.

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e. Open the door slightly to allow the escape of steam before unloading. Stand away from or behind the door when opening to avoid thermal burns.

f. Wear insulated gloves or mitts when unloading, unless items inside are properly cooled.

g. Once the sterilizer cycle has been shown to be successful (by the complete color change witnessed on the indicator strip, NOT the autoclave tape alone), the items may be removed from the autoclave.

4. Verification

a. Autoclave will be on an annual preventative maintenance program or more often if recommended by manufacturer.

b. Biological indicators will be run quarterly and/or after repair or non-routine maintenance on the autoclave. When analyzed, BI’s will be run with a positive control.

C. Proper Use of Centrifuges

1. Improperly used or maintained centrifuges can present significant hazards to users.

Failed mechanical parts can result in release of flying objects, hazardous chemicals, and biohazardous aerosols. The high-speed spins generated by centrifuges can create large amounts of aerosol if a spill, leak, or tube breakage occurs.

2. To avoid contaminating centrifuge:

a. Check glass and plastic centrifuge tubes for stress lines, hairline cracks, and chipped rims before use. Use unbreakable tubes whenever possible.

b. Avoid filling tubes to the rim.

c. Follow manufacturer’s recommendations for tube and rotor maximum safe operation speeds.

d. Aerosol-free (sealed) centrifuge buckets or rotors should be used whenever possible for the centrifuging of bacteria. Only the correct size tubes will be used in any centrifuge bucket.

e. Buckets will be kept clean and free of broken glass and plastic.

f. Use caps or stoppers on centrifuge tubes. Caps are recommended.

g. Buckets and sealed rotors will be opened in a BSC after centrifugation to prevent exposure from aerosolized particles. Always visually inspect rotor for signs of tube leakage prior to opening buckets.

h. Decontaminate the outside of the cups or buckets after centrifugation. Inspect o-rings before use and replace if cracked or dry.

i. Ensure that the centrifuge is properly balanced.

3. Inside a Centrifuge. The potential for multiple infections from a single centrifuge accident is great. Aerosols are created when fluid escapes from the rotor or cup while the centrifuge is operating at high speed. Whenever possible, use bottles, tubes, or buckets that have o-rings or gaskets to eliminate leaking from tubes when spinning potentially contaminated material. Rotors should be constantly monitored for leaks. All opening of centrifuges must be performed slowly.

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4. Centrifuges will be on annual preventative maintenance program or more often if recommended by the manufacturer.

2-7. Personal Protective Equipment

A. General

1. Purpose. This chapter provides policies and procedures for the use of PPE within the COBRATF biological areas.

2. PPE includes clothing and equipment used to protect individuals from contact with infectious, toxic, and corrosive agents, and known physical and environmental hazards.

3. Inspect all PPE before using it. Use PPE appropriate for the hazard present. If there is any damage or distress identified with PPE, do not attempt to fix it; replace it with new

PPE.

B. Hand Protection

1. Personnel working in the Class II BSC will use nitrile gloves (or equivalent) while working with chemicals or biological material. Personnel should change gloves when contaminated, when glove integrity has been compromised, or when otherwise necessary.

2. Personnel will wear chemical-resistant gloves, based on the manufacturers’ recommendations, while performing procedures where there is a potential for skin contact with hazardous chemicals.

3. Gloves will be properly disposed of in a biohazard bag after working with biological materials.

4. Thermal-resistant gloves will be worn for handling hot items, exothermic reaction vessels, dry ice, and cryogenic liquids.

5. In the Toxic Agent Area, personnel will wear butyl gloves.

C. Eye Protection

1. Personnel will wear safety glasses meeting regulatory standards when conducting operations that may generate a projectile hazard in the laboratory.

2. A full-face shield will be worn during transfer and handling operations involving hazardous chemicals outside the BSC, based on the hazard(s) of the chemical(s) involved when a splash hazard exists in the laboratory.

3. Eye protection must be worn when additional eye hazards are anticipated. This includes individuals who wear contact lenses.

4. If contaminated, eye and/or face protection must be disposed of with other contaminated laboratory waste or decontaminated before reuse.

5. Operators will wear an M40A1 respirator in the Toxic Agent Area. No additional eye protection is required.

D. Foot Protection

1. Sandals, perforated shoes, and bare feet are prohibited in the laboratory. Shoes manufactured of tightly woven canvas are acceptable if they do not have perforations (air holes) through the canvas.

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2. In the Toxic Agent Area, personnel will wear chemical protective boots.

E. Protective Clothing

1. Laboratory: Personnel will wear long sleeve laboratory coats when performing operations with biological materials or chemicals. Laboratory coats should not be taken out of the laboratory, and should be disposed of properly when soiled or otherwise showing signs of wear and tear.

2. Toxic Agent Area: Personnel will wear a chemical protective suit when in the Toxic Agent Area. Chemical protective suits will be worn when dispensing agent and by personnel performing gross decontamination of the Toxic Agent Area.

F. Hearing Protection

There are no specific hearing protection requirements in the laboratory or Toxic Agent Area. In the event that a sonicator is used in the laboratory, see the CDP Safety Plan, Hearing Conservation Program, available in the technical library for specific requirements on the hearing protection program.

G. Respiratory Protection

1. All personnel who wear respiratory protection will be enrolled in the COBRATF Respiratory Protection Program.

2. Respirators are not routinely worn in the biological laboratory, but there may be certain situations where some type of a respirator may be required based on a risk assessment. This determination will be made between the Laboratory Manager, Biologist, OHN, and BSO.

3. An M40A1 air purifying respirator with HEPA and organic vapor cartridges will be worn in the Toxic Agent Area.

2-8. Laboratory-Specific Biological Safety Practices

A. General Practices

1. The biological laboratory follows the provisions found in the latest edition of the CDC

BMBL.

2. Eating, drinking, smoking, handling contact lenses, use of smokeless tobacco, and applying cosmetics are not permitted in the laboratory. Food and drink must be stored outside the laboratory area in cabinets or refrigerators designated and used for that purpose.

3. Personnel will wash their hands after removing gloves and before leaving the laboratory.

4. Mouth pipetting is strictly prohibited. Mechanical pipetting aids must be used.

5. Gloves:

a. Will be worn when manipulating biological materials and handling containers of biological materials (to include agar plates, cryovials, etc.).

b. Are not required when materials are packaged appropriately for shipment.

c. Will be selected based on the hazards associated in each process and procedure.

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d. Will be changed frequently and will be discarded into an appropriate labeled biohazard waste container after use with a biological material. NOTE: It is preferable to remove contaminated gloves prior to removal from a BSC, but if the situation or task precludes changing gloves, then gloved hands may be thoroughly disinfected prior to removal from the BSC.

e. Will be removed at the workspace (workbench or hood) after handling biological materials to ensure that doorknobs and other environmental surfaces are not contaminated.

6. Housekeeping

a. Each laboratory worker is directly responsible for the cleanliness of his/her workspace, and jointly responsible for common areas of the laboratory. The Biologist will enforce compliance with housekeeping standards. Housekeeping duties are listed in Appendix 3 of this manual.

b. Housekeeping standards in the laboratory:

(1) Clutter free work areas.

(2) Animals and plants are not permitted in the laboratory.

(3) Laboratory benches shall be kept clear of equipment and chemicals except those necessary for the work currently being performed.

(4) The work area shall be cleaned at the end of each operation. Benches and general work areas will be cleaned using disposable paper towels with disinfectant effective against the agent in use, being careful not to stir up dust.

(5) Equipment shall be thoroughly cleaned and returned to storage upon completion of usage as appropriate.

(6) The work environment shall be kept free of tripping hazards. Floors, aisles, exits, fire extinguishing equipment, emergency eyewashes, and emergency showers, electrical disconnects, and other emergency equipment shall remain free of impediments.

(7) After use, chemical containers shall be cleaned and returned to storage.

(8) Air filters (AC unit) will be changed at least every three (3) months (sooner if deemed dirty and impeding air flow from laboratory). The date changed will be recorded on the filter itself or the vent cover.

(9) All contaminated liquid or solid wastes will be autoclaved or chemically decontaminated before disposal.

(10) Equipment used to store biological materials will be labeled with the universal biohazard sign.

(11) Refrigerators and deep freezers will be checked, cleaned out, and defrosted periodically to remove any ampoules, tubes, or other vessels broken during storage. Appropriate PPE will be worn during cleaning.

(12) Flammable solutions will be stored in approved flammable cabinets.

7. Practical jokes or other behavior (horseplay) that might confuse, startle, or distract another worker is prohibited.

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B. Additional Techniques Applicable to Work with Biological Materials

1. The objective of these techniques is to improve protection against laboratory acquired infections. Air sampling studies have shown that aerosols are generated from most of the manipulations of bacterial, viral, and fugal cultures common to research laboratories.

2. All procedures will be performed carefully to minimize the creation of aerosols.

Procedures with a potential for creating infectious aerosols or splashes may include pipetting, centrifuging, grinding, blending, shaking, mixing, sonicating, and opening containers of infectious materials, and should be conducted in a Class II BSC or other physical containment device using proper PPE to limit the risk of exposure.

3. High concentrations or large volumes of biological materials may only be centrifuged in the open laboratory using sealed rotor heads or centrifuge cups.

4. At no time will infectious mixtures be prepared by bubbling air through a liquid outside of appropriate engineering controls.

5. Test tubes

a. Tubes containing biological materials will be manipulated with extreme care.

b. Tubes and racks of tubes will be clearly marked, listing the contents. Employees must ensure that tubes are properly sterilized prior to disposal or glassware washing. Whenever possible, plastic laboratory ware will be used in place of glassware.

C. Storage of Biological Agents

1. All biological materials will be stored and secured appropriately and properly labeled at all times.

2. A written or electronic inventory record will be maintained for biological materials stored in designated freezers and refrigerators.

3. The Laboratory Manager will ensure that all laboratory workers and visitors understand physical security requirements.

2-9. Decontamination and Disposal

A. Decontamination

1. Biological materials will be decontaminated. Decontamination methods include autoclaving, using an effective chemical decontaminant, incineration, or other validated decontamination method.

2. Autoclave requirements for the laboratory are listed in Chapter 2-6, paragraph B.

3. Chemical Disinfection: Sodium Hypochlorite: free available chlorine is the active ingredient and is active against most microorganisms. Chlorine solutions at 2.5% free available chlorine are effective against most toxins (sodium hydroxide may be required).

Chlorine solutions should be made fresh daily. Commercial bleach contains approximately 5.25% NaOCl. A 1:10 solution of bleach with a contact time of 15 minutes is sufficient for decon of most biological organisms.

4. Inactivation of Bacillus anthracis spores may require pH neutralization of the 10% bleach solution prior to disposal in a sanitary sewer. A pH 7, 5000 ppm Cl- solution is

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prepared by mixing: one part bleach (5.25% NaOCl); eight parts water; and one part 5- 8% acetic acid (white vinegar).