Biosafety Manual - Arizona State University

ASU Biosafety Manual 1

Biosafety Manual

Arizona State University Department of Environmental Health & Safety

Last Updated: July 2012


F O R E W O R D

The Biosafety Manual has been adopted by Arizona State University to be a resource for information, guidelines,

policies, and procedures that will enable and encourage those working in the laboratory environment to work

safely and to eliminate, or reduce, the potential for exposure to biological hazards. The Department of Environmental Health and Safety has developed this manual to help ensure compliance with the following

federal, state, and local regulations:

7 Code of Federal Regulations § 331


18 United States Code § 175b

29 Code of Federal Regulations § 1910.1030




49 Code of Federal Regulations, Parts 171-180

Arizona Administrative Code, Article 14, Biohazardous Medical Waste and Discarded Drugs

Centers for Disease Control & Prevention/National Institutes of Health. Biosafety in Microbiological and Biomedical Laboratories.

National Institutes of Health. Guidelines for Research Involving Recombinant DNA Molecules.

Public Act 107-188, HR3448

The Biosafety Manual provides a compilation of suggested work practices, protocols and systems to work safely

at Arizona State University. The Biosafety Manual should not be considered the only reference for health and safety concerns. It is intended that the Principal Investigator (PI) and supervisory personnel will supplement this

information with instruction and guidance regarding specific practices and procedures unique to the work being done in their laboratories. In addition, the Department of Environmental Health and Safety is always available to

address health and safety concerns.

The Biosafety Manual will be reviewed at least annually by the Department of Environmental Health and Safety

and the Institutional Biosafety Committee.

July 19, 2012

Leon Igras, Director Date Environmental Health and Safety

July 19, 2012 David Gillum, Biosafety Officer Date

Environmental Health and Safety


Table of Contents

I. PREFACE ............................................................................................................................................ 6

II. INTRODUCTION ................................................................................................................................. 6

A. Scope ........................................................................................................................................... 6

B. Regulatory Requirements and Guidelines ........................................................................................ 6

C. Select Agents and Toxins ............................................................................................................... 7

D. Risk Group Classifications .............................................................................................................. 8

E. Laboratory Biosafety Levels ........................................................................................................... 8

F. Animal Biosafety Levels ............................................................................................................... 10

G. Biohazardous Waste .................................................................................................................... 12

H. Biohazardous Waste Handling ...................................................................................................... 12

I. Biological Safety Audits ............................................................................................................... 13

III. RESPONSIBILITIES ........................................................................................................................... 14

A. Arizona State University............................................................................................................... 14

B. Institutional Biosafety Committee ................................................................................................. 14

C. Department of Environmental Health & Safety/Biosafety Officer ..................................................... 15

D. Office of Research Integrity and Assurance ................................................................................... 16

E. Deans, Directors, and Chairs ........................................................................................................ 16

F. Responsible Official ..................................................................................................................... 16

G. Principal Investigator ................................................................................................................... 17

H. Laboratory Employees ................................................................................................................. 18

I. Institutional Animal Care and Use Committee ............................................................................... 18

J. Other Organizations .................................................................................................................... 19

K. Visitors, Vendors, and Contractors ............................................................................................... 19

IV. INCIDENT REPORTING ...................................................................................................................... 20

A. Reportable Incidents and Violations ............................................................................................. 20

B. Principal Investigator Responsibilities ........................................................................................... 20

C. Biosafety Officer Responsibilities .................................................................................................. 20

D. Institutional Responsibilities ......................................................................................................... 20

E. Institutional Official Responsibilities .............................................................................................. 21

V. BIOHAZARDOUS RESEARCH PROJECT REGISTRATION AND APPROVAL ............................................... 22

A. Introduction................................................................................................................................ 22

B. Registration and Approval Process ............................................................................................... 22

C. Additional Information and Requirements ..................................................................................... 23

1. Select Agents and Toxins ....................................................................................................... 23

2. Human Blood and Tissue ....................................................................................................... 23


3. Animal Handling .................................................................................................................... 23

4. Recombinant DNA Materials ................................................................................................... 24

5. Environmental Samples ......................................................................................................... 24

6. Protective Clothing Beyond the Laboratory ............................................................................. 24

7. Food and Beverages in the Laboratory ................................................................................... 25

VI. TRAINING FOR WORKING SAFELY WITH BIOHAZARDOUS AGENTS ..................................................... 26

VII. LABORATORY PROCEDURES AND EQUIPMENT ................................................................................... 27

A. Exposure Control ........................................................................................................................ 27

Laboratory Practice and Technique ........................................................................................ 27 1.

Safety Equipment (Primary Barriers) ...................................................................................... 27 2.

Facility Design (Secondary Barriers) ....................................................................................... 28 3.

B. Biological Safety Cabinets (BSCs) ................................................................................................. 28

VIII. GUIDELINES FOR GOOD LABORATORY PRACTICES ............................................................................ 31

A. Guidelines for Good Laboratory Practices at BSL-1 ........................................................................ 31

1. Standard Microbiological Practices .......................................................................................... 31

2. Special Practices ................................................................................................................... 32

3. Safety Equipment (Primary Barriers and Personal Protective Equipment) .................................. 32

4. Laboratory Facilities (Secondary Barriers) ............................................................................... 32

B. Guidelines for Good Laboratory Practices at BSL-2 ........................................................................ 33





C. Guidelines for Good Laboratory Practices at BSL-3 ........................................................................ 36





IX. EMERGENCY RESPONSE PROCEDURES .............................................................................................. 42

A. Decontamination ......................................................................................................................... 42

B. Exposure to Biohazards ............................................................................................................... 43

C. Spills of Biohazards ..................................................................................................................... 44

D. Spills Inside a Biological Safety Cabinet (BSC) ............................................................................... 44

E. Small Spill of Material Outside of a BSC ........................................................................................ 45

F. Large Spill of Biohazardous Material (>500 ml) Outside of a BSC ................................................... 45

G. Small Spill (<500 ml) of Recombinant DNA Materials ..................................................................... 45

H. Large Spill (>500 ml) of Recombinant DNA Materials in a BSC ....................................................... 45


I. Large Spill (>500 ml) of Recombinant DNA Materials outside of a BSC ........................................... 46

J. Spill of Recombinant DNA Materials in a Centrifuge ....................................................................... 47

K. Reporting Exposures ................................................................................................................... 47

X. TRANSFERS, PACKAGING, AND SHIPPING OF BIOLOGICAL MATERIALS ............................................... 48

A. Transfers .................................................................................................................................... 48

B. Packaging ................................................................................................................................... 48

C. Packaging with Dry Ice ................................................................................................................ 50

D. Labeling ..................................................................................................................................... 50

E. Shipping and Transportation Methods and Requirements ............................................................... 50

F. Other Permits ............................................................................................................................. 52

XI. SECURITY ........................................................................................................................................ 53

XII. COMPLIANCE .................................................................................................................................... 54

XIII. RECORDKEEPING .............................................................................................................................. 55

XIV. PROGRAM EVALUATION .................................................................................................................... 56

Appendix A: Definitions ............................................................................................................... 60

Appendix B: Lab-Specific Biosafety Manual Template .................................................................... 61

Appendix B-1: Floor Diagram ....................................................................................................... 73

Appendix B-2: Health Hazard Assessment Worksheet .................................................................... 74

Appendix B-3: IBC Application Documentation .............................................................................. 82

Appendix B-4: Suggested Format for the Lab-Specific Biosafety Manual ......................................... 83

Appendix C: Special Considerations for Select Agents and Toxins ................................................... 84


I. PREFACE

The Arizona State University (ASU) Biosafety Manual is intended to be a resource for information,

guidelines, policies, and procedures that will enable and encourage those working in the laboratory environment to work safely and to eliminate, or reduce, the potential for exposure to biological hazards.

The information presented here also reflects the requirements and guidelines of federal and state

regulations. The most current version of the ASU Biosafety Manual is available on-line on the ASU Environmental Health & Safety (EH&S) website.

II. INTRODUCTION

A. Scope

The ASU Biosafety Manual is applicable to all laboratory, research, teaching, service, and support activities that may involve exposure to biohazards. Biohazards are microorganisms, microbial

toxins, or other biological agents that can infect and/or cause disease in humans, animals, or plants. Biohazards may include bacteria, bacterial toxins, viruses, fungi, rickettsia, prions,

protozoans, parasites, genetically-modified organisms, or recombinant DNA molecules. In

addition, biohazards include human blood, body fluid, tissues, and cell lines of human origin. Biohazards are often referred to as infectious agents or etiological agents.

Biosafety encompasses the knowledge, techniques, equipment, and facilities necessary to

prevent or minimize an exposure to, or release of, a biological agent. The mission of the Biosafety Division in the ASU Department of Environmental Health and Safety is to assure a safe

and healthy environment for individuals working with biohazards and to protect the community

and environment by preventing the release and exposure to biohazards.

B. Regulatory Requirements and Guidelines

Guidance documents from the National Institutes of Health (NIH) and the Centers for Disease

Control and Prevention (CDC) form the basis for the biosafety practices included in this manual. There are additional guidance documents and regulations imposed by various funding agencies

that individual PIs must be aware of and incorporate into their Lab-Specific Biosafety Manuals. Biosafety requirements must be followed to ensure the continuation of grant funding

from federal agencies and for health and safety purposes.

The NIH Guidelines for Research Involving Recombinant DNA Molecules (NIH Guidelines) detail

procedures and practices for the containment and safe conduct of various forms of recombinant DNA research, including research involving genetically modified plants and animals, as well as

human gene transfer. The NIH Guidelines:

Mandate the establishment of an Institutional Biosafety Committee for the review and

oversight of biological research;

Outline roles and responsibilities for biosafety; and

Establish the practices, procedures, and conditions under which recombinant DNA

activities must be conducted.

All institutions, including ASU, receiving NIH funding for recombinant DNA activities must comply with the NIH Guidelines. Researchers at institutions that are subject to the NIH Guidelines must

comply with the requirements even if their individual projects are not funded by NIH. Non-

compliance with the NIH Guidelines may result in suspension, limitation, or termination of financial assistance for the research project and of NIH funds for other

recombinant DNA activities at ASU or the requirement for prior NIH approval of any and/or all recombinant DNA projects at ASU.

http://cfo.asu.edu/ehs

http://oba.od.nih.gov/oba/rac/Guidelines/NIH_Guidelines.htm


The CDC/NIH manual, Biosafety in Microbiological and Biomedical Laboratories (BMBL), describes

the appropriate measures and facilities for work with all microbial agents, including bacterial, viral, fungal, parasitic, rickettsial, and prion agents as well as toxins of biological origin.

The requirements described in the Occupational Safety and Health Administration’s (OSHA)

Bloodborne Pathogens regulation (29 CFR § 1910.1030) apply to work with human blood, tissue,

organs, body fluids, and cell cultures. Special training, medical surveillance, procedures, and equipment that must be in place for protection against bloodborne pathogens, needlesticks, and

other sharps injuries, are described in the ASU Exposure Control Plan.

Handling and disposal of biohazardous waste is regulated by OSHA under the Bloodborne Pathogens regulation and by state and federal statutes. The procedures for biohazardous waste

handling are described in the ASU Biological Waste Handling Procedures.

The requirements for packaging and shipment of biohazardous materials are provided in the

Department of Transportation’s hazardous materials regulation 49 CFR, Parts 171 – 180. In addition, permits may be required to ship biological materials. Please refer to the CDC Etiological

Agent Import Permit Program and the Animal and Plant Health Inspection Service (APHIS) permit

program. Information on shipping procedures that comply with these regulations is found in the section on “Shipping and Transportation Methods and Requirements” in this manual.

Specific requirements for handling toxins found in 29 CFR § 1910.1450 Occupational Exposure to

Hazardous Chemicals in Laboratories are covered in the ASU Chemical Hygiene Plan. Information on ASU’s radiation safety program is found in the Radioactive Materials Manual.

C. Select Agents and Toxins

Select agents are particular microorganisms and toxins specifically identified in federal

regulations. Select agents also include specific genetically modified microorganisms or genetic elements that contain specific nucleic acid sequences. The most current list is found on the CDC’s

website at http://www.selectagents.gov/.

The following toxins are not regulated as select agents or toxins if the amount under the control

of a principal investigator, treating physician or veterinarian, or commercial manufacturer or distributor does not exceed, at any time, the amounts indicated in the table below.

HHS Select Agent Toxins CAS # Threshold Amount

Abrin 1393-62-0 100 mg

Botulinum neurotoxins 93384-43-1 0.5 mg

Clostridium perfringens epsilon toxin 100 mg

Conotoxin 76862-65-2 / 156467-85-5 100 mg

Diacetoxyscirpenol (DAS) 2270-40-8 1000 mg

Ricin 96638-28-7 100 mg

Saxitoxin 35523-89-8 100 mg

Shiga-like ribosome inactivating proteins 100 mg

Shigatoxin 75757-64-1 100 mg

Staphylococcal enterotoxins 11100-45-1 5 mg

T-2 toxin 21259-20-1 1000 mg

Tetrodotoxin 4368-28-9 100 mg

http://www.cdc.gov/od/ohs/biosfty/bmbl5/bmbl5toc.htm

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051

http://www.asu.edu/uagc/EHS/documents/bloodborne_pathogens_plan.pdf



http://www.asu.edu/uagc/EHS/documents/biological-waste-handling.pdf

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02-20118-filed.pdf

http://www.cdc.gov/od/eaipp/


http://www.aphis.usda.gov/permits/index.shtml


http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10106

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10106

http://www.asu.edu/uagc/EHS/documents/asu_chp.pdf

http://www.asu.edu/uagc/EHS/documents/rad_materials_manual.pdf

http://www.selectagents.gov/


The ASU Biosafety Manual, when used in combination with the Lab-Specific Biosafety

Manual, is designed to meet the federal requirements of the Department of Health and Human Services (HHS) Standard “Possession, Use, and Transfer of Select Agents and Toxins; Final Rule“

(42 CFR § 73) and the Department of Agriculture (USDA) Standard, “Agricultural Bioterrorism Protection Act of 2002; Possession, Use, and Transfer of Biological Agents and Toxins; Final Rule“

(7 CFR § 331 and 9 CFR § 121). All laboratory specific requirements for these regulations can be

found in the appendix titled “Special Considerations for Select Agents and Toxins.”

D. Risk Group Classifications

According to the CDC/NIH document, Biosafety in Microbiological and Biomedical Laboratories, also known as the BMBL, the three primary hazardous characteristics associated with biological

agents include:

The capability of an agent to infect and cause disease in a susceptible human or animal

host;

The virulence of an agent as measured by the severity of disease; and

The availability of preventive measures and effective treatments for the disease.

By taking the route of transmission of the disease into consideration, a standardized methodology

was developed to classify biological agents into four different risk groups (please see the table

below). Knowing the risk group of an agent assists researchers and safety professionals in determining the appropriate safety protocols to be followed.

Risk Group (RG) Classifications

RG-1 RG-2 RG-3 RG-4

Agents that are not associated with disease

in healthy adult humans.

Agents that are associated with human disease which is rarely serious and for which

preventive or therapeutic

interventions are often available.

Agents that are associated with serious or lethal human disease for which preventive or

therapeutic interventions may be

available (high individual risk but low

community risk).

Agents that are likely to cause serious or lethal

human disease for which preventive or

therapeutic interventions are not usually available (high individual risk and high

community risk).

E. Laboratory Biosafety Levels

CDC and NIH have established four levels of biosafety, based on the degree of hazard associated with a microbial agent, to describe the combination of laboratory practices and techniques, safety

equipment, and facilities needed to protect against exposure. The BMBL outlines four different biological safety levels that are appropriate for the operations performed in a laboratory, the

documented or suspected routes of transmission of the biological agent, and the laboratory

function or activity. These four biosafety levels (BSL) require successively more stringent practices and facilities as work moves from the least restrictive, BSL-1, to work with the highest

hazard level of BSL-4. Exposure to biohazardous agents may be prevented or limited by establishing and following the appropriate biosafety level practices and conditions. The

requirements for each laboratory biosafety level can be found in the BMBL.

The following bullets provide a brief summary of the four biological safety levels:

BSL-1 is required for work involving well-characterized agents not known to consistently

cause disease in immunocompetent adult humans, and present minimal potential hazard

to laboratory personnel and the environment.

http://www.cdc.gov/od/sap/pdfs/42_cfr_73_final_rule.pdf

http://www.aphis.usda.gov/programs/ag_selectagent/downloads/FinalRule3-18-05.pdf

http://www.aphis.usda.gov/programs/ag_selectagent/downloads/FinalRule3-18-05.pdf

http://www.cdc.gov/biosafety/publications/bmbl5/

http://www.cdc.gov/biosafety/publications/bmbl5/


BSL-2 is required for work involving agents that pose moderate hazards to personnel

and the environment.

BSL-3 is required for clinical, diagnostic, teaching, research, or production facilities

where work is performed with indigenous or exotic agents that may cause serious or potentially lethal disease through the inhalation route of exposure.

BSL-4 is required for work with dangerous and exotic agents that pose a high individual

risk of aerosol-transmitted laboratory infections and life-threatening disease that is frequently fatal, for which there are no vaccines or treatments, or a related agent with

unknown risk of transmission.

Note: No research with biohazardous agents at BSL-4 is permitted in Arizona State University

facilities.

Personal protective equipment varies depending upon the biological safety level. Please refer to the table below for specific requirements for each of the four biological safety levels.

Biological Safety - Personal Protective Equipment (PPE) Requirements*

BSL-1 BSL-2 BSL-3 BSL-4

Protective laboratory coats, gowns, or uniforms recommended preventing contamination of personal clothing.

Protective eyewear worn when conducting procedures that have the potential to create splashes of microorganisms or other hazardous materials.

Personnel who wear contact lenses in laboratories should also wear eye protection.

Gloves must be worn to protect hands from exposure to hazardous materials.

Protective laboratory coats, gowns, smocks, or uniforms must be worn while working with hazardous materials.

Eye and face protection (goggles, mask, face shield or other splatter guard) must be used for anticipated splashes or sprays of infectious or other hazardous materials when the microorganisms are handled outside the Biological Safety Cabinet (BSC) or physical containment device.

Personnel who wear contact lenses in laboratories should also wear eye protection.


Eye, face and respiratory protection should be used in rooms containing infected animals.

Protective laboratory clothing with a solid-front, such as tie-back or wrap-around gowns, scrub suits, or coveralls must be worn.

Eye and face protection (goggles, mask, face shield or other splash guard) must be used for anticipated splashes or sprays of infectious or other hazardous materials. [All procedures involving the manipulation of infectious materials must be conducted within a BSC, or other physical containment devices.]

Personnel who wear contact lenses in laboratories must also wear eye protection.


Eye, face, and respiratory protection must be used in rooms containing infected animals.

Not permitted at ASU.

Please refer to the CDC/NIH document, “Biosafety in Microbiological and Biomedical Laboratories” for PPE requirements.

* Safety is improved when PPE is used in combination with physical containment devices or equipment, such as Biological Safety Cabinets (BSCs).


F. Animal Biosafety Levels

Similar to the BSL, there are four animal biosafety levels (ABSL). These four animal biosafety

levels are required for the use of experimentally-infected animals housed in indoor research facilities (e.g., vivaria), and also in the maintenance of laboratory animals that may naturally

harbor zoonotic infectious agents. As a general principle, the biosafety level (facilities,

practices, and operational requirements) recommended for working with infectious agents in vivo and in vitro are comparable with the animal biosafety level.

The four animal biosafety levels provide increasing levels of protection to personnel and to the

environment, and are recommended as minimal standards for activities involving infected laboratory animals. The four ABSLs describe animal facilities and practices applicable to work

with animals infected with agents assigned to Biosafety Levels 1-4, respectively. Investigators

that are inexperienced in conducting these types of experiments should seek help in designing their experiments from individuals who are experienced in this special

work.

The following bullets provide a brief summary of the four biological safety levels:

ABSL-1 is required for work in animals involving well-characterized agents that are not

known to cause disease in immunocompetent adult humans, and present minimal

potential hazard to personnel and the environment. ABSL-2 is suitable for work involving laboratory animals infected with agents associated

with human disease and pose moderate hazards to personnel and the environment, and

also addresses hazards from ingestion as well as from percutaneous and mucous membrane exposure.

ABSL-3 is required for work with laboratory animals infected with indigenous or exotic

agents, agents that present a potential for aerosol transmission, and agents causing

serious or potentially lethal disease. ABSL-4 is required for work with animals infected with dangerous and exotic agents that

pose a high individual risk of aerosol-transmitted laboratory infections and life-

threatening disease that is frequently fatal, for which there are no vaccines or treatments; or a related agent with unknown risk of transmission.

Note: No research with biohazardous agents at BSL-4 is permitted in Arizona State University facilities.

In addition to animal biosafety consideration, laboratory animal facilities, operational practices,

and quality of animal care must meet applicable standards and regulations (e.g., Guide for the Care and Use of Laboratory Animals and Laboratory Animal Welfare Regulations) and that

appropriate species have been selected for animal experiments. The USDA has also developed

facility parameters and work practices for handling agents of agriculture significance.

Personal protective equipment varies depending upon the biological safety level. Please refer to the following table for specific requirements for each of the four biological safety levels.


Animal Biological Safety - Personal Protective Equipment (PPE) Requirements*

ABSL-1 ABSL-2 ABSL-3 ABSL-4

Protective laboratory coats, gowns, or uniforms recommended to prevent contamination of personal clothing.

Eye, face, and respiratory protection should be used in rooms containing infected animals.

Protective eyewear must be worn when conducting procedures that have the potential to create splashes of microorganisms or other hazardous materials.

Personnel who wear contact lenses should also wear eye protection when entering areas with potentially high concentrations or airborne particulates.

Gloves must be worn to prevent skin contact with contaminated, infectious, and hazardous materials, and when handling animals.

Protective laboratory coats, gowns, or uniforms must be worn while in areas where infectious materials and/or animals are housed or manipulated.

Eye and face protection (mask, goggles, face shield or other splatter guard) must be worn when performing manipulations or activities that may result in splashes or sprays from infectious or other hazardous materials and when the animal or microorganisms must be handled outside the BSC or physical containment device.

Personnel who wear contact lenses should also wear eye protection when entering areas with potentially high concentrations or airborne particulates.

Gloves must be worn to prevent skin contact with contaminated, infectious and hazardous materials and when handling animals.

Eye, face, and respiratory protection should be used in rooms containing infected animals.

Disposable personal protective equipment, such as non-woven olefin cover-all suits, wrap-around or solid-front gowns, should be worn (over uniforms or scrub suits) before entering areas where infectious materials and/or animals are housed or manipulated. Front-button laboratory coats are unsuitable.

Eye, face, and respiratory protection must be used in rooms containing infectious materials and in areas where animals are housed or manipulated. [All procedures involving the manipulation of infectious materials must be conducted within a BSC, or other physical containment devices.]

Personnel who wear contact lenses in laboratories must also wear eye protection.

Gloves must be worn to prevent skin contact with contaminated, infectious, and hazardous materials and when handling animals. Double-glove practices should be used.

Boots, shoe covers, or other protective footwear, are used to prevent cross-contamination.

Not permitted at ASU.

Please refer to the CDC/NIH document, “Biosafety in Microbiological and Biomedical Laboratories” for PPE requirements.

* Safety is improved when PPE is used in combination with physical containment devices or equipment, such as Biological Safety Cabinets (BSCs).

It is the responsibility of institutional management to provide facilities, staff, and established practices that reasonably ensure appropriate levels of environmental quality, safety, security and

care for the laboratory animal. There are unique hazards associated with infected animals that must be understood by personnel with animal contact. Animal activity may create aerosols, and

bites and scratches can occur.


G. Biohazardous Waste

According to the State of Arizona, biohazardous waste is defined as:

1) Any solid waste which is generated in the diagnosis, treatment, or immunization of a

human being or animal or in any research relating to that diagnosis, treatment, or

immunization, or in the production or testing of biological materials. 2) Animal carcasses, body parts, and bedding of animals that have been infected with

agents that produce, or may produce, human infection. 3) Discarded cultures and stocks generated in the diagnosis, treatment, or immunization of

a human being or animal or in any research relating to that diagnosis, treatment or

immunization, or in the production or testing of biological. 4) Discarded products and materials containing blood or blood components.

5) Discarded organs and body parts removed during surgery. 6) Discarded sharps used in animal or human patient care, medical research, or clinical

laboratories. Examples of sharps include:

Hypodermic needles;

Syringes;

Pipettes;

Pipette tips;

Scalpel blades;

Blood vials;

Needles attached to tubing;

Broken and unbroken glassware;

Slides; and

Coverslips.

As a best management practice, EH&S manages discarded preparations made from genetically altered living organisms and their products as biohazardous waste. For example, recombinant

DNA waste materials used in research laboratories is considered biohazardous waste.

H. Biohazardous Waste Handling

Wastes associated with biological research materials must be disposed of in special ways. Examples of potentially hazardous items include:

All sharps (e.g., glass implements, needles, syringes, blades, coming from facilities using

infectious materials).

Biologically-cultured stocks and plates.

Agents (of any biosafety level) containing recombinant DNA.

Human blood, tissues, organs, and cell lines.

Transgenic plants and animals.

Any regulated biohazardous material.

In order for the biological waste to be removed by EH&S, the following procedures must be

followed:

Biological wastes derived from human sources (e.g., blood, body fluids, tissues, tumors,

human cell lines) are hazardous biological wastes and should be placed in a red or

orange biohazard bag. Autoclave the bag under appropriate time and temperature and place it in a red drum for removal by hazardous waste personnel.

BSL-1 materials containing recombinant DNA must be autoclaved or the DNA must be

denatured with bleach.


Bacteria, viruses, or other microorganisms that are known human pathogens should also

be put into a red or orange bag, autoclaved, and placed in a red drum for removal by

hazardous waste personnel. Sharps and sharp objects such as glass, syringes, disposable pipettes, and pipette tips

that may be contaminated with biological waste (human or non-human) or pathogenic

material should be placed in a rigid, leak-proof, puncture-resistant container. The container is autoclaved and then placed in a red drum for removal by hazardous waste

personnel.

Non-human biological wastes are handled by the same methods as human biological wastes: placed in autoclave bags, autoclaved, and put into red drums for removal by

hazardous waste personnel.

When your “red-bag,” “yellow drum,” or liquid hazardous waste is ready for removal, call

Environmental Management at (480) 965-3899 to arrange a pick-up, or submit a hazardous

waste pick-up request. If you need any other assistance or have questions, please feel free to contact Environmental Health & Safety at (480) 965-1823.

There are additional requirements for disposing of select agents and toxins. Please see the

appendix titled “Special Considerations for Select Agents and Toxins.”

I. Biological Safety Audits

EH&S audits laboratories at least once a year. The safety audit typically includes an evaluation of the autoclave, biological safety cabinet, microbiological techniques, emergency and safety

equipment, storage of biohazardous material, general housekeeping, and review of the Lab-

Specific Biosafety Manual. Please refer to the ASU Biosafety & Biosecurity inspection checklists for more information about the biosafety audit form used by EH&S.

EH&S will make every attempt to schedule laboratory audits with faculty members. However, if

the principal investigator is unavailable or is unresponsive, EH&S will proceed with the safety

audit. EH&S may also conduct unannounced accident investigations. Please be aware that federal, state, and local inspectors may also conduct unannounced inspections.

Following the biological safety survey, a report listing the safety concerns is sent to the faculty

member responsible for the laboratory. The faculty member is responsible for correcting the

hazards. If the faculty member fails to correct the hazard, a second notice is sent to the department head with a copy to the faculty member. Follow-up audits may be conducted in

laboratories with extremely hazardous conditions and/or numerous violations.

https://ehsaweb.asu.edu/

https://ehsaweb.asu.edu/

https://cfo.asu.edu/ehs-biosafety


III. RESPONSIBILITIES

The biological safety program at ASU developed from the University’s commitment to address and comply

with the NIH Guidelines regarding safe research with recombinant DNA and associated biohazardous materials as well as the HHS and USDA regulations on select agents and toxins. The Institutional

Biosafety Committee (IBC) and the department of Environmental Health & Safety (EH&S) provide

oversight of ASU’s biological safety program. The roles and responsibilities of ASU faculty and staff are described in this section.

A. Arizona State University

ASU has instituted and maintains a biosafety program for personnel who may be exposed to

biological hazards (biohazards) during the performance of their duties. The biosafety program is

designed to achieve regulatory compliance and to provide a means for employees to be informed about and protected from biohazards. To maintain regulatory compliance and to protect

personnel from biohazards, Arizona State University must:

Appoint a Biological Safety Officer (BSO) for the institution.

Ensure appropriate training is provided to personnel conducting research with biohazardous or recombinant DNA materials.

Ensure that research conforms to the provisions of the NIH Guidelines. Establish an Institutional Biosafety Committee with adequate expertise and training.

Establish and maintain a health surveillance program for personnel. Implement policies for safe conduct of biological and recombinant DNA research.

Report any significant problems, violations or significant research-related accidents or

illnesses to the NIH OBA within 30 days.

B. Institutional Biosafety Committee

The Institutional Biosafety Committee (IBC) shall be constituted of a minimum of five (5) voting

members. Collectively, the membership shall have experience and expertise in recombinant DNA technology and the capability to assess the safety of recombinant DNA research and identify any

potential risks to public health or the environment. The IBC shall include at least one individual with expertise in plant, plant pathogen, or plant pest containment principles and one scientist

with expertise in animal containment principles. At least two members shall not be affiliated with

the institution (apart from their membership on the committee) and shall represent the interest of the surrounding community with respect to public health and protection of the environment.

The Biological Safety Officer (BSO) for the campus must be a voting member of the IBC. A quorum will consist of a simple majority. A passing vote will be a simple majority of members

present; minority views will be recorded in the minutes. The committee’s current membership may be obtained by contacting ORIA at http://researchintegrity.asu.edu/.

The responsibilities of the Institutional Biosafety Committee (IBC) include, but are not limited to, the following:

Address biosafety issues related to experimentally infected laboratory animals.

Adopt policies supporting the safe use of biological materials and the elimination or

reduction of exposure to potentially biohazardous materials and agents. Assess the facilities, procedures, practices, training and expertise of personnel involved in

research utilizing recombinant DNA and/or biohazardous materials. Determine necessity of health surveillance of personnel.

Direct development of appropriate procedures to oversee the possession and/or use of recombinant DNA and biohazardous materials.

Ensure training for IBC members, staff, Principal Investigators, and laboratory staff.

Facilitate the registration of biological research by providing materials and information to Principal Investigators.

http://researchintegrity.asu.edu/


Make a final determination of physical and biological containment for recombinant DNA

and biohazardous materials, and modify containment levels as necessary. Notify the Principal Investigator of the results of the IBC’s review, approval, or

disapproval. Obtain specific review, registration and/or approval from NIH/OBA for research that falls

under Sections III-A, III-B, III-C and Appendix M of the NIH Guidelines. Review and report any significant problems, violations of the NIH Guidelines and any

significant research-related accidents or illnesses to the Institutional Official and to the

appropriate authorities. Review, approve and oversee research utilizing recombinant DNA and biohazardous

materials, conducted at or sponsored by the University, for adherence with the NIH Guidelines, the BMBL, and University policies. This pertains to the initial and continuing

reviews and modifications to the currently approved research.

Review and approve research involving the use of select agents and toxins. Review research involving recombinant DNA and other potentially biohazardous agents.

Set biosafety containment levels as required by the NIH Guidelines. Suspend or terminate disclosure approval for the possession or use of recombinant DNA

and biohazardous materials, where the IBC finds non-compliance or that such use or

possession poses undue risk to research personnel or a threat to the health and safety of the community.

Periodically review the IBC policies and procedures and modify them as necessary to ensure appropriate biosafety measures and adherence with federal and state

requirements. Review research disclosures that include the possession and/or use of recombinant DNA

and biohazardous materials for compliance with NIH Guidelines. As part of the review

process, the IBC will do the following:

o Conduct an independent assessment of the containment levels (i.e., BSL-1, BSL-2, BSL-3) in collaboration with EH&S, as required by the NIH Guidelines.

o Conduct an assessment of the facilities, procedures, practices, training, and expertise

of personnel conducting research involving recombinant DNA and biohazardous materials.

o Ensure adherence with all surveillance, data reporting, and adverse event reporting requirements set forth in the NIH Guidelines for recombinant DNA.

Submit membership roster (completed by the ASU ORIA) including members’ biographical sketches to the NIH Office of Biotechnology Activities (OBA).

According to the NIH Guidelines, the IBC must review and approve architectural designs for new

facilities and renovations to existing facilities where recombinant DNA research may be performed. The IBC has delegated the authority to EH&S to review and approve these

documents on their behalf.

C. Department of Environmental Health & Safety/Biosafety Officer

The responsibilities of EH&S and the Biological Safety Officer (BSO) include, but are not limited

to, the following:

Advise researchers on proper waste disposal methods based on federal and state

regulations. Assist in the development of emergency plans for handling accidental spills and

personnel contamination. Consult with researchers on issues of biosafety and the safe use of biological materials in

the laboratory.

Investigate laboratory accidents involving recombinant DNA research. Develop protocols and procedures to address issues of biosafety.


Develop, implement, and maintain the university’s biosafety program.

Develop, implement, and maintain the university’s program for select agents and toxins. Perform periodic inspections to ensure that laboratory standards are rigorously followed.

Promote regulatory compliance and a safe laboratory environment. Provide advice on laboratory security.

Provide oversight of the ASU Bloodborne Pathogen Program and conduct training for

laboratory personnel with such exposure. Provide technical advice to Principal Investigators and the Institutional Biosafety

Committee on research safety procedures. Provide training in the safe use and practices for those working with potentially

biohazardous materials and activities. Report to the Institutional Biosafety Committee and the institution any significant

problems, violations of the NIH Guidelines, and any significant research-related accidents

or illnesses of which the Biological Safety Officer becomes aware unless the Biological Safety Officer determines that a report has already been filed by the Principal

Investigator. Work in conjunction with the IBC and the ORIA to review all registration forms for

research proposals submitted by Principal Investigators.

D. Office of Research Integrity and Assurance

Accepts all IBC forms from PIs for research involving any of the following: 1)

recombinant DNA, 2) biohazardous agents, and 3) select agents and toxins, and coordinates their review with the IBC and EH&S.

Reviews biological Material Transfer Agreements (MTA) and coordinates approval with

EH&S. Accepts research protocols involving the use of animals and coordinates review by the

Institutional Animal Care and Use Committee (IACUC). Accepts research protocols involving the use of human subjects and coordinates review

by the Institutional Review Board (IRB).

E. Deans, Directors, and Chairs

Ensure that registration forms are completed by each Principal Investigator conducting

research involving biohazardous materials (microorganisms, microbial toxins, or other

biological agents that can infect and/or cause disease in humans, animals, or plants), human blood, body fluid, tissues, and cell lines of human origin, genetically-modified

organisms, and recombinant DNA molecules.

F. Responsible Official

A Responsible Official (RO) is required under the HHS and USDA select agent regulations. This

individual’s responsibilities can be found in the applicable regulations. Although this list is not intended to be a complete list, critical responsibilities include:

Developing and implementing safety, security, and emergency response plans.

Allowing only approved individuals to have access to select agents or toxins.

Providing appropriate training for safety, security and emergency response. Transferring select agents or toxins only to registered individuals.

Providing immediate notice of any theft, loss, or release of a select agent or toxin. Providing proper laboratory facilities to contain and dispose of select agents and toxins.

Maintaining complete records relating to select agents as defined in 42 CFR 73.15. Reporting the identification of a select agent or toxin as a result of diagnosis, verification,

or proficiency testing.

Submitting changes in the registration information by promptly notifying the CDC or Animal and Plant Health Inspection (APHIS)/USDA in writing. This includes modifications

http://www.asu.edu/uagc/EHS/documents/bloodborne_pathogens_standards.pdf


to the list of individuals that have been approved to work or access select agents,

changes in work locations, and changes in protocols or objectives of the studies. Conducting regular inspections, at least annually, of the laboratory where select agents

or toxins are stored or used to ensure compliance with all procedures and protocols of this safety plan. The results of these inspections must be documented and any

deficiencies must be corrected and documented.

The RO for Arizona State University is:

Leon C. Igras, Director, EH&S

The Alternate Responsible Officials (ARO) for Arizona State University is:

David Gillum, Associate Director of Biosafety/Biosecurity, EH&S

Steven Hunter, Associate Director, EH&S

Irene Mendoza, Assistant Biosafety Officer, EH&S

G. Principal Investigator

A scientist, trained and knowledgeable in appropriate laboratory techniques, safety procedures, and hazards associated with handling biohazardous agents must be responsible for the conduct

of work with any biohazardous agents or materials. This individual should consult with biosafety

or other health and safety professionals with regard to risk assessment. Responsibilities of the Principal Investigator (PI) include:

Accept direct responsibility for the health and safety of those working with biohazardous

materials and/or select agents and toxins in the laboratory. Adhere to IBC-approved emergency plans for handling accidental spills and personnel

contamination.

Be adequately trained in good microbiological techniques. Comply with shipping requirements for biohazardous.

Develop specific biosafety standard operating procedures for biohazardous materials used in the laboratory.

Ensure compliance by laboratory personnel with relevant regulations, guidelines, and

policies. Ensure personal protective equipment is provided and used.

Ensure proper training and instruction for laboratory personnel in safe practices and protocols, including, at a minimum, training in aseptic techniques and biology of the

organism(s) used. Please refer to the ASU Lab-Specific Biosafety Training Checklist. Ensure the integrity of the physical containment (e.g., biological safety cabinets) and the

biological containment (e.g., purity, genotypic and phenotypic characteristics) through

annual testing and certification. Inform the laboratory staff of the reasons and provisions for any precautionary medical

practices advised or requested (e.g., vaccinations or serum collection). Instruct and train laboratory staff in: (i) the practices and techniques required to ensure

safety, and (ii) the procedures for dealing with accidents.

Propose appropriate microbiological practices and laboratory techniques to be used for the research.

Provide to all laboratory staff the protocols that describe the potential biohazards and the precautions to be taken.

Remain in communication with the IBC throughout the conduct of the project.

Report any significant problems pertaining to the operation and implementation of containment practices and procedures in writing to the Biological Safety and other

authorities, as appropriate. Submit a disclosure to the Institutional Biosafety Committee (IBC) for review and

approval or disapproval.

http://www.asu.edu/uagc/EHS/forms/asu_lab_specific_biosafety_training.pdf


Supervise laboratory staff to ensure that the required safety practices and techniques are

employed. Correct work errors and conditions that may result in accidents, injuries, or the release of biohazardous materials.

PIs are also responsible for full compliance with the NIH Guidelines during the conduct of

recombinant DNA research.

Determine whether the recombinant DNA research is subject to the NIH Guidelines. Develop specific biosafety standard operating procedures for recombinant DNA materials

used in the laboratory.

Obtain IBC approval before initiating recombinant DNA research subject to the NIH Guidelines.

Petition OBA, with notice to the IBC, for proposed exemptions from the NIH Guidelines. Propose physical and biological containment levels in accordance with the NIH Guidelines

when registering research with the IBC.

Report any significant problems, violations of the NIH Guidelines, or any significant research-related accidents and illnesses to the Biological Safety Officer,

Greenhouse/Animal Facility Director, Institutional Biosafety Committee, NIH/OBA, and

other authorities, as appropriate, within 30 days. Seek OBA approval, in addition to IBC approval, to conduct experiments specified in

Sections III-A and III-B of the NIH Guidelines. Seek the NIH Office of Biotechnology’s (OBA) determination of containment for

experiments that require a case-by-case review. Submit any subsequent changes (e.g., changes in the source of DNA or host-vector

system) to the disclosure to the IBC for review and approval or disapproval.

H. Laboratory Employees

Participate in appropriate training and instruction and ensure that they are adequately

trained and fully understand the instructions.

Fully comprehend all biological agents and select agents and toxins being used in the lab and the potential risks associated with exposure, as well as fully understanding the

associated emergency response procedures. Follow all laboratory practices and protocols and comply with all applicable policies,

procedures, and guidelines.

Complete any necessary medical surveillance. Report all thefts, security incidents, accidents, spills, or contamination incidents to

supervisor.

I. Institutional Animal Care and Use Committee

The Institutional Animal Care and Use Committee (IACUC) works in cooperation with the

Occupational Health Nurse, the Director of the Department of Animal Care and Technologies (DACT), and the University Veterinarian, to advise investigators and animal care personnel on the

potential biohazards and risk of physical injury associated with laboratory animals and on the procedures for reducing or eliminating exposure. It also ensures compliance with all applicable

regulations, policies, and procedures based on the Public Health Service Policy on Humane Care

and Use of Laboratory Animals.

DACT ensures that biosafety cabinets in animal facilities are certified as needed. DACT and the University Veterinarian provide training to all animal users in proper

methodology and safe animal handling. ORIA ensures that all employees receive appropriate training and maintains those records.


J. Other Organizations

Other committees, including the Human Subjects Committee, Radiation Safety Committee, and

the Department of Public Safety must:

Consult and coordinate with the IBC and EH&S on any proposals under their purview

which involve the use of potentially biohazardous materials or activities.

K. Visitors, Vendors, and Contractors

All visitors, vendors, and contractors must:

Comply with all security requirements and procedures.

Be accompanied by a Department of Justice approved person at all times while in areas with select agents or toxins; and

Use personal protective equipment provided for them by the laboratory.

NOTE: Contractors must ensure that appropriate personal protective equipment is available

for their own workers.


IV. INCIDENT REPORTING

A. Reportable Incidents and Violations

Incidents or problems involving recombinant DNA and/or biohazardous materials must be immediately reported to the Biological Safety Officer (BSO). Examples of reportable significant

incidents include but are not limited to any overt exposure, such as a needle stick, splash, and

contamination due to equipment failure, and any potential exposure to biohazardous materials. A significant event may also occur from a containment breach, which may be subsequently

determined to pose either an overt or potential exposure to individuals. It should be noted that waste from recombinant DNA research is considered biohazardous and incidents involving

improper disposal of recombinant DNA must also be reported. Questions regarding reportable incidents should be directed to the BSO.

Failure by research personnel to follow federal and institutional regulations, guidelines, policies and/or procedures may also require reporting to the appropriate institutional, local, state and/or

federal agencies. Violations may include but are not limited to conduct of new or ongoing research without appropriate federal or institutional registration, review, approval or oversight.

B. Principal Investigator Responsibilities

The Principal Investigator and their personnel must report any significant incident, violation of the NIH Guidelines, or any significant, research-related accidents and illnesses immediately by

contacting the BSO. Examples of incidents and violations include:

Overt exposures, which are defined as exposures that result in direct personnel exposure

to biohazardous materials such as injection, spills, splashes or aerosol inhalation.

Potential exposures, which are defined as exposures that have a high risk of exposing

personnel to biohazardous materials such as spills, containment failure while working with the agent or equipment failure that may produce aerosols.

Any exposure (overt or potential) in a BSL-3 laboratory.

Overt exposure in BSL-1 or BSL-2 laboratories.

Any illness that may be caused by the agents used in the laboratory.

Any incident involving the improper disposal of recombinant DNA.

C. Biosafety Officer Responsibilities

The Biological Safety Officer (BSO) is required, by the NIH Guidelines, to report to the IBC:

• All violations of the NIH Guidelines and significant incidents. • Any significant research-related accidents or illnesses.

D. Institutional Responsibilities

The IBC is required, by the NIH Guidelines, to report to the appropriate University official and to

the NIH/OBA within 30 days any significant incidents, violations of the NIH Guidelines, or any significant research-related accidents and illnesses. The IBC will be responsible to determine

what actions, if any, are necessary. For example the IBC may choose to change the frequency of lab inspections, or change the biosafety level of the disclosure, based on results of the incident.

Other IBC reporting requirements (to OBA and other agencies) include but are not limited to:

• Research involving recombinant DNA or biohazardous materials without prior IBC approval.

• Lax security, unsafe procedures used in a laboratory setting, improper disposal of recombinant waste.


• Significant changes to proposed research risk without prior notification and approval by

IBC.

Some incidents must be reported to OBA on an expedited basis. Spills or accidents in BSL-2 laboratories (involving recombinant DNA) resulting in an overt exposure must be immediately

reported to OBA. In addition, spills or accidents involving recombinant DNA occurring in high

containment (BSL-3 or higher) laboratories resulting in an overt or potential exposure must be immediately reported to OBA. The IBC will report to the appropriate institutional official, who, in

turn will report to OBA, any of the above-described incidents.

Institutional violations that will be reported to the appropriate college or department head may include but are not limited to:

• Lapses in disclosure approval. • Failure to comply with institutional and federal regulations, guidelines, and policies.

• Unsafe work practices.

E. Institutional Official Responsibilities

Upon receiving a report from the IBC, the Institutional Official (IO) will directly report:

• In writing any problems with or violations (non-compliance) of the NIH Guidelines, or any

significant incident, accidents, or illnesses related to recombinant DNA, to the NIH/OBA within 30 days or immediately for overt exposure to a BSL-2 agent or potential/overt

exposure to a BSL-3 agent.

• Any significant research-related illness or accident that may be hazardous to the public health and cooperate with state and local public health departments.


V. BIOHAZARDOUS RESEARCH PROJECT REGISTRATION AND APPROVAL

A. Introduction

Each PI is responsible for the preparation of registration documents for all research involving

potentially biohazardous materials, including the assignment of the required Biological Safety

Level (BSL) to the proposed biological research. Biological research includes research involving:

Bacterial, viral, fungal, parasitic, or other potentially infectious agents. Recombinant DNA, including experiments that may be exempt under the NIH Guidelines. Human blood, body fluid, and tissue, including human cell lines. Listed select agents and toxins.

The IBC, in conjunction with EH&S, will review all submitted registration documents; confirm, where applicable, that exempt status is appropriate for certain recombinant DNA work; and

consider approval for those registration documents that are complete and that provide for safe handling of potentially biohazardous materials under the appropriate BSL.

B. Registration and Approval Process

Additional requirements referred to in the registration documents for research involving select agents or toxins, infectious materials, or human blood or tissue (as outlined below) will need to

be fulfilled for final approval to be given.

If the project involves or may involve recombinant DNA; infectious agents (other

than select agents and toxins); human blood, tissue or cell cultures; or other biosafety concerns, the following steps must occur:

1. The Office of Research Integrity and Assurance (ORIA) or the Biosafety Officer distributes

registration forms and the ASU Biosafety Manual to anyone requesting them and to other

researchers who may work with recombinant DNA, infectious agents, human samples, or other biosafety concerns.

2. The Principal Investigator (PI) or researcher reviews the ASU Biosafety Manual and, if

applicable, completes Form 112 for recombinant DNA, infectious agents, human blood, and

tissue or cell culture. The PI may contact ORIA or the Biosafety Officer in EH&S to discuss the project or for guidance in completing the forms. In addition, to assist the PI in

determining the appropriate biosafety level for the proposed research, the PI is directed to the Agent Summary Statements in the BMBL and Appendix B, Classification of Human

Etiologic Agents on the Basis of Hazard in the NIH Guidelines.

3. The PI submits the completed application and necessary attachments to ORIA.

4. ORIA reviews the submitted application for completeness and may contact the PI for

additional information.

5. The Biosafety Officer and members of the Institutional Biosafety Committee review the

completed application to determine whether the project meets federal and university standards.

6. At its monthly meeting, the IBC discusses the proposed project and votes to approve the

research as presented, to approve it with stipulations, or to table it for further information.

7. If the project is approved, the Chair of the IBC signs the application. ORIA retains all

administrative records.

http://researchintegrity.asu.edu/biosafety/forms

http://www.cdc.gov/biosafety/publications/bmbl5/index.htm


8. ORIA, on behalf of the IBC, will notify the PI of the status of the application, including any

stipulations or comments for resolution.

Additional Notes:

A “Continuing Review to Original 112AB Disclosure” Form 112AR is available to facilitate

the annual renewal process.

If the research involves any listed select agents or toxins, the PI must submit Form 112C

as an initial starting point.

Copies of the 112 application forms can be downloaded from the ORIA website at

http://researchintegrity.asu.edu/biosafety/forms or can be obtained the Biosafety Officer

through EH&S.

C. Additional Information and Requirements

1. Select Agents and Toxins

All personnel at Arizona State University are prohibited from possessing, using, receiving, or transferring listed select agents or toxins unless ASU has been granted a certificate of

registration by the HHS Secretary or the USDA Secretary. Additional requirement for

Select Agents and Toxins are found in the appendix titled “Special Considerations for Select Agents and Toxins.”

2. Human Blood and Tissue

In any laboratory where work involves the use of and/or exposure to human blood, body

fluids, or unfixed human tissue, including human cell cultures, there is the danger of

exposure to bloodborne pathogens (disease-causing microorganisms) that may be found in such material. Work with any of these materials in a laboratory setting must follow

ASU procedures as described in the ASU Exposure Control Plan.

In addition, when human blood or tissue donors are involved, the PI must contact ORIA

to determine whether a human subject Institutional Review Board (IRB) application is required. The IRB Coordinator may be contacted in ORIA.

3. Animal Handling

When research involves exposure to and handling of animals, consideration must be

given to the potential allergens, animal pathogens, zoonoses, and physical hazards, e.g.,

bites and scratches that may be encountered by researchers and staff. All research involving the use of animals conducted under the auspices of ASU is reviewed by the

Institutional Animal Care and Use Committee (IACUC), in compliance with federal regulations. Projects involving animal research require that applications be submitted to

the IACUC for protocol approval before research begins.

Principal Investigators and all personnel involved in the care and use of research animals

must obtain certification in the ASU's Humane Practice of Animal Care and Use Training Program. All of these requirements must be fulfilled prior to the acquisition and use of

laboratory animals, including medical review with the Occupational Health Nurse at ASU

Campus Health Services.




http://www.asu.edu/uagc/EHS/documents/bloodborne_pathogens_plan.pdf

http://researchintegrity.asu.edu/animals




4. Recombinant DNA Materials

The use of recombinant DNA is regulated by the NIH, as outlined in the NIH Guildelines. At ASU this research must be reviewed by the IBC prior to initiation of the work. Guidelines include registration of the recombinant DNA, understanding the classification

of the use of recombinant DNA, and safe work practices/proper disposal of material

(including whole animals) containing recombinant DNA. The use of more than 10 liters of recombinant material requires special practices.

5. Environmental Samples

Environmental samples, such as water, air, or earth, may contain pathogens (i.e., bacteria, viruses, spores) that could present a health hazard to people, animals, or the

environment. Using appropriate personal protective equipment when collecting environmental samples will reduce exposure to potential pathogens. Use care when

handling environmental samples, especially if the sample will be enhanced in the laboratory by culturing or other growing mechanisms. Techniques used to enhance

and/or culture environmental samples should be conducted at BSL-2 or higher levels in

an appropriate containment device, such as a biological safety cabinet or fume hood. If the environmental sample is sterilized prior to experimentation, then the sample may be

manipulated in a BSL-1 rated laboratory.

Research involving environmental samples must be registered with the ASU Institutional

Biosafety Committee (IBC) for approval. If you require assistance determining whether you need to register this research with the IBC, please contact the Biological Safety

Officer.

6. Protective Clothing Beyond the Laboratory

The improper use or lack of protective clothing and equipment in a laboratory can lead to

chemical burns, biological exposures, or other potential dangers. To help reduce the risk of exposure, personnel in ASU laboratories are required to wear gloves, safety glasses,

lab coats and other personal protective clothing. However, in public areas, such as hallways and lounges, wearing personal protective clothing and equipment is not

recommended. This is because contaminated clothing may present a hazard, and the

perception of contaminated protective clothing and equipment in a public area may project a careless image to both colleagues and visitors.

Wearing gloves outside the laboratory should be minimized, except to move hazardous

materials between laboratories. Chemicals should be transported from place to place on

a cart, in a clean secondary container, or in a bottle carrier with secure handles. When this is not an option, personnel should use a clean, ungloved hand to touch common

surfaces and a gloved hand to carry the items: the one-glove rule. Alternatively, the material should be packaged so the outer container may be transported without the need

for personal protective equipment.

Protective gloves should never come into contact with door handles, elevator buttons,

telephones, lavatory faucets, vending machines, bottled water dispensers, ice-making machines, or other surfaces outside the laboratory. Also, please be aware that strict

federal and state regulations address the transport of hazardous (i.e., biological, chemical, radiological) materials on public roads.

For the sake of safety, appearances, and courtesy, personnel are asked not to wear contaminated, stained, or potentially contaminated lab coats and other research clothing

and equipment in any public area, especially dining areas, lounges, auditoriums, conference rooms, or other non-hazardous areas.


7. Food and Beverages in the Laboratory

In order to reduce potential exposures and to ensure compliance with prudent laboratory

operations, regulations, and other best management practices, ASU prohibits the storage and consumption of food and drink in all campus laboratories. The only exception is for

food and beverages used in research and teaching projects. These materials must be

labeled, “Not for Human Consumption.”

In order to prevent potential exposure to hazardous materials:

Do not eat, drink, smoke, chew gum, apply cosmetics, or take medicine in

laboratories where hazardous materials are handled or stored. Do not store food, beverages, cups, or other drinking and eating utensils in areas

where hazardous materials are handled or stored.

Do not use glassware for laboratory operations to prepare or consume food or

beverages.

Do not use laboratory refrigerators, ice chests, cold rooms, and ovens for food

storage or preparation. Do not use laboratory water sources or deionized laboratory water for drinking

water.

Important: Food and beverages must never be stored in any laboratory refrigerator in

which chemicals, biological, and radioactive materials are kept unless they have been

labeled, “Not for Human Consumption.


VI. TRAINING FOR WORKING SAFELY WITH BIOHAZARDOUS AGENTS

The PI or laboratory supervisor is responsible for providing or arranging for site-specific training of all

personnel. In addition, each employee must attend Biosafety Training and Laboratory Chemical Safety Training. Contact EH&S or the Biosafety Officer for more information on scheduling training. Training

must be documented. Please refer to the ASU Laboratory-Specific Training Checklist for more

information.



VII. LABORATORY PROCEDURES AND EQUIPMENT

A. Exposure Control

The term “containment” is used in describing safe methods for managing biohazardous and

select agents and toxins 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 people, and the outside environment to potentially hazardous agents. The three

elements of containment include laboratory practices and techniques, safety equipment, and facility design. The risk assessment of the work to be done with a specific agent will determine

the appropriate combination of these elements. Each PI is required to complete a Health Hazard Assessment for each biological agent and toxin stored in his or her laboratory (see Appendix B of

this manual). Copies of the Health Hazard Assessments must be included in the PI’s Lab-Specific

Biosafety Manual.

Laboratory Practice and Technique 1.

The most important element of containment is strict adherence to standard

microbiological practices and techniques. Persons working with infectious agents or 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 PI of each laboratory is responsible for providing or arranging the appropriate training of personnel

and for verifying each person’s competence. In addition, each PI must develop a Lab-Specific Biosafety Manual to address the use, handling, and disposal of biohazardous

material (including select agents and toxins) in the laboratory. The Lab-Specific Biosafety

Manual must identify specific hazards that will or may be encountered and consider procedures needed to minimize or eliminate risks. Personnel should be advised of special

hazards and are expected to follow the required practices and procedures. A template for the Lab-Specific Biosafety Manual may be found in Appendix B of this manual.

Safety Equipment (Primary Barriers) 2.

Safety equipment includes biological safety cabinets (BSC), enclosed biohazardous containers, and other engineering controls designed to eliminate or minimize exposures

to biohazardous agents and toxins. The biological safety cabinet is the principal device

used to provide containment of infectious splashes or aerosols generated by many microbiological procedures. More information on BSCs may be found in the “Biological Safety Cabinet” section of this manual.

Primary safety barriers may also include personal protection equipment (PPE) such as

gloves, lab coats, safety glasses or goggles, face shields and respirators. Personal protective equipment is often used in combination with BSCs and other containment

devices. In some situations in which it is impractical to work in a BSC, personal protective equipment may form the primary barrier between the worker and the infectious

materials. ASU policy requires the use of gloves, lab coat and eye protection at all times when handling biohazardous materials.


Facility Design (Secondary Barriers) 3.

The design of a facility is important in providing a barrier to protect those working inside

and outside the laboratory and to protect people or animals in the community from biohazardous agents and toxins which may be accidentally released from the laboratory.

Facilities must be commensurate with the laboratory's function and the recommended

biosafety level for the agent being manipulated.

The secondary barriers required will depend on the risk of transmission of specific agents. For example, in working with agents at Biosafety Level 2, the exposure risks

involve direct contact with the agents or inadvertent contact through contaminated work environments. Recommended secondary barriers in these laboratories include separation

of the laboratory work area from public access, handwashing facilities, and availability of

a decontamination facility such as an autoclave.

When the risk of infection by exposure to an infectious aerosol is present, higher levels of primary containment and multiple secondary barriers may become necessary to prevent

infectious agents from escaping into the environment. Such design features include

specialized ventilation systems to ensure directional airflow, HEPA filtration to remove agents from exhaust air, controlled access zones, airlocks as laboratory entrances, or

separate modules to isolate the laboratory.

B. Biological Safety Cabinets (BSCs)

BSCs are classified as Class I, Class II, or Class III cabinets. When properly maintained and

operated, they effectively contain and capture microbial contaminants and infectious agents using HEPA (High Efficiency Particulate Air) filters (See Figure 1. Source: Biosafety in

Microbiological and Biomedical Laboratories 5th Edition, Appendix A). Biosafety cabinets should

not be confused with clean benches which only protect the material being worked with and are not suitable for work with infectious or toxic material. (Although clean benches, like BSCs, have

HEPA-filtered air, in clean benches the air flows over the experimental material toward the user rather than being drawn away.) BSCs should also not be confused with conventional fume hoods

that do not filter microorganisms.


Types of BSCs:

Class I BSCs provide personnel and environmental protection, but not product protection (See Figure 2. Source: Biosafety in Microbiological and Biomedical Laboratories 5th Edition, Appendix A).

Class II BSCs are the most commonly used BSC at ASU for biohazardous agents. These

cabinets provide personnel, environmental, and product protection (See Figure 3. Source: Biosafety in Microbiological and Biomedical Laboratories 5th Edition, Appendix A). Only those

which are hard ducted to the outside and provide a face velocity of 80 to 125 feet per minute should be used when working with volatile chemicals. Additionally, cabinets are not designed to

prevent ignition of volatile flammable chemicals, such as ethanol and isopropanol.


Guidelines for Working in a BSC

1. Turn off the ultraviolet lamp if one is in use. Turn on the fluorescent lamp. 2. Inspect the air intake grilles for obstructions and foreign material and remove if necessary.

3. Adjust view screen to proper height.

4. Turn the cabinet on for at least 10 minutes prior to use, if the cabinet is not left running. 5. Prepare a written checklist of materials necessary for the particular activity.

6. Wash hands and arms with mild soap. Put on a rear-fastening, long-sleeved gown with tight-fitting cuffs. Put on safety glasses and a pair (or two pairs) of high quality nitrile gloves.

7. Disinfect work surface with a suitable disinfectant. 8. Place items into the cabinet so that they can be worked with efficiently without unnecessary

disruption of the airflow, working with materials from the clean to the dirty side.

9. Adjust the working height of the stool so that the worker's face is above the front opening. 10. Delay manipulation of materials for approximately one minute after placing hands/arms

inside the cabinet. 11. Minimize the frequency of moving hands in and out of the cabinet.

12. Do not disturb the airflow by covering any portion of the grillwork with materials.

13. Work at a moderate pace to prevent the air flow disruption that occurs with rapid movements.

14. Wipe the bottom and side of the hood surfaces with disinfectant when work is completed.

NOTE: Be very careful when using small pieces of materials such as chemwipes in the hood. These can be blown into the hood and disrupt the motor operations.

Certification of the BSC

Certification is a series of performance tests on the BSC to confirm that it will provide the user and experimental material the protection for which it is designed. The airflow, filters, and cabinet

integrity are checked to ensure that the cabinet meets minimum performance standards.

Certification is arranged through each department and provided by an outside vendor.

BSCs intended for research with biohazardous materials must be certified:

After they are received and installed (before use with infectious materials).

After filter changes.

After being moved (even a few feet).

Annually.

BSC decontamination (using the formaldehyde gas production process) must be provided (e.g.,

by an outside vendor) and needs to be done:

Before any maintenance work requiring disassembly of the air plenum, including filter

replacement.

Prior to cabinet recertification.

Before moving the cabinet to a new laboratory.

Before discarding or salvaging.

The production of formaldehyde gas is a health concern. Many BSCs at ASU are not ducted to the

outside; therefore, extreme caution should be used when having the procedure performed.


VIII. GUIDELINES FOR GOOD LABORATORY PRACTICES

A. Guidelines for Good Laboratory Practices at BSL-1

BSL-1 is suitable for work involving well-characterized agents not known to consistently cause

disease in immunocompetent adult humans, and present minimal potential hazard to laboratory personnel and the environment. BSL-1 laboratories are not necessarily separated from the

general traffic patterns in the building. Work is typically conducted on open bench tops using standard microbiological practices. Special containment equipment or facility design is not

required, but may be used as determined by appropriate risk assessment. Laboratory personnel

must have specific training in the procedures conducted in the laboratory and must be supervised by a scientist with training in microbiology or a related science.

The following standard practices, safety equipment, and facility requirements apply to BSL-1:

1. Standard Microbiological Practices

a) The laboratory supervisor must enforce the institutional policies that control

access to the laboratory. b) Persons must wash their hands after working with potentially hazardous

materials and before leaving the laboratory.

c) Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption must not be permitted in laboratory areas.

Food must be stored outside the laboratory area in cabinets or refrigerators designated and used for this purpose.

d) Mouth pipetting is prohibited; mechanical pipetting devices must be used. e) Policies for the safe handling of sharps, such as needles, scalpels, pipettes, and

broken glassware must be developed and implemented. Whenever practical,

laboratory supervisors should adopt improved engineering and work practice controls that reduce risk of sharps injuries.

Precautions, including those listed below, must always be taken with sharp

items. These include:

i. Careful management of needles and other sharps are of primary

importance. Needles must not be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand

before disposal. ii. Used disposable needles and syringes must be carefully placed in

conveniently located puncture-resistant containers used for sharps

disposal. iii. Non disposable sharps must be placed in a hard walled container for

transport to a processing area for decontamination, preferably by autoclaving.

iv. Broken glassware must not be handled directly. Instead, it must be

removed using a brush and dustpan, tongs, or forceps. Plasticware should be substituted for glassware whenever possible.

f) Perform all procedures to minimize the creation of splashes and/or aerosols.

g) Decontaminate work surfaces after completion of work and after any spill or

splash of potentially infectious material with appropriate disinfectant. h) Decontaminate all cultures, stocks, and other potentially infectious materials

before disposal using an effective method. Depending on where the decontamination will be performed, the following methods should be used prior

to transport:


i. Materials to be decontaminated outside of the immediate laboratory

must be placed in a durable, leak proof container and secured for transport

ii. Materials to be removed from the facility for decontamination must be packed in accordance with applicable local, state, and federal

regulations.

i) A sign incorporating the universal biohazard symbol must be posted at the

entrance to the laboratory when infectious agents are present. The sign may include the name of the agent(s) in use, and the name and phone number of the

laboratory supervisor or other responsible personnel. Agent information should be posted in accordance with the institutional policy.

j)

k) An effective integrated pest management program is required. l) The laboratory supervisor must ensure that laboratory personnel receive

appropriate training regarding their duties, the necessary precautions to prevent exposures, and exposure evaluation procedures. Personnel must receive annual

updates or additional training when procedural or policy changes occur. Personal

health status may impact an individual’s susceptibility to infection, ability to receive immunizations or prophylactic interventions. Therefore, all laboratory

personnel and particularly women of child-bearing age should be provided with information regarding immune competence and conditions that may predispose

them to infection. Individuals having these conditions should be encouraged to self-identify to the institution’s healthcare provider for appropriate counseling

and guidance.

2. Special Practices

None required.

3. Safety Equipment (Primary Barriers and Personal Protective Equipment)

a) Special containment devices or equipment, such as BSCs, are not generally

required. b) Protective laboratory coats, gowns, or uniforms are recommended to prevent

contamination of personal clothing. c) Wear protective eyewear when conducting procedures that have the potential to

create splashes of microorganisms or other hazardous materials. Persons who

wear contact lenses in laboratories should also wear eye protection. d) Gloves must be worn to protect hands from exposure to hazardous materials

Glove selection should be based on an appropriate risk assessment. e) Alternatives to latex gloves should be available. Wash hands prior to leaving the

laboratory. In addition, BSL-1 workers should:

i. Change gloves when contaminated, integrity has been compromised, or

when otherwise necessary. ii. Remove gloves and wash hands when work with hazardous materials

has been completed and before leaving the laboratory.

iii. Do not wash or reuse disposable gloves. Dispose of used gloves with other contaminated laboratory waste. Hand washing protocols must be

rigorously followed.

4. Laboratory Facilities (Secondary Barriers)

a) Laboratories should have doors for access control.

b) Laboratories must have a sink for hand washing.


c) The laboratory should be designed so that it can be easily cleaned. Carpets and

rugs in laboratories are not appropriate. d) Laboratory furniture must be capable of supporting anticipated loads and uses

Spaces between benches, cabinets, and equipment should be accessible for cleaning.

i. Bench tops must be impervious to water and resistant to heat, organic solvents, acids, alkalis, and other chemicals.

ii. Chairs used in laboratory work must be covered with a non-porous material that can be easily cleaned and decontaminated with appropriate

disinfectant. iii. Laboratories windows that open to the exterior should be fitted with

screens.

B. Guidelines for Good Laboratory Practices at BSL-2

BSL-2 builds upon BSL-1 practices. BSL-2 is suitable for work involving agents that pose

moderate hazards to personnel and the environment. It differs from BSL-1 in that 1) laboratory

personnel have specific training in handling pathogenic agents and are supervised by scientists competent in handling infectious agents and associated procedures; 2) access to the laboratory is

restricted when work is being conducted; and 3) all procedures in which infectious aerosols or splashes may be created are conducted in BSCs or other physical containment equipment.

The following standard and special practices, safety equipment, and facility requirements apply to

BSL-2:


a) The laboratory supervisor must enforce the institutional policies that control

access to the laboratory.

b) Persons must wash their hands after working with potentially hazardous materials and before leaving the laboratory.

c) Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption must not be permitted in laboratory areas.

Food must be stored outside the laboratory area in cabinets or refrigerators

designated and used for this purpose. d) Mouth pipetting is prohibited; mechanical pipetting devices must be used.

e) Policies for the safe handling of sharps, such as needles, scalpels, pipettes, and broken glassware must be developed and implemented. Whenever practical,

laboratory supervisors should adopt improved engineering and work practice controls that reduce risk of sharps injuries.

Precautions, including those listed below, must always be taken with sharp items. These include:

i. Careful management of needles and other sharps are of primary

importance. Needles must not be bent, sheared, broken, recapped,

removed from disposable syringes, or otherwise manipulated by hand before disposal.

ii. Used disposable needles and syringes must be carefully placed in conveniently located puncture-resistant containers used for sharps

disposal. iii. Non-disposable sharps must be placed in a hard walled container for

transport to a processing area for decontamination, preferably by

autoclaving.


iv. Broken glassware must not be handled directly. Instead, it must be

removed using a brush and dustpan, tongs, or forceps. Plasticware should be substituted for glassware whenever possible.


g) Decontaminate work surfaces after completion of work and after any spill or

splash of potentially infectious material with appropriate disinfectant. h) Decontaminate all cultures, stocks, and other potentially infectious materials

before disposal using an effective method. Depending on where the decontamination will be performed, the following methods should be used prior

to transport:

i. Materials to be decontaminated outside of the immediate laboratory

must be placed in a durable, leak proof container and secured for transport.

ii. Materials to be removed from the facility for decontamination must be packed in accordance with applicable local, state, and federal

regulations.


entrance to the laboratory when infectious agents are present. Posted information must include: the laboratory’s biosafety level, the supervisor’s name

(or other responsible personnel), telephone number, and required procedures for entering and exiting the laboratory. Agent information should be posted in

accordance with the institutional policy.

j) An effective integrated pest management program is required. k) The laboratory supervisor must ensure that laboratory personnel receive

appropriate training regarding their duties, the necessary precautions to prevent exposures, and exposure evaluation procedures. Personnel must receive annual

updates or additional training when procedural or policy changes occur. Personal


personnel and particularly women of child-bearing age should be provided with information regarding immune competence and conditions that may predispose

them to infection. Individuals having these conditions should be encouraged to

self-identify to the institution’s healthcare provider for appropriate counseling and guidance.


a) All persons entering the laboratory must be advised of the potential hazards and meet specific entry/exit requirements.

b) Laboratory personnel must be provided medical surveillance and offered

appropriate immunizations for agents handled or potentially present in the laboratory.

c) Each institution must establish policies and procedures describing the collection and storage of serum samples from at-risk personnel.

d) A Lab-Specific Biosafety Manual must be prepared and adopted as policy. The

biosafety manual must be available and accessible. e) The laboratory supervisor must ensure that laboratory personnel demonstrate

proficiency in standard and special microbiological practices before working with BSL-2 agents.

f) Potentially infectious materials must be placed in a durable, leak proof container during collection, handling, processing, storage, or transport within a facility.

g) Laboratory equipment should be routinely decontaminated, as well as, after

spills, splashes, or other potential contamination.


i. Spills involving infectious materials must be contained, decontaminated, and cleaned up by staff properly trained and equipped to work with

infectious material. ii. Equipment must be decontaminated before repair, maintenance, or

removal from the laboratory.

h) Incidents that may result in exposure to infectious materials must be

immediately evaluated and treated according to procedures described in the laboratory biosafety safety manual. All such incidents must be reported to the

laboratory supervisor. Medical evaluation, surveillance, and treatment should be provided and appropriate records maintained.

i) Animals and plants not associated with the work being performed must not be

permitted in the laboratory. j) All procedures involving the manipulation of infectious materials that may

generate an aerosol should be conducted within a BSC or other physical containment devices.


a) Properly maintained BSCs (preferably Class II), other appropriate personal protective equipment, or other physical containment devices must be used

whenever:

i. Procedures with a potential for creating infectious aerosols or splashes

are conducted. These may include pipetting, centrifuging, grinding, blending, shaking, mixing, sonicating, opening containers of infectious

materials, inoculating animals intranasally, and harvesting infected tissues from animals or eggs.

ii. High concentrations or large volumes of infectious agents are used. Such

materials may be centrifuged in the open laboratory using sealed rotor heads or centrifuge safety cups.

b) Protective laboratory coats, gowns, smocks, or uniforms designated for

laboratory use must be worn while working with hazardous materials. Remove

protective clothing before leaving for non-laboratory areas (e.g., cafeteria, library, administrative offices). Dispose of protective clothing appropriately, or

deposit it for laundering by the institution. It is recommended that laboratory clothing not be taken home.

c) Eye and face protection (goggles, mask, face shield or other splatter guard) is used for anticipated splashes or sprays of infectious or other hazardous

materials when the microorganisms must be handled outside the BSC or

containment device. Eye and face protection must be disposed of with other contaminated laboratory waste or decontaminated before reuse. Persons who

wear contact lenses in laboratories should also wear eye protection. d) Gloves must be worn to protect hands from exposure to hazardous materials.

Glove selection should be based on an appropriate risk assessment. Alternatives

to latex gloves should be available. Gloves must not be worn outside the laboratory. In addition, BSL-2 laboratory workers should:

a. Change gloves when contaminated, integrity has been compromised, or

when otherwise necessary. Wear two pairs of gloves when appropriate. b. Remove gloves and wash hands when work with hazardous materials

has been completed and before leaving the laboratory.


c. Do not wash or reuse disposable gloves. Dispose of used gloves with

other contaminated laboratory waste. Hand washing protocols must be rigorously followed.

e) Eye, face and respiratory protection should be used in rooms containing

infected animals as determined by the risk assessment.


a) Laboratory doors should be self-closing and have locks in accordance with the

institutional policies. b) Laboratories must have a sink for hand washing. The sink may be manually,

hands-free, or automatically operated. It should be located near the exit door.]

c) The laboratory should be designed so that it can be easily cleaned and decontaminated. Carpets and rugs in laboratories are not permitted.

d) Laboratory furniture must be capable of supporting anticipated loads and uses. Spaces between benches, cabinets, and equipment should be accessible for

cleaning.

i. Bench tops must be impervious to water and resistant to heat, organic

solvents, acids, alkalis, and other chemicals. ii. Chairs used in laboratory work must be covered with a non-porous

material that can be easily cleaned and decontaminated with appropriate disinfectant.

e) Laboratory windows that open to the exterior are not recommended. However, if a laboratory does have windows that open to the exterior, they must be fitted

with screens. f) BSCs must be installed so that fluctuations of the room air supply and exhaust do

not interfere with proper operations. BSCs should be located away from doors,

windows that can be opened, heavily traveled laboratory areas, and other possible airflow disruptions.

g) Vacuum lines should be protected with High Efficiency Particulate Air (HEPA) filters, or their equivalent. Filters must be replaced as needed. Liquid disinfectant

traps may be required.

h) An eyewash station must be readily available. i) There are no specific requirements on ventilation systems. However, planning of

new facilities should consider mechanical ventilation systems that provide an inward flow of air without recirculation to spaces outside of the laboratory.

j) HEPA filtered exhaust air from a Class II BSC can be safely re-circulated back into the laboratory environment if the cabinet is tested and certified at least

annually and operated according to manufacturer’s recommendations. BSCs can

also be connected to the laboratory exhaust system by either a thimble (canopy) connection or a direct (hard) connection. Provisions to assure proper safety

cabinet performance and air system operation must be verified. k) A method for decontaminating all laboratory wastes should be available in the

facility (e.g., autoclave, chemical disinfection, incineration, or other validated

decontamination method).

C. Guidelines for Good Laboratory Practices at BSL-3

BSL-3 is applicable to clinical, diagnostic, teaching, research, or production facilities where work

is performed with indigenous or exotic agents that may cause serious or potentially lethal disease through inhalation route exposure. Laboratory personnel must receive specific training in

handling pathogenic and potentially lethal agents, and must be supervised by scientists competent in handling infectious agents and associated procedures.


All procedures involving the manipulation of infectious materials must be conducted within BSCs, other physical containment devices, or by personnel wearing appropriate personal protective

equipment. A BSL-3 laboratory has special engineering and design features.

The following standard and special safety practices, equipment, and facility requirements apply to

BSL-3:


a) The laboratory supervisor must enforce the institutional policies that control access to the laboratory.

b) Persons must wash their hands after working with potentially hazardous

materials and before leaving the laboratory. c) Eating, drinking, smoking, handling contact lenses, applying cosmetics, and

storing food for human consumption must not be permitted in laboratory areas. Food must be stored outside the laboratory area in cabinets or refrigerators

designated and used for this purpose.

d) Mouth pipetting is prohibited; mechanical pipetting devices must be used. e) Policies for the safe handling of sharps, such as needles, scalpels, pipettes, and

broken glassware must be developed and implemented. Whenever practical, laboratory supervisors should adopt improved engineering and work practice

controls that reduce risk of sharps injuries.

Precautions, including those listed below, must always be taken with sharp

items. These include:

i. Careful management of needles and other sharps are of primary importance. Needles must not be bent, sheared, broken, recapped,

removed from disposable syringes, or otherwise manipulated by hand

before disposal. ii. Used disposable needles and syringes must be carefully placed in

conveniently located puncture-resistant containers used for sharps disposal.

iii. Non-disposable sharps must be placed in a hard walled container for

transport to a processing area for decontamination, preferably by autoclaving.

iv. Broken glassware must not be handled directly. Instead, it must be removed using a brush and dustpan, tongs, or forceps. Plasticware

should be substituted for glassware whenever possible.


g) Decontaminate work surfaces after completion of work and after any spill or splash of potentially infectious material with appropriate disinfectant.

h) Decontaminate all cultures, stocks, and other potentially infectious materials before disposal using an effective method. A method for decontaminating all

laboratory wastes should be available in the facility, preferably within the

laboratory (e.g., autoclave, chemical disinfection, incineration, or other validated decontamination method). Depending on where the decontamination will be

performed, the following methods should be used prior to transport:

i. Materials to be decontaminated outside of the immediate laboratory must be placed in a durable, leak proof container and secured for

transport.


ii. Materials to be removed from the facility for decontamination must be

packed in accordance with applicable local, state, and federal regulations.


entrance to the laboratory when infectious agents are present. Posted

information must include the laboratory’s biosafety level, the supervisor’s name (or other responsible personnel), telephone number, and required procedures for

entering and exiting the laboratory. Agent information should be posted in accordance with the institutional policy.

j) An effective integrated pest management program is required. k) The laboratory supervisor must ensure that laboratory personnel receive

appropriate training regarding their duties, the necessary precautions to prevent

exposures, and exposure evaluation procedures. Personnel must receive annual updates or additional training when procedural or policy changes occur. Personal


personnel and particularly women of child-bearing age should be provided with

information regarding immune competence and conditions that may predispose them to infection. Individuals having these conditions should be encouraged to

self-identify to the institution’s healthcare provider for appropriate counseling and guidance.


a) All persons entering the laboratory must be advised of the potential hazards and

meet specific entry/exit requirements.

b) Laboratory personnel must be provided medical surveillance and offered

appropriate immunizations for agents handled or potentially present in the laboratory.

c) Each institution must establish policies and procedures describing the collection and storage of serum samples from at-risk personnel.

d) A Lab-Specific Biosafety Manual must be prepared and adopted as policy. The biosafety manual must be available and accessible.

e) The laboratory supervisor must ensure that laboratory personnel demonstrate

proficiency in standard and special microbiological practices before working with BSL-3 agents.

f) Potentially infectious materials must be placed in a durable, leak proof container during collection, handling, processing, storage, or transport within a facility.

g) Laboratory equipment should be routinely decontaminated, as well as, after

spills, splashes, or other potential contamination.

i. Spills involving infectious materials must be contained, decontaminated, and cleaned up by staff properly trained and equipped to work with

infectious material. ii. Equipment must be decontaminated before repair, maintenance, or

removal from the laboratory.

h) Incidents that may result in exposure to infectious materials must be

immediately evaluated and treated according to procedures described in the laboratory biosafety safety manual. All such incidents must be reported to the

laboratory supervisor. Medical evaluation, surveillance, and treatment should be

provided and appropriate records maintained. i) Animals and plants not associated with the work being performed must not be

permitted in the laboratory.


j) All procedures involving the manipulation of infectious materials must be

conducted within a BSC, or other physical containment devices. No work with open vessels is conducted on the bench. When a procedure cannot be performed

within a BSC, a combination of personal protective equipment and other containment devices, such as a centrifuge safety cup or sealed rotor, must be

used.


a) All procedures involving the manipulation of infectious materials must be

conducted within a BSC (preferably Class II or Class III), or other physical containment devices.

b) Protective laboratory clothing with a solid-front such as tie-back or wraparound

gowns, scrub suits, or coveralls is worn by workers when in the laboratory. Protective clothing is not worn outside of the laboratory. Reusable clothing is

decontaminated with appropriate disinfectant before being laundered. Clothing is changed when contaminated.

c) Eye and face protection (goggles, mask, face shield or other splatter guard) is

used for anticipated splashes or sprays of infectious or other hazardous materials. Eye and face protection must be disposed of with other contaminated

laboratory waste or decontaminated before reuse. Persons who wear contact lenses in laboratories must also wear eye protection.

d) Gloves must be worn to protect hands from exposure to hazardous materials. Glove selection should be based on an appropriate risk assessment. Alternatives

to latex gloves should be available. Gloves must not be worn outside the

laboratory. In addition, BSL-3 laboratory workers should:

i. Change gloves when contaminated, integrity has been compromised, or when otherwise necessary. Wear two pairs of gloves when appropriate.

ii. Remove gloves and wash hands when work with hazardous materials

has been completed and before leaving the laboratory. iii. Do not wash or reuse disposable gloves. Dispose of used gloves with

other contaminated laboratory waste. Hand washing protocols must be rigorously followed.

e) Eye, face, and respiratory protection must be used in rooms containing infected animals.


a) Laboratory doors must be self-closing and have locks in accordance with the

institutional policies. The laboratory must be separated from areas that are open

to unrestricted traffic flow within the building. Access to the laboratory is restricted to entry by a series of two self-closing doors. A clothing change room

(anteroom) may be included in the passageway between the two self-closing doors.

b) Laboratories must have a sink for hand washing. The sink must be hands-free or

automatically operated. It should be located near the exit door. If the laboratory is segregated into different laboratories, a sink must also be available for hand

washing in each zone. Additional sinks may be required as determined by the risk assessment.

c) The laboratory must be designed so that it can be easily cleaned and decontaminated. Carpets and rugs are not permitted. Seams, floors, walls, and

ceiling surfaces should be sealed. Spaces around doors and ventilation openings

should be capable of being sealed to facilitate space decontamination.


i. Floors must be slip resistant, impervious to liquids, and resistant to

chemicals. Consideration should be given to the installation of seamless, sealed, resilient or poured floors, with integral cove bases.

ii. Walls should be constructed to produce a sealed smooth finish that can be easily cleaned and decontaminated.

iii. Ceilings should be constructed, sealed, and finished in the same general

manner as walls.

Decontamination of the entire laboratory should be considered when there has been gross contamination of the space, significant changes in laboratory usage,

for major renovations, or maintenance shut downs. Selection of the appropriate materials and methods used to decontaminate the laboratory must be based on

the risk assessment of the biological agents in use.

d) Laboratory furniture must be capable of supporting anticipated loads and uses.

Spaces between benches, cabinets, and equipment must be accessible for cleaning.

i. Bench tops must be impervious to water and resistant to heat, organic solvents, acids, alkalis, and other chemicals.

ii. Chairs used in laboratory work must be covered with a non-porous material that can be easily cleaned and decontaminated with appropriate

disinfectant.

e) All windows in the laboratory must be sealed.

f) BSCs must be installed so that fluctuations of the room air supply and exhaust do not interfere with proper operations. BSCs should be located away from doors,

heavily traveled laboratory areas, and other possible airflow disruptions. g) Vacuum lines must be protected with HEPA filters, or their equivalent. Filters

must be replaced as needed. Liquid disinfectant traps may be required.

h) An eyewash station must be readily available in the laboratory. i) A ducted air ventilation system is required. This system must provide sustained

directional airflow by drawing air into the laboratory from “clean” areas toward “potentially contaminated” areas. The laboratory shall be designed such that

under failure conditions the airflow will not be reversed.

i. Laboratory personnel must be able to verify directional air flow. A visual

monitoring device which confirms directional air flow must be provided at the laboratory entry. Audible alarms should be considered to notify

personnel of air flow disruption. ii. The laboratory exhaust air must not re-circulate to any other area of the

building.

iii. The laboratory building exhaust air should be dispersed away from occupied areas and from building air intake locations or the exhaust air

must be HEPA filtered.

j) HEPA filtered exhaust air from a Class II BSC can be safely re-circulated into the

laboratory environment if the cabinet is tested and certified at least annually and operated according to manufacturer’s recommendations. BSCs can also be

connected to the laboratory exhaust system by either a thimble (canopy) connection or a direct (hard) connection. Provisions to assure proper safety

cabinet performance and air system operation must be verified. BSCs should be certified at least annually to assure correct performance. Class III BSCs must be

directly (hard) connected up through the second exhaust HEPA filter of the

cabinet. Supply air must be provided in such a manner that prevents positive pressurization of the cabinet.


k) A method for decontaminating all laboratory wastes should be available in the

facility, preferably within the laboratory (e.g., autoclave, chemical disinfection, incineration, or other validated decontamination method).

l) Equipment that may produce infectious aerosols must be contained in devices that exhaust air through HEPA filtration or other equivalent technology before

being discharged into the laboratory. These HEPA filters should be tested and/or

replaced at least annually. m) Facility design consideration should be given to means of decontaminating large

pieces of equipment before removal from the laboratory. n) Enhanced environmental and personal protection may be required by the agent

summary statement, risk assessment, or applicable local, state, or federal regulations. These laboratory enhancements may include, for example, one or

more of the following; an anteroom for clean storage of equipment and supplies

with dress-in, shower-out capabilities; gas tight dampers to facilitate laboratory isolation; final HEPA filtration of the laboratory exhaust air; laboratory effluent

decontamination; and advanced access control devices such as biometrics. HEPA filter housings should have gas-tight isolation dampers; decontamination ports;

and/or bag-in/bag-out (with appropriate decontamination procedures) capability.

The HEPA filter housing should allow for leak testing of each filter and assembly. The filters and the housing should be certified at least annually.

o) The BSL-3 facility design, operational parameters, and procedures must be verified and documented prior to operation. Facilities must be re-verified and

documented at least annually.


IX. EMERGENCY RESPONSE PROCEDURES

ASU has a campus-wide emergency response plan, the ASU Emergency Operations Plan, which is

compliant with 29 CFR 1910.120. Protocols for handing biological emergencies are outlined in the plan. A summary of this plan can be found by reviewing the ASU Emergency Procedures Flipchart or the ASU

Police Department Policies and Procedures Manual.

Principal Investigators must be aware of the provisions for emergency procedures and preparedness.

Emergency procedures and preparedness must be incorporated into the Lab-Specific Biosafety Manual and used in the laboratory. Each laboratory should have a written emergency plan specifying the

appropriate response to potential emergencies. Accidents and spills of infectious materials will be discussed in Emergency Procedures below.

In addition, each PI will submit to EH&S the following:

A completed Responsible Party Information Sheet;

An annual chemical and biological inventory; and

A Health Hazard Assessment for each biological agent and toxin stored or used in the laboratory.

(See Appendix B of this manual.)

A. Decontamination

Decontamination is a process or treatment that renders an instrument or environmental surface

safe to handle. A decontamination procedure can be as simple as clean-up with detergent and water or as thorough as sterilization.

Sterilization is the use of physical or chemical processes to destroy all viable forms of

microbial life, such as bacterial spores.

Disinfection is a chemical or physical treatment that destroys the most resistant

vegetative microbes or viruses, but not the spores, in or on inanimate surfaces.

Effectiveness is influenced by a number of factors, including the type and number of organisms, amount of organic matter, the object being disinfected, the disinfectant being

used, concentration, temperature and exposure time. Antisepsis is the application of a liquid antimicrobial to skin or other living tissue to

inhibit or destroy microorganisms. Examples include handwashing with germicidal

solutions or swabbing skin with alcohol before an injection.

Sterilization, disinfection, and antisepsis are all forms of decontamination.

1. When to Decontaminate

All material and equipment contaminated with or containing potentially biohazardous

agents should be decontaminated:

Upon completion of procedures involving the use of biohazardous material;

In the event of spills of biohazardous materials;

Before being washed, stored, or discarded; and

At least daily.

In most ASU laboratories, it is recommended that decontamination be accomplished by steam heat sterilization in an autoclave or by surface application of or placement in a

chemical disinfectant solution, such as 1:10 bleach solution or its equivalent.

http://cfo.asu.edu/emergency-guide

http://www.asu.edu/aad/manuals/pdp/index.html

http://www.asu.edu/aad/manuals/pdp/index.html

http://www.asu.edu/uagc/EHS/forms/rpi_chemical.pdf


2. Autoclave Use

Autoclaving (saturated steam under pressure of approximately 15 pounds per square

inch (psi) to achieve a chamber temperature of at least 250˚F for a designated time) is the preferred and most convenient method to rapidly destroy all forms of microbial life.

However, to do this, the autoclave process must reach proper temperature, pressure,

and time, and also prevent the entrapment of air in the bag or container of treated material.

Material to be sterilized must come into contact with live steam.

Bags or containers should be left open during autoclaving or water (~200 ml)

should be added to sealed bags to generate steam.

Heat indicator tape should be used inside the bag or container with each

autoclave load to indicate that sterilization has been completed. Autoclave sterility monitoring should be conducted on a regular basis using

biological indicators (such as B. stearothermophilus spore strips) placed among

treated materials and at locations throughout the autoclave. The spores, which

are more resistant to heat than most other biological materials, provide validation of general microbial destruction when they are effectively inactivated

by autoclave operation (typically 250˚F for 30 minutes).

3. Chemical Disinfectant Use

The most practical use of chemical disinfectants is for surface decontamination and,

when used in sufficient concentration, as a decontaminant for liquid wastes prior to final disposal. General recommendations are:

Liquid Decontamination

Add liquid chlorine bleach to provide a final 1:10 dilution;

Let stand at least 20 minutes; and

Discard the solution appropriately.

Surface Decontamination

Wipe with 1:10 dilution of chlorine bleach; or

Wipe with iodophor disinfectant (per label concentration).

See Table 1, “Disinfectant Activity” at the end of this manual for further information on

disinfectants.

B. Exposure to Biohazards

In the event of an exposure to a biohazardous agent or material, the following guidelines should be used:

Intact Skin

1. Remove contaminated clothing. Clothing should not be pulled over the face as contact with eyes, nose, and mouth may occur. Shirts should be cut off.

2. Vigorously wash contaminated skin for 1 minute with soap and water.

3. Call 911 or seek medical attention at the ASU Health Services, if necessary. 4. Inform the laboratory’s PI and EH&S.


Broken, Cut or Damaged Skin or Puncture Wound

1. Remove contaminated clothing. Clothing should not be pulled over the face as contact

with eyes, nose, and mouth may occur. Shirts should be cut off. 2. Vigorously wash contaminated skin for 5 minutes with soap and water.

3. Call 911 or seek medical attention at the ASU Health Services, if necessary.

4. Inform the laboratory’s PI and EH&S.

Eye

1. Immediately flush eyes for at least 15 minutes with water, using an eyewash. Hold eyelids away from your eyeball and rotate your eyes so that all surfaces may be washed

thoroughly.

2. Remove contaminated clothing. Clothing should not be pulled over the face as contact with eyes, nose, and mouth may occur. Shirts should be cut off.

3. Call 911 or seek medical attention at the ASU Health Services, if necessary. 4. Inform the laboratory’s PI and EH&S.

Ingestion or Inhalation

1. Move to fresh air immediately. 2. Call 911 or seek medical attention at the ASU Health Services, if necessary.

3. Do not induce vomiting unless advised to do so by a health care provider. 4. Inform the laboratory’s PI and EH&S.

C. Spills of Biohazards

ASU does not have a centralized biological spill response team. Therefore, each laboratory working with potentially hazardous biological material must be prepared and trained to handle its

own biological spills. EH&S is available for assistance if necessary. Additional information pertaining to spills which involve recombinant DNA, blood, microorganisms, or any other

bioresearch materials can be found at http://cfo.asu.edu/emergency.

Performing all work on plastic-backed liners to absorb spills can minimize the consequences of a

spill of a biohazardous or select agent. The quantities of these materials should be limited so they can be easily contained, cleaned, or destroyed. If respiratory protection is required, the ASU

Respiratory Protection Program must be followed. A simple spill kit should be on hand including:

Chlorine bleach or some other concentrated disinfectant

A package or roll of paper towels

Autoclave bags

Rubber gloves

Forceps for picking up broken glass.

D. Spills Inside a Biological Safety Cabinet (BSC)

1. Alert the other laboratory employees.

2. Leave the cabinet turned on. 3. While wearing gloves, spray or wipe cabinet walls, work surfaces and equipment with

disinfectant equivalent to 1:10 bleach solution. If necessary, flood the work surface, as well

as drain-pans and catch basins below the work surface, with disinfectant for a contact time of at least 20 minutes.

4. Report the spill to the laboratory’s PI, who will report the spill to the RO if a select agent or toxin is involved.

http://cfo.asu.edu/emergency/

http://www.asu.edu/uagc/EHS/documents/asu_respriatory_protection_plan.pdf

http://www.asu.edu/uagc/EHS/documents/asu_respriatory_protection_plan.pdf


5. Soak up disinfectant and spill with paper towels. Drain catch basin into a container. Lift front

exhaust grill and tray and wipe all surfaces. Ensure that no paper towels or solid debris are blown into the area beneath the grill.

6. Autoclave all clean-up materials before disposal in the biohazard waste container. 7. Wash hands and any exposed surfaces thoroughly after the clean-up procedure.

E. Small Spill of Material Outside of a BSC

1. Alert laboratory employees.

2. Wearing gloves, safety glasses, and a lab coat, cover the spill with paper towels and gently apply disinfectant, proceeding from the outer edge of the spill to its center. Leave in place for

20 minutes. 3. Report the spill to the laboratory’s PI, who will report the spill to the RO if a select agent or

toxin is involved.

4. Pick up the towels and discard into a biohazard container. Pick up any pieces of broken glass with forceps and place in sharps container.

5. Re-wipe the spill area with disinfectant and thoroughly wash hands after glove removal.

F. Large Spill of Biohazardous Material (>500 ml) Outside of a BSC

1. Hold your breath and leave the room immediately.

2. Warn others to stay out of the spill area to prevent spread of contamination. 3. Post a sign stating: “DO NOT ENTER, BIOHAZARD SPILL, contact (name and phone #) for

information.” 4. Remove any contaminated clothing, ensuring that clothing is not pulled over the face, and

put into a biohazard bag for later autoclaving.

5. Wash hands and exposed skin. 6. Notify the Principal Investigator, supervisor, and EH&S.

7. Put on protective clothing (lab coat, gloves and, if indicated, respirator, eye protection, shoe covers) and assemble clean-up materials.

8. Wait 30 minutes before re-entering the contaminated area to allow for dissipation of

aerosols. 9. Cover the spill with paper towels and gently apply disinfectant, proceeding from the outer

edge of the spill to its center. Leave in place for 20 minutes. 10. Collect and autoclave all treated material and discard in a biohazard container. Pick up any

broken glass with forceps and place them into a sharps container. 11. Re-wipe the spill area with disinfectant and wash hands thoroughly at completion of clean-

up.

G. Small Spill (<500 ml) of Recombinant DNA Materials

1. Put on gloves and eye protection if you are not already wearing them.

2. Cover spilled material with an absorbent paper towel or Kimwipe. Once the absorbent

material is in place over the spill, wet the material with a 10% solution of bleach or other appropriate disinfectant.

3. Let stand 15 minutes, wipe up and wash surface with appropriate disinfectant. 4. Wipe down all equipment and surfaces which may have been splashed.

5. Dispose of contaminated paper towels as infectious waste.

H. Large Spill (>500 ml) of Recombinant DNA Materials in a BSC

1. BSC must run during cleanup to contain aerosols and HEPA-filter exhaust air. 2. Don appropriate personal protective gear before initiating cleanup

3. Initiate clean up as soon as possible using a germicidal disinfectant (phenolic or iodophor). Alcohol is not acceptable.


4. If the spill is contained on a bench pad, remove the contaminated bench pad discard as

infectious waste. 5. If the spill is on the work area surface, cover spilled material with disinfectant-soaked towels.

Allow 20 minutes contact time then remove the contaminated towels and discard as infectious waste.

6. Wipe down the interior of the cabinet and any splatter on items within the cabinet with a

disinfectant-soaked towel. 7. Wipe down non-autoclavable materials with disinfectant. Allow 20 minutes of contact time

with disinfectant before any items are removed from cabinet. 8. Place items designated as contaminated used sharps in an appropriate infectious waste

sharps container using tongs/forceps. Place other contaminated disposable materials used in the cleanup process in an autoclave bag. Process as infectious waste.

9. Place contaminated re-usable items in biohazard bags, autoclavable pans with lids or wrap

them in newspaper. Sterilize, preferably by autoclaving, and then clean for re-use. 10. If the cabinet has a catch basin beneath the work surface and the spill resulted in liquids

flowing into this area, more extensive decontamination is required.

a. Ensure the drain valve under the cabinet is closed.

b. Pour disinfectant onto the work surface and through the front and rear grilles into the drain pan. Allow 20-30 minutes contact time.

c. Absorb spilled fluid-disinfectant from work surface with paper towels and discard in biohazard bag.

d. Prepare to empty drain pan. Place disinfectant solution in a collection vessel. Attach flexible tubing to the drain valve. The tube should be of sufficient length to allow the

open end to be submerged in the collection vessel to minimize aerosol generation.

e. Open the drain valve and empty the drain pan into the collection vessel containing disinfectant. Flush the drain pan with water and remove the flexible tubing. Manage

contaminated materials as if they are infectious. f. Remove protective clothing used during cleanup and place in a biohazard bag for

autoclaving. Wash hands when gloves are removed.

g. Notify Principal Investigator, supervisor, and EH&S. Consult with EH&S to determine whether formaldehyde decontamination of the cabinet and filters is necessary, especially

if a high-risk agent or a major spill of a moderate-risk agent occurred. h. Run BSC at least 10 minutes after cleanup, before resuming activity in the cabinet.

I. Large Spill (>500 ml) of Recombinant DNA Materials outside of a BSC

1. If a spill of a biohazardous material occurs, outside the BSC, notify other individuals in the laboratory to evacuate.

2. Exit the laboratory to the hallway, closing the door behind you. 3. Remove any contaminated clothing (turn contaminated portion inward) and place it in an

autoclave bag.

4. Wash all exposed skin. 5. Place signs on door(s) to the laboratory warning individuals who may want to enter that a

spill occurred and access is denied. 6. Allow aerosols to settle for 30 minutes before re-entering the laboratory.

7. Notify the Principal Investigator, supervisor, and EH&S prior to proceeding with cleanup.

8. Assemble supplies (e.g., disinfectant, sharps containers, towels, tongs, autoclave bags) before entering the laboratory.

9. Don appropriate personal protective equipment (i.e. disposable gown, protective eyewear, gloves, shoe coverings and respiratory protection [if needed]).

10. Clean up spill with a suitable disinfectant as follows:

a. Surround spill area with disinfectant or diking material that is soaked in disinfectant.

b. Place paper towels soaked in a disinfectant over the entire spill area. c. Allow 20-minute contact time with the disinfectant to ensure adequate germicidal action.


d. Wipe down non-autoclavable materials with germicidal disinfectant.

e. Place items designated as contaminated used sharps in an appropriate infectious waste sharps container. Place other disposable materials used in the cleanup process in an

autoclave bag. Process as infectious waste. f. Place contaminated re-usable items in biohazard bags or autoclavable pans with lids.

Sterilize preferably by autoclaving, and then clean for re-use. Remove protective clothing

used during cleanup then place in a biohazard bag for autoclaving. g. Wash hands when gloves are removed.

J. Spill of Recombinant DNA Materials in a Centrifuge

A single centrifuge spill or release can lead to multiple infections in a laboratory. Aerosols are

created when fluid escapes from the rotor or cup while the centrifuge is operating at high speed.

Therefore, whenever opening a centrifuge, it must be performed slowly.

Unsealed Buckets

1. If a centrifuge tube breaks while the centrifuge is running, turn off motor. Allow the machine

to be at rest for 30 minutes before opening. If breakage is discovered after the machine has stopped, re-close the lid immediately and allow the unit to be at rest for 30 minutes.

2. Unplug centrifuge before initiating clean up. 3. Don strong, thick, rubber gloves, and other PPE before proceeding with clean up.

4. Flood centrifuge bowl with a germicidal disinfectant. Place paper towels soaked in a disinfectant over the entire spill area. Allow a 20 minutes contact time.

5. Use mechanical means (e.g., forceps) to remove broken tubes and glass fragments. Place

them in a sharps container for autoclaving and disposal as infectious waste. 6. Remove buckets, trunnions, and rotor and place in disinfectant for 20 minutes or autoclave.

7. Unbroken, capped tubes may be placed in disinfectant and recovered after 20 minutes contact time or autoclaved.

8. Use mechanical means to remove remaining disinfectant soaked materials from centrifuge

bowl and discard as infectious waste. 9. Place paper towels soaked in a disinfectant in the centrifuge bowl and allow it to soak

overnight, wipe down again with disinfectant, wash with water and dry. Discard disinfectant soaked materials as infectious waste.

10. Remove protective clothing used during cleanup and place in a biohazard bag for

autoclaving. Wash hands whenever gloves are removed. 11. Notify Principal Investigator, supervisor, and EH&S.

Sealed Buckets (Safety Cups)

1. If breakage is suspected, remove the sealed bucket to a biological safety cabinet before

opening.

2. If breakage occurred, replace the cap on the safety cup loosely and autoclave. 3. Notify Principal Investigator, supervisor, and EH&S.

K. Reporting Exposures

In the event of an exposure to a biohazardous material:

1. Report to an Occupational Health Nurse or a primary healthcare provider. 2. Complete an Accident-Illness Report Form and submit to EH&S.

3. Work with the Principal Investigator, supervisor, and EH&S to report accident to the NIH

Office of Biotechnology Activities as required by the NIH Guidelines.


X. TRANSFERS, PACKAGING, AND SHIPPING OF BIOLOGICAL MATERIALS

A. Transfers

The transferring, packing and shipping of select agents and toxins is HIGHLY regulated. No select

agent or toxin shall be transferred, packed, or shipped without the express approval from the RO. Please see the appendix titled “Special Considerations for Select Agents and Toxins” for additional

information.

For materials that are not Select Agents, each PI must develop procedures for transferring or

shipping from the laboratory. The PI must ensure the following:

Package, label, and transport biohazardous agents in compliance with all applicable local,

federal, and international transportation and shipping regulations, including US Department of Transportation (DOT) regulations. Materials that are transported by airline

carrier should also comply with packaging and shipping regulations set by the

International Air Transport Association (IATA). Personnel who package, handle, and ship these agents (including import and export) are subject to all applicable training. Please

refer to EHS Form 406. The RO must be notified of all select agent transfers; internal or external (see section below for additional information).

Required permits (e.g., granted by the US Public Health Service, USDA, DOT, US

Department of Commerce and IATA) are obtained before biohazardous agents are

prepared for transport. Standard operating procedures should be in place for import and export activities.

Decontaminate contaminated or potentially contaminated materials before they are

removed from the laboratory area. Avoid hand-carrying biohazardous agents when transferring them to other external

facilities. If biohazardous agents are to be hand-carried on common carriers, all

applicable packaging, transport, and training regulations should be followed. Develop and follow a protocol for intra-facility transfer (between laboratories on ASU

campuses) of all biological and biohazardous agents. Contact EHS for assistance.

Packaging and shipping of biological materials must be completed in a way that ensures the contents will not leak and that the package will arrive in good condition.

The definitions below apply to the packaging and shipping instructions that follow:

Etiologic agent means a viable microorganism or its toxin which causes, or may cause,

human disease. Diagnostic specimen means any human or animal material including, but not limited

to, excreta, secreta, blood and its components, tissue and tissue fluids, etc., which is

reasonably believed to contain an etiologic agent and is being shipped for purposes of diagnosis.

Biological product means a biological prepared and manufactured in accordance with

regulations that govern the manufacture of vaccines, reagents, etc. Interstate shipping means shipping across state lines within the continental United

States. Intrastate shipping means shipping within the State of Arizona.

B. Packaging

All biological materials including diagnostic specimens and biological products that may contain an etiologic/biohazardous agent must be packaged to withstand leakage of contents, shocks,

pressure changes and other conditions possible with ordinary handling and transportation (e.g.,

passage through cancellation machines, sorters, conveyors). Contents should not leak to the outside of the shipping container even if leakage of the primary container occurs.

http://www.asu.edu/aad/manuals/ehs/ehs406.html


Specific packaging requirements apply to materials that are known to contain, or reasonably

believed to contain certain etiologic agents. For such materials the following procedures apply (See Figure 1. Source: Biosafety in Microbiological and Biomedical Laboratories 5th Edition, Appendix C).

Figure 1

Volume not exceeding 50 milliliters (mL):

1. Place material in a securely enclosed, watertight primary container (test tube, vial, etc.). Enclose this primary container in a secondary, durable, watertight container. Several primary

containers may be enclosed in a single secondary container as long as the total volume of material in all the primary containers enclosed does not exceed 50 ml.

2. Place absorbent nonparticulate material (e.g., paper towels, not sawdust or vermiculite, etc.)

in the spaces at the top, bottom, and sides between the primary and secondary containers. Use enough absorbent material to absorb the entire contents of the primary container(s) in

case of breakage or leakage. 3. Enclose each set of primary and secondary containers in an outer shipping container

constructed of corrugated fiberboard, cardboard, wood or other material of equal strength.

Do not use bags, envelops, or similar materials. 4. If you package the material with dry ice, see the section below (Packaging with Dry Ice).


Volume greater than 50 ml:

1. Follow requirements for lesser volumes outlined above.

2. Place shock absorbent material at the top, bottom, and sides between the secondary container and the outer shipping container. (This material should at least equal the amount

of absorbent material placed between the primary and secondary containers).

3. Ensure single primary containers contain no more than 1000 ml of material; however, two or more primary containers (combined volumes not exceeding 1000 ml) may be placed in a

single secondary container. The maximum amount of etiologic agent which may be enclosed within a single outer shipping container must not exceed 4000 ml.

C. Packaging with Dry Ice

1. If used, place dry ice between the secondary and outside containers.

2. Place shock absorbent material so as to prevent the secondary container from becoming loose inside the outer container as the dry ice sublimates.

3. Use the DOT dry ice label. Guidelines for shipping with dry ice can be found at EHS MazMat shipping.

D. Labeling

The outer shipping container of all materials containing etiologic/biohazardous agents which are being shipped or transported must bear a special label, as illustrated in Figure 2. These labels are

available from your laboratory supply vendor.

Figure 2 – Example of a Etiological Agent Label

E. Shipping and Transportation Methods and Requirements

Registered Mail or the Equivalent

For a list of etiologic agents that use registered mail or an equivalent system which provides the sender with immediate notification of receipt refer to Appendix A of the CDC Guidelines on

Additional Requirements for Facilities Transferring or Receiving Select Agents and Toxins, 49 CFR

Part 72.

Federal Express or UPS

1. For Federal Express/UPS shipments, internationally or domestically, follow the International

Air Transport Association (IATA) Dangerous Goods Regulations. (Receipt of shipment notice is not required since the shipment is traceable through the specific carrier.)

http://cfo.asu.edu/ehs-environmentalaffairs

http://cfo.asu.edu/ehs-environmentalaffairs


2. Apply appropriate labels to the outer shipping container for packages containing dry ice

and/or biohazardous substances as shown in Figures 3 and 4, respectively. 3. Contact the specific carrier's dangerous goods agent prior to shipment for any additional

packaging and labeling requirements.

Figure 3 Figure 4

Damaged Packages

When evidence of leakage or any other damage to packages bearing an Etiological Agents/Biomedical Material label is discovered, the carrier must promptly isolate the package and

notify the Director, Centers for Disease Control and Prevention (CDC), (404) 633-5313, 1600 Clifton Road NE, Atlanta, Georgia 30333.

Notice of Delivery

In the event that a package sent from ASU is not received by the recipient within 5 days following the anticipated delivery of the package, the sender must notify the Director, Centers for

Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, Georgia 30333 or by telephone (404) 633-5313.

Importation/Exportation of Etiologic Agents

Importation of biohazardous agents, etiologic agents, and vectors that may contain such agents is governed by federal regulation. In general, an importation permit is required for any infectious

agent known to cause disease to humans. This includes, but is not limited to, bacteria, viruses, rickettsia, parasites, yeasts, and molds. In some instances, an agent which is suspected of

causing human disease also requires a permit.

Importation permits are issued by the U.S. Public Health Service (USPHS) only to the importer,

who must be located in the United States. The importation permit, with the proper packaging and labeling, will expedite clearance of the package of infectious materials through the USPHS

Division of Quarantine and release by U.S. Customs.

Instead of an importation permit, a Letter of Authorization may be issued by the Centers for

Disease Control and Prevention after review of an “Application to Import an Etiological Agent.” The letter is issued for materials that are judged to be noninfectious, but which might be

construed to be infectious by U.S. Customs inspection personnel. Letters of Authorization may be

issued for items such as formalin-fixed tissues, sterile cell cultures, clinical materials such as human blood, serum, plasma, urine, cerebrospinal fluid, and other tissues or materials of human


origin when there is no evidence or indication that such materials contain an infectious agent.

Letters of Authorization are in effect for two years and do not require a shipping label to be issued by CDC.

Importation permits and Letters of Authorization are issued by the Biosafety Branch, Office of

Health and Safety, CDC, 1600 Clifton Road, Atlanta, Georgia 30333, after review of a completed

application form. Application forms may be obtained by calling CDC at their FAX Information System. Dial 1-888-CDC-FAXX and enter document number 101000. CDC can also be contacted

on the Internet at http://www.cdc.gov/od/eaipp/ . Completed forms may be returned to CDC by mail or FAX at 404-639-2294. Application to CDC for the importation permit should be made 15

working days in advance of the shipment date to allow time for processing, issuance, and delivery of the permit and shipping labels to the permittee.

F. Other Permits

APHIS permits are required for importation or domestic shipping of infectious agents of livestock, poultry, and other animal diseases, and any materials that might contain these agents. Tissue

(cell) culture techniques customarily use bovine material as a stimulant for cell growth. Tissue

culture materials, and suspensions of cell culture-grown viruses or other etiologic agents containing growth stimulants of bovine or other livestock origin are, therefore, controlled by the

USDA due to the potential risk of introduction of exotic animal disease into the U.S. Applications for USDA/APHIS permits may be obtained by calling the USDA/APHIS at (301) 734-3277 or

through the Internet at http://www.aphis.usda.gov/permits/index.shtml.

The importation or domestic transfer of plant pests is also regulated by the USDA. Such a permit

is required for plant pests, plant biological agents, or any material that might contain them. Information may be obtained by calling (301) 734-3277 or through the Internet at

http://www.aphis.usda.gov/plant_health/permits/index.shtml

USDA permits are required for certain live animals and all live bats. Call (800) 358-2104 for

further information.

Export of infectious materials may require license from the Department of Commerce (DoC). Exporters of a wide variety of etiologic agents of human, plant, and animal diseases, including

genetic material and products which might be used for culture of large amounts of agents will

require an export license. Information may be obtained by calling the DoC Bureau of Export Administration at 202-482-4811 or through the Internet at https://bxa.ntis.gov/.



http://www.aphis.usda.gov/plant_health/permits/index.shtml

https://bxa.ntis.gov/


XI. SECURITY

Laboratory security is an integral part of an effective safety program. Follow these steps to ensure a

secure working environment in your laboratory:

1. Keep laboratory doors closed and locked when unoccupied.

2. Keep stocks of organisms and hazardous chemicals locked when the laboratory is unoccupied. 3. Keep an accurate record of chemicals, stocks, cultures, project materials, growth media, and those

items that support project activities. 4. Notify ASU police if materials are damaged or missing from laboratories.

5. Inspect all packages arriving into the laboratory. 6. When research is completed for the day, ensure that chemicals and biological materials have been

stored properly and securely.

7. Decontaminate materials and work surfaces after completing work and at least daily. 8. Turn off equipment, flames, steam supply, and electrical appliances after completing work.

9. Ask strangers (someone you do not recognize as a co-worker or support staff person) to exit the room if they are not authorized to be there.

10. Discuss other security-specific requirements with your supervisor and colleagues.

Security procedures for laboratories with select agents and toxins can be found in the appendix titled

“Special Considerations for Select Agents and Toxins.”


XII. COMPLIANCE

ASU Environmental Health and Safety (EH&S) will conduct regular inspections, at least annually, of each

laboratory to ensure compliance with the procedures and protocols of this manual. Inspection reports will document violations and be directed to the PI. The results of these inspections will be documented and

kept on file with EH&S. Any significant problems will be reported to the IBC.


XIII. RECORDKEEPING

At a minimum, the PI must maintain the following records and be prepared to present these at the

annual laboratory inspection:

An accurate, current list of each biological agent or toxin stored in that room;

A Health Hazard Assessment for each biological agent or toxin stored in that room;

A current Responsible Information Party Sheet;

Training Documentation Forms;

Safety, security, and emergency response plans; and

Safety and security incident reports.

http://cfo.asu.edu/ehs-forms


XIV. PROGRAM EVALUATION

The review of the elements as noted in the Compliance and Recordkeeping sections of this document will

constitute an evaluation of the ASU Biosafety and Biosecurity Program.


Table 1 - Disinfectant Activity

Disinfectants Practical Requirements Inactivates

Type Category Use

Dilution

Contact Time (min) Lipovirus.

Contact Time (min)

Broad Spectrum

Temperature (Co)

Relative Humidity

(%)

Vegetative Bacteria

Lipoviruses Nonlipid Viruses

Mycobacteria Bacterial Spores

Liquid Quat. Ammon.

Cpds 0.1%-2.0%

10 NE + +

Phenolic Cpds 1.0%-5.0%

10 NE + + B

Chlorine Cpds 500 ppm* 10 30 + + + + +

Iodophor 25-1600 ppm*

10 30 + + +

Alcohol, Ethyl 70%-85% 10 30 + + B

Alcohol, Isopropyl 70%-85% 10 30 + + B

Formaldehyde 0.2%-8.0%

10 30 + + + + +

Glutaraldehyde 2% 10 30 + + + + +

Gas Ethylene Oxide 8-23g/ft3 60 60 37 30 + + + + +

Paraformaldehyde 0.3 g/ft3 60 60 >23 60 + + + + +

NE=not effective

B=Variable results dependent on virus *=Available halogen (1:100)


Table 2 - Disinfectant Characteristics

Disinfectants Important Characteristics

Type Category Effective Shelf

Life >1 week (A) Corrosive Flammable

Explosion Potential

Residue Inactivated by Organic

Matter

Compatible for Optics

(D)

Skin Irritant

Eye Irritant

Respiratory Irritant

Toxic (E)

Liquid Quat. Ammon.

Cpds + + + + + +

Phenolic Cpds + + + + + +

Chlorine Cpds + + + + + + +

Iodophor + + + + + + +

Alcohol, Ethyl + + + +

Alcohol, Isopropyl + + + +

Formaldehyde + + + + + +

Glutaraldehyde + + + + + + +

Gas Ethylene Oxide N/A +(B) +(B) + + + + +

Paraformaldehyde N/A +(C) +(C) + + + + +

N/A=not applicable (A)=Protected from light and air (B)=Neither flammable nor explosive in 90% CO2 or fluorinated hydrocarbon, the usual form (C)=At concentrations of 7%-73% by volume in air, solid exposure to open flame (D)=Usually compatible, but consider interferences from residues and effects on associated materials such as

mounting (E)=By skin or mouth, or both. Refer to manufacturer's literature and the MSDS.


Table 3 - Disinfectant Applications

Disinfectants Important Characteristics

Type Category Work Surface Dirty

Glassware Large Area

Air Handling

Portable Equip. Surface Decon

Port-able Equip.

Penetrating Decon

Fixed Equip. Surface Decon

Fixed Equip.

Penetrating Decon

Optical & Electronic

Inst.

Liquid & Discard

Book, Paper

Liquid Quat. Ammon.

Cpds + + + +

Phenolic Cpds + + + +

Chlorine Cpds + + + + +

Iodophor + + + +

Alcohol, Ethyl + + + +

Alcohol, Isopropyl + + + +

Formaldehyde + + + +

Glutaraldehyde + + + +

Gas Ethylene Oxide + + + +

Paraformaldehyde + + + + + +

Appendix A: Definitions

Biohazardous Agent: Any microorganism (including, but not limited to, bacteria, viruses, fungi, rickettsia,

protozoa or prions) or infectious substance, or any naturally occurring, bioengineered, or synthesized component of any such microorganism or infectious substance, capable of causing:

Death, disease, or other biological malfunction in a human, animal, plant, or another living organism;

Deterioration of food, water, equipment, supplies, or material of any kind; or

Deleterious alteration of the environment.

Recombinant DNA:

Molecules that are constructed outside living cells by joining natural or synthetic DNA segments to DNA

molecules that can replicate in a living cell, or Molecules that result from the replication of those described above, and

Synthetic DNA segments which are likely to yield a potentially harmful polynucleotide or polypeptide.

Centers for Disease Control and Prevention (CDC): The Centers for Disease Control and Prevention of the

United States Department of Health and Human Services

Etiologic Agent: A viable microorganism or its toxin that causes, or may cause, human disease

Overlap agent or toxin: Any microorganism (including, but not limited to, bacteria, viruses, fungi, rickettsia, or

protozoa) or toxin that poses a risk to both human and animal health.

Responsible Official: The individual designated by an institution to act on its behalf. This individual must have the authority and control to ensure compliance with the regulations

Toxin: The toxic material or product of plants, animals, microorganisms (including, but not limited to, bacteria, viruses, fungi, rickettsia, or protozoa), or infectious substances, or a recombinant or synthesized molecule,

whatever their origin and method of production, and includes:

Any poisonous substance or biological product that may be engineered as a result of biotechnology

produced by a living organism; or Any poisonous isomer or biological product, homolog or derivative of such a substance.

61

Appendix B: Lab-Specific Biosafety Manual Template

Arizona State University

Lab-Specific Biosafety Manual

Template

[Your Name]

[Your Title]

[Arizona State University, Department Name]

[Building Name, Room Number]

Tempe, AZ

[Preparation Date]

Instructions to Principal Investigators (PI) for completing this template for Lab-Specific Biosafety

Manual

Before completing this template for the use of select agents and toxins in your laboratory, please review the ASU

Biosafety Manual and its appendices as well as the CDC Guidelines for Working with Toxins of Biological Origin.

In addition, each PI must submit to EH&S the following:

o A completed Responsible Party Information Sheet;

o An annual chemical and biological inventory; and o A Health Hazard Assessment for each biological agent and toxin stored in the laboratory. A copy of this

Health Hazard Assessment should be placed in Appendix B of this document.

Complete all highlighted sections with the laboratory policies and procedures specific to the biohazardous

agent(s) in your laboratory. If you have any questions on completing these procedures, please contact the EH&S, (480) 965-1823, for additional assistance.

http://www.cdc.gov/OD/OHS/biosfty/bmbl4/b4ai.htm

http://www.asu.edu/uagc/EHS/forms/rpi_chemical.pdf

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SIGNATURE and ACKNOWLEDGEMENT PAGE

Authorization [This section is based upon your specific laboratory setup]

All members of the [Principal Investigator’s name] Laboratory who have signed the list below are

approved for entry into Room [XXXX] while work with biohazardous agents is in progress. Anyone (including any workers not in the PI’s Lab) who uses Room [XXXX] lab must sign below.

Acknowledgement

We, the undersigned, understand that [the agents used in Room XXXX] handled in Room [XXXX] of

[Building Name] may be hazardous to humans. Furthermore, we have read and understood this manual

and have attended ASU Laboratory Safety Training, ASU Bloodborne Pathogen Training, and Biosafety Training specific to the agent used in this laboratory prior to handling samples in Room [XXXX].

Name Signature Date Agent Vaccination

(Yes/No/ Declined/NA)

*Agent vaccination in table should be specified, as appropriate to potential exposure in the laboratory: HBV, Vaccinia, Influenza, etc.

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PURPOSE

This document, in addition to the ASU Biosafety Manual, provides a comprehensive information source for

all matters covering the use of biohazardous agents handled in this laboratory [Room Address of Principal Investigator]. Specifically, it describes the procedures to be used to ensure a safe working environment

while handling biohazardous agents. This manual will be reviewed annually by the Principal Investigator

for changes or corrections to ensure that it is accurate.

[The information in the following two sections is an example of the type of specific description of your operations and activities that you should include in your manual. You should discuss detailed procedures and the actual precautions to be taken by those who actually work with the biohazardous agents found in your laboratory.]

BACKGROUND

Description of work to be performed and biohazardous agents to be used (as shown in the following example):

Biological Hazards under Routine Use [insert a brief summary of the hazards]

Biological Hazards as result of a spill or other accident [insert a brief summary of the hazards]

Procedures involving the use of Biological Hazards [insert a step-by-step procedure for this work]

DESCRIPTION OF LABORATORIES

[Provide a summary of required project equipment and a floor plan showing its location]. Laboratory(s)

is/are located on the [xxx floor] of [Building Name] building within Arizona State University. All biohazardous agents manipulations occur(s) in Room(s) [XXXX].

Floor diagrams are displayed as Appendix A at the end of this manual. Ensure that the location of the sinks, eyewash, safety shower, spill kits, fire extinguishers, exits, MSDSs, and phones are included on the

diagram.

NOTE: PLEASE EDIT THE FOLLOWING POLICES AND PROCEDURES TO FIT YOUR LAB OPERATIONS.

ENSURE THAT ALL ITEMS FROM THE ASU SAFETY BIOSAFETY MANUAL ARE INCORPORATED INTO THIS DOCUMENT.

GENERAL LAB RULES

Work with biohazardous agents will be performed in [Building Name, Room XXXX].

1. Laboratory employees must immediately notify the laboratory supervisor or PI in case of an accident, injury, illness, spill or exposure associated with laboratory activities.

2. Access to this area will be limited to persons meeting the following qualifications:

Have attended all applicable training sessions; and

Have read and signed this manual.

3. No eating, drinking, smoking, handling contact lenses, or applying cosmetics in [Room XXXX or Room YYYY] at any time. Persons who wear contact lenses should also wear goggles or a face shield while

working with biohazardous agents. If laboratory employees elect to wear respirators, all aspects of ASU’s Respiratory Protection Program must be followed. All fit testing and training documentation

should be included in Appendix C.

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4. Food, medications, or cosmetics should not be brought into the laboratory for storage or later use.

Food is stored outside the work area in cabinets or refrigerators designated specifically for that purpose and labeled accordingly.

5. Mouth pipetting is prohibited; mechanical pipetting devices are to be used at all times.

6. All procedures are performed carefully to minimize the creation of splashes or aerosols.

7. Wash hands: after handling biohazardous materials

after removing gloves, and

before leaving the laboratory.

8. Razor blades, scalpels, and hypodermic needles (“sharps”) should be used only when absolutely needed in [Room XXXX].

9. Work surfaces are decontaminated at least once a day and after any spill of biohazardous agents with [specify the appropriate disinfectant (refer to the ASU Biosafety Manual)].

10. All cultures, stocks, and other regulated biological wastes are decontaminated before disposal by

[specify an approved decontamination method, such as autoclaving].

11. Plastic-ware should be substituted for glassware whenever possible.

12. When biohazards are in use, the room should be posted to indicate “Biohazards in Use - Authorized

Personnel Only.’’ Any special entry requirements should be posted on the entrance(s) to the room. Only personnel whose presence is required should be permitted in the room while biohazards are in

use.

13. All high-risk operations should be conducted with at least two knowledgeable individuals present.

Each must be familiar with the applicable procedures, maintain visual contact with the other, and be ready to assist in the event of an accident.

CONTAINMENT REQUIREMENTS

1. Preparation of biohazardous stock solutions and manipulations of high concentrations or large volumes of biohazard agents should be conducted in a biological safety cabinet or equivalent

containment system approved by a licensed outside contractor.

2. Preparation of primary containers of toxin stock solutions and manipulations of primary containers of

dry forms of toxins should be conducted in a chemical fume hood, a glove box, or a biological safety cabinet or equivalent containment system approved by a licensed outside contractor. HEPA and/or

charcoal filtration of the exhaust air may be required.

3. The user should verify inward airflow of the fume hood or biological safety cabinet before initiating

work.

4. All work should be done within the operationally effective zone of the fume hood or biological safety cabinet.

5. Before containers are removed from the hood, cabinet, or glove box, the exterior of the closed primary container should be decontaminated and placed in a clean secondary container.

Biohazardous agents and toxins should be transported only in leak-proof and spill-proof secondary containers.

6. Contaminated and potentially contaminated protective clothing and equipment should be

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decontaminated using methods known to be effective against the toxin before removal from the

laboratory for disposal, cleaning or repair. If decontamination is not possible or practical, materials (e.g., used gloves) should be disposed of as biological or toxic waste. Materials contaminated with

infectious agents as well as toxins should also be autoclaved or otherwise rendered non-infectious before leaving the laboratory.

7. The interior of the hood, glove box, or cabinet should be decontaminated periodically (e.g. at the end of a series of related experiments). Until decontaminated, the hood, box, or cabinet should be posted

to indicate that toxins are in use, and access to the equipment and apparatus restricted to necessary, authorized personnel.

8. When vacuum lines are used with systems containing toxins, they should be protected with a HEPA

filter to prevent entry of toxins into the lines. Sink drains should be similarly protected when water

aspirators are used.

PROPER USE OF BIOLOGICAL SAFETY CABINETS

[NOTE: PLEASE REFER TO THE SECTION ON BIOLOGICAL SAFETY CABINETS IN THE ASU BIOSAFEY MANUAL

FOR ADDITIONAL INFORMATION.]

Biological safety cabinets (BSC) must be certified prior to use. A qualified outside contractor must certify

each BSC annually. Check the certification sticker on the front of the unit to verify your C’s condition. The

latest certification can be found in Appendix C.

To assure sterility inside the BSC and establish proper airflow for containment, the blower should be turned on at least ten minutes before infectious materials are put in the BSC.

The BSC airflow (“magnahelic”) gauge should be checked to assure proper operation of the cabinet before placing any materials into it. (Reading is equal to approximately 0.5 inches.) Readings indicate

relative pressure drop across the HEPA filter. Higher readings may, therefore, indicate filter clogging. Zero readings may indicate loss of filter integrity.

After use, wipe inner surfaces (especially the pan) with a solution of [The disinfectant chosen as effective for the agent you are using (refer to Table 1 in the ASU Biosafety Manual) and allow to dry. Always keep

a bottle of the disinfectant in the cabinet for decontaminating or in case of a spill.

NEVER place anything over the front or rear grill of a biosafety cabinet.

Disrupting the airflow into the front grill allows contaminated air from inside the cabinet to blow into the

lab or directly at the person sitting at the cabinet. It also allows non-sterile air from the room to blow into the biosafety cabinet over the experiments.

Materials should be placed in the cabinet so as not to block airflow into the rear grill. Leave a few inches

for air to flow around objects. Any disruption of the air flow in the cabinet decreases its effectiveness.

Remember: “A biosafety cabinet is only as safe as the person using it.”

Before manipulating infectious materials, make sure that you have everything you need in the cabinet.

The fewer times you pull your hands out of the cabinet, the less disruption of the air flow.

Work should be performed in the center of the work surface of the cabinet whenever possible. Work

outward progressing from clean to dirty (contaminated). However, biohazardous agents should not be placed directly adjacent to or directly on the intake grills.

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After manipulating biohazardous agents, make sure all containers are tightly closed before removing

them. Wipe down the surface of all equipment used in manipulations (mechanical pipettes, etc.) with disinfectant before removing from the cabinet. All waste and disposable items should be left in the

cabinet until properly decontaminated or contained.

After the cabinet has been emptied, wipe exposed surfaces including the front grill and splash area with

disinfectant. Allow the blower to run for a minimum of ten minutes to purge any potentially infectious aerosols from inside the cabinet before shutting off the blower.

NOTE: Class IIA cabinets recirculate about 70% of the air inside themselves and exhaust the remainder

to the lab. Any use of volatile solvents, including ethanol and isopropanol, should be kept to a minimum or done elsewhere. Dangerously high levels of volatile fumes can accumulate inside the cabinet and pose

a threat of fire or explosion.

DECONTAMINATION

[NOTE: PLEASE REFER TO THE SECTION ON EMERGENCY RESPONSE IN THE BIOSAFETY MANUAL FOR

ADDITIONAL INFORMATION.]

The decontaminant of choice is [xxxx. (Please see Table 1 in the ASU Biosafety Manual for disinfectant selections)].

Pans and splash guards (inside and out) should be cleaned after every use.

All material and equipment contaminated with or containing potentially biohazardous agents should be

decontaminated:

Upon completion of procedures involving the use of biohazardous agents;

In the event of spills of such materials;

At least daily; and

Before being washed, stored, or discarded.

Pipettes and other shared small equipment should be wiped with appropriate disinfectant after use and

before removing them from the cabinet.

BIOLOGICAL WASTE DISPOSAL

Wastes associated with biohazardous agents must be disposed of in special ways because they may have

been contaminated with infectious organisms or toxic agents. These potentially infectious items include all sharps, e.g. glass implements, needles, syringes, blades, etc. coming from facilities using infectious

materials; and biologically cultured stocks and plates, human blood or tissues.

For disposal of these wastes, the personnel must:

Sterilize or disinfect waste materials associated with viral, bacterial or other agents infectious to

humans by autoclaving or disinfectant equivalent to 1:10 bleach solution;

Disposed of or destroyed toxins per the Lab-Specific Biosafety Manual;

Place all biohazardous wastes, except for sharps, directly into the red bag-lined medical waste

boxes. The procedures for biohazardous waste handling are described in the ASU Biological Hazardous Waste Management Compliance Guidelines.

PERSONAL PROTECTIVE EQUIPMENT

1. When using an open-fronted fume hood or biological safety cabinet, protective clothing, including gloves and a long-sleeved body covering (gown, laboratory coat, smock, coverall, or similar garment)



68

should be worn so that hands and arms are completely covered.

2. Eye protection should be worn when handling a biohazardous agent or toxin, infectious organism, or

chemicals (e.g. ethanol or other disinfectant).

3. Other protective equipment may be required, depending on the characteristics of the biohazard or

toxin and the containment system. [INSERT ANY ADDITIONAL REQUIRED PPE HERE]

4. When handling dry forms of toxins that are electrostatic:

Do not wear gloves (such as latex) that help to generate static electricity; and

Use glove bag within a hood or biological safety cabinet, a glove box, or a Class III biological

safety cabinet.

5. When handling biohazardous agents that are percutaneous hazards (irritants, necrotic to tissue, or

extremely toxic from dermal exposure), select gloves that are known to be impervious to the biohazard or toxin. GLOVES WORN IN THE LABORATORY WILL BE XXX.

6. Consider the chemical characteristics and potential routes of exposure of biohazardous agents,

diluent, and disinfectant when selecting gloves and other protective clothing.

7. If infectious agents and toxins are used together in an experimental system, consider both when

selecting protective clothing and equipment.

MANAGEMENT OF SPILLS

[NOTE: PLEASE REFER TO THE SECTION ON BIOLOGICAL MATERIAL SPILLS IN THE ASU BIOSAFETY

MANUAL TO COMPLETE THIS SECTION.]

Inside of a containment device such as biosafety cabinet:

Alert the other laboratory employees;

Leave the cabinet turned on;

While wearing gloves, lab coat, and safety glasses, spray or wipe cabinet walls, work surfaces and

equipment with disinfectant equivalent to 1:10 bleach solution. If necessary, flood the work surface, as well as drain pans and catch basins below the work surface, with disinfectant for a contact time of

at least 20 minutes; Soak up disinfectant and spill with paper towels. Drain catch basin into a container. Lift front exhaust

grill and tray and wipe all surfaces. Ensure that no paper towels or solid debris are blown into the

area beneath the grill; Autoclave all clean-up materials before disposal in the biohazard waste container. Wash hands and

any exposed surfaces thoroughly after the clean-up procedure; and

Report the spill to the laboratory’s PI.

Small spills of infectious material outside of a containment device:

All spills must be reported to [the Principal Investigator].

All spills of any nature must be described in your laboratory notebook. The description must

include:

The name of the biohazardous agent and any identifying information (e.g., strain or other

characterization information); An estimate of the quantity released;

The time and duration of the release;

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The environment into which the release occurred (e.g., in building or outside of building, waste

system);

The location [building, room] from which the release occurred;

The number of individuals potentially exposed at the facility;

Actions taken to respond to the release; and

Hazards posed by the release.

MANAGEMENT OF ACCIDENTAL EXPOSURES

In the event of an exposure to a biohazardous agent:

Intact skin

Remove contaminated clothing;

Vigorously wash contaminated skin for 1 minute with soap and water;

Inform the laboratory’s PI and seek medical attention at the ASU Campus Health Services.

Broken, cut, or damaged skin or puncture wound Remove contaminated clothing;

Vigorously wash contaminated skin for 5 minutes with soap and water; and


Eye Immediately flush eyes for at least 15 minutes with water, using an eyewash;

Hold eyelids away from your eyeball and rotate your eyes so that all surfaces may be washed

thoroughly; and


Ingestion or Inhalation Inform the laboratory’s PI and seek medical attention at the ASU Campus Health Services; and

Do not induce vomiting unless advised to do so by a health care provider.

MEDICAL SURVEILLANCE

Specific biohazards and toxins will be evaluated by [PI’s name] for appropriate medical surveillance

procedures. [Insert any applicable procedures].

TRAINING

[NOTE: PLEASE REFER TO THE SECTION TRAINING IN THE ASU BIOSAFETY MANUAL TO COMPLETE

THIS SECTION.]

Laboratory personnel shall demonstrate the following:

Understand the hazards associated with [the biohazardous agent];

Understand the required practices and procedures for working with [the biohazardous agent];

Know the necessary precautions to prevent exposures; and

Know the safety and security policies and procedures in place for reporting and investigating

unintentional injuries, spills, incidents (e.g., unauthorized personnel in restricted areas, missing

biologic agents or toxins, and unusual or threatening phone calls), or breaches in security measures.

This document will provide the basis of training.

[The PI] will provide information and training at the time of an individual's initial assignment to a work

area where biohazardous agents are present and prior to assignments involving new potential exposure situations. [The PI] will provide refresher training at least annually and when there are any changes in

70

processes or procedures. [Current training records and an outline of the training program can be found in

Appendix C.]

RECEIVING BIOLOGICAL AGENTS

[NOTE: PLEASE REFER TO THE SECTION ON RECEIVING BIOLOGICAL AGENTS IN THE ASU BIOSAFETY

MANUAL TO COMPLETE THIS SECTION.]

Biohazardous agents will be received into the laboratory by [insert procedure here].

EMERGENCY PHONE NUMBERS AND PROCEDURES

Emergency Phone Numbers [insert any additional contacts here]

Fire and Medical Emergencies 911

Police 911

Principal Investigator’s Home Phone xxx-xxxx

Campus Health 965-3346

Hospital Emergency Room xxx-xxxx

ASU Department of Public Safety 965-3456

Department of Environmental Health & Safety 965-1823

Emergency Procedures

[NOTE: PLEASE REFER TO THE SECTION ON EMERGENCY RESPONSE PROCEDURES IN THE ASU BIOSAFETY MANUAL TO COMPLETE THIS SECTION.]

Principal Investigators must be aware of the provisions for emergency procedures and preparedness.

Emergency procedures and preparedness must be incorporated into specific biosafety standard operating

procedures (SOP) for each biohazardous agent used in the laboratory. The Lab-Specific Biosafety Manual must address the following:

The hazards associated with the use of the biohazardous agent;

Personal protective equipment and emergency equipment;

Site security and control;

Emergency recognition and prevention;

Any hazards associated with response actions that could lead to a spread of a biohazardous

agent;

Roles of the laboratory faculty and staff in the event of an emergency;

Decontamination;

Emergency alerting and response procedures;

Emergency medical treatment and first aid;

Safe distances and places of refuge;

Evacuation routes and procedures;

Any additional special procedures needed to address the hazards of the specific agents; and

Reevaluate the ER Plan at least annually. Train employees and conduct exercises of the

emergency response plan at least annually.

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SPECIMEN TRANSPORT

Biohazardous agents will be transported in the laboratory within a secondary container.

72

VALIDATION AND HISTORY FOR BIOSAFETY MANUAL

Principal Investigator’s Certification

I hereby certify that I have reviewed the contents of this manual and that it reflects my current operating

policy for the laboratories #[XXXX] and [YYYY] located in [Location] research building.

[Principal Investigator’s Name] [Principal Investigator’s Title] Signature Annual Review Date ________

Approvals

Department of Environmental Health & Safety

Signature: Date:

Department Chair

Signature: ______________________ Date: ___________________

Institutional Biosafety Committee Chair

Signature: ______________________ Date: ___________________

History of Manual’s Creation

Date Created:

Author:

Reference Source(s): [Insert P.I. NAME AND ANY APPLICABLE DOCUMENTS]

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Appendix B-1: Floor Diagram

Include the location of sinks, eyewash, safety shower, spill kits, fire extinguishers, exits, MSDS and phones.

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Appendix B-2: Health Hazard Assessment Worksheet

Instructions to Principal Investigators (PI) Conducting a Health Hazard Assessment for biological or select agents at ASU Laboratories

Before completing this Health Hazard Assessment (HHA), please review the ASU Biosafety Manual. In addition, it may be helpful to refer to the Public Health Agency of Canada’s MSDS website.

Complete all sections accurately of the attached worksheet. This information must be included in the Lab-Specific

Biosafety Manual. If you have any questions on completing these procedures, please contact Environmental Health & Safety, (480) 965-1823, for additional assistance.

The Principal Investigator (PI) is responsible for initially assessing health hazards in order to set the biosafety level for the work to be done. This must be done in close collaboration with Environmental Health & Safety and

Animal Care (if applicable) to ensure compliance with established guidelines and regulations. The PI should be aware of the following factors prior to conducting the HHA:

1. Biological, chemical, and physical hazards in the laboratory 2. Principles of biological, chemical, and physical safety

3. Method of transmission of various infectious agents o Direct versus Indirect Contact

Direct contact (i.e., between humans, between humans and animals)

Indirect contact through common environmental surfaces (e.g., lab benches, equipment) o Airborne versus Vehicle

Airborne (i.e., inhalation of particles into the respiratory system) Vehicle (i.e., sharps)

o Vectors

Vector-borne (e.g., insects, mites, fleas) 4. Route of Infection

o Ingestion o Inhalation

o Inoculation o Penetration of abraded skin or mucous membrane through skin (e.g., cuts, abrasions)

o Bites (animals or insect) Contact with mucous membranes of eyes, nose, and mouth

5. Biological Agent o Pathogenicity (severity of ability to cause infection). The virulence of microorganisms varies

greatly among types and strains. [Some microbes are highly pathogenic, even in healthy adults, while others are opportunistic and only able to infect hosts with a lowered immunity.]

o Infectious or intoxicating dose (i.e., the number of microorganisms required to initiate an

infection). o Effect of route of exposure (infectious dose and intoxicating dose vary with route of exposure).

o Virulence (primary or secondary communicability) of microorganisms varies greatly among types and strains.

o Host susceptibility or resistance (genetic composition, age, gender, race). Conditions that alter

host defenses at body surfaces or impair the functioning of the immune system my put a worker at increased risk.

o Biological modifiers to resistance (preexisting condition, secondary infection, pregnancy, stress, immunosuppression, vaccination).

o Viability. If the agent is not viable and able to replicate, possibility of infection does not exist. o Sensitization reactions (allergen, acute hypersensitivity).

o Incidence of laboratory infections.

o Treatment (success rate considering various routes of exposure and doses, antibiotic resistance and susceptibility).

o Environmental impact (survival and dissemination in the environment, remediation, public health concerns, impact on humans, flora and fauna).

http://www.phac-aspc.gc.ca/msds-ftss/index.html

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o Unique animal hazards:

Species ectoparasite vectors (fleas, ticks, lice). Species specific in apparent infections (SIV, Monkey B Virus, TB, Hepatitis).

Agent excretion in urine, feces, saliva, blood (offspring) transmission. Escape from facility.

6. Environmental Factors

o Ventilation and laboratory design (directional air, pressure gradients, air breaks, separation of laboratories from offices, interlocking autoclave and airlock doors).

o Laboratory procedures (use of sharps, mouth pipetting, minimization of creating aerosols). o Containment equipment (Class II and III biosafety cabinets, sealed centrifuges cups and rotors).

o Personal protective equipment (gloves, goggles, respirators, aprons, gowns). o Training (handling, containment, destruction and transporting pathogens, emergency evacuation,

spill procedures).

o Laboratory sanitation (decontamination, housekeeping, disinfection, routine cleaning, pest and rodent control).

7. Effects of aerosol-generation in the lab o How aerosols act as modes of transmission for infectious agents and chemical vapors?

o What procedures are likely to cause aerosols?

o What methods can be used to reduce or contain aerosols? 8. Essential safety features necessary to lab operations

o Air handling system. o Safety equipment.

o Adequacy and limitations for decontaminating waste. 9. Type of medical surveillance needed based on each employee's job duties. A medical surveillance

program ensures that safeguards decided upon in fact produce the expected health outcomes. It may

include serum banking, monitoring employee health status, and participating in post-exposure management.

10. How the facility, equipment, personnel, procedures, and hazardous materials must be integrated to create a safe work environment.

11. Local, state, and federal regulations under which the lab operates.

12. Concentration. The number of infectious organisms per unit volume is important to know because an increase in the working volume of high-titered microorganisms increases the risk of infection.

13. Origin. This refers to the geographic location, natural host, or the nature of the source. 14. Availability of data from animal studies.

15. Availability of an effective prophylaxis or therapeutic intervention.

16. Experience and skill level of “at-risk” personnel.

In the United States, the most current classification of biological agents is found in the National Institutes of Health (NIH) Guidelines for Research Involving Recombinant DNA Molecules (NIH Guidelines), May 1999. The

NIH Guidelines classify biological agents (see Table below) known to infect humans as well as select animal

agents that may pose theoretical risk if inoculated into humans. Risk Groups established by the NIH correspond to the Biosafety Levels established by the Centers for Disease Control (CDC).

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Transmission of Disease

It is important to understand how an infectious disease is transmitted before conducting any work with an agent

of the disease. This should be noted in the PI’s Health Hazard Assessment. The interactions among the biological agent, human, and environment do not always result in disease and/or death. For an infection or illness to occur

in a human, the following conditions must be met:

The biological agent must be capable of causing disease;

There must be a reservoir of sufficient number for the agent to live and reproduce;

The agent must be able to escape the reservoir;

The agent must be able to move through the environment (e.g., airborne, contact, vectors);

There must be a means of transmission into the host (e.g., broken skin, inhalation, blood transfer,

mucous membrane); and

The human must be susceptible to the agent.

Every biosafety control strategy is intended to break one or more of the links in the transmission chain. One of

the basic principles of biosafety is performing a Health Hazard Assessment (described in Administrative Controls),

which involves understanding how an agent is transmitted to humans.

Direct Transmission

Direct transmission from host to host occurs anytime an infected host transmits the disease to a susceptible host

by any number of means. The most frequent portal of entry into the human body occur at sites where mucous membranes meet with the skin, including respiratory (upper and lower airways), gastrointestinal (primarily

mouth), genital, and urinary tracts. Abnormal areas of mucous membranes and skin (e.g., cuts, burns, and other injuries) are also frequent sites of direct transmission.

Indirect Transmission

Indirect host-to-host transmission occurs by either living or inanimate means. Living agents transmitting infection

are called vectors; they are generally arthropods (e.g., insects, mites, fleas) or vertebrates (e.g., dogs, rodents). Arthropods may not actually be hosts for the disease but rather carriers. Indirect transmission by a living agent

may occur from patient to patient on the hands of health care workers.

Inanimate objects such as bedding, toys, books, or surgical instruments may also transmit disease. These

inanimate objects are collectively called fomites. If the inanimate object is food, water, or air, it is referred to as a disease vehicle.

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Steps for completing the Health Hazard Assessment:

1. Identify the agents to be used;

2. Gather and evaluate existing data on the agents looking at the factors listed above; 3. Evaluate ways the agents can escape containment;

4. Determine the training required of personnel handling the agent;

5. Determine proper lab procedures; 6. Determine personal protective equipment required;

7. Determine safety equipment and containment needs; 8. Assess the capability of each facility to contain the material during normal and emergency situations

9. Determine potential exposure limits;

10. Consider whether the acceptance of risk is voluntary or imposed; 11. Recognize factors that give the illusion of no risk (e.g., unknown history of the agent, lack of toxicity

testing); 12. Fill out the Environmental Health & Safety Health Hazard Assessment Worksheet (attached below); and

13. Include your completed Health Hazard Assessment Worksheet in your Lab-Specific Biosafety Manual.

(There are several systems for classifying human and animal pathogens. All systems are based upon the

pathogenicity of the organism, mode of transmission, host range, availability of effective preventative measures and/or effective treatment.)

78

Please fully complete each section.

1. Agent Identification

Name (genus/species):

Type of Agent (check all that apply)

Bacterium:

Parasite: Fungus:

Rickettsia: Prion:

Toxin derived from living organism: Virus:

Recombinant DNA:

For recombinant DNA, the following questions must be answered:

1) Does the inserted gene encode a known toxin or a relatively uncharacterized toxin?

No: Yes: If yes explain:

2) Does the modification have the potential to alter the host range or cell tropism of the virus?


3) Does the modification have the potential to increase the replication capacity of the virus?


4) Does the inserted gene encode a known oncogene?


5) Does the inserted gene have the potential for altering the cell cycle?


6) What is the probability of generating replication-competent viruses?


2. Health Hazards

Disease(s) caused by agent:

Pathogenicity:

Species:

Potential pathogen:

Principal Investigator: Phone No:

Department: Fax No:

Building, Room, Mail

Code: Email:

79

Pathogenic:

Highly pathogenic:

Opportunistic pathogen:

Other:

Epidemiology:

Host Range (check all that apply):

Humans:

Animals: Specify:

Plants: Specify:

Concentration (number of organisms per unit volume):

Infectious Dose:

Known:

Unknown:

Mode of Transmission (check all that apply):

Direct Contact:

Human/human:

Human/animal:

Indirect Contact:

Vector-borne:

Inanimate objects:

Food, water, air:

Airborne:

Vehicle:

Vector:

Route(s) of Entry: (check all that apply)

Ingestion:

Inhalation:

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Penetration through skin:

Contact with mucous membranes of eyes, nose, and mouth:

Incubation Period:

Dissemination:

Reservoir:

Zoonosis:

No:

Yes: Name:

Vectors:

None:

Yes: Name:

Viability:

Drug Susceptibility:

Drug Resistance:

Disinfectant Susceptibility:

Physical Inactivation:

Survival Outside Host:

Medical:

Surveillance/ known symptoms of infection:

First Aid/Treatment:

Immunization:

Prophylaxis:

Laboratory Hazards:

Laboratory-Acquired Infections (epidemiology of lab-acquired infections):

Sources/Specimens:

Primary Hazards:

Flammable: Reactive: Carcinogenic: Toxic: Corrosive: Oxidizer:

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Special Hazards:

Recommended Precautions:

Containment Requirements:

Personal Protective Equipment:

Staff Trained and Experienced with Agent:

Other Precautions:

Handling Information:

Spills:

Disposal:

Storage:

Miscellaneous Information:

Congratulations! You now have a material safety data sheet for your biological agent.

Principal Investigator’s Signature

Title: Date:

Updated:

Please forward a copy of this form to Environmental Health & Safety, Mail Code 5412

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Appendix B-3: IBC Application Documentation

Insert the completed and approved EHS 112 form(s) at this appendix.


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Appendix B-4: Suggested Format for the Lab-Specific Biosafety Manual

According to federal regulations, all laboratories using biohazardous materials must have a Lab-Specific Biosafety Manual. This manual must be adopted as policy and be accessible to all laboratory personnel. To help the Principal Investigators comply with these regulations, the Biosafety group at ASU has developed documents and

templates that should be incorporated into the Lab-Specific Biosafety Manual. Each laboratory should have a

binder available that includes the following documents in addition to any supplemental materials the Principal Investigator feels will augment the safe and proper handling of biohazardous materials in their laboratory.

1. ASU Biosafety Manual − Every laboratory operating at BSL2 or BSL3 must have a copy of this manual

available.

2. NIH Guidelines Research Involving Recombinant DNA − Laboratories that work with recombinant DNA must have a copy of these guidelines available.

3. Institutional Biosafety Committee (IBC) Disclosures – It is recommended that all approved IBC disclosures be made available to laboratory personnel.

4. Biosafety Inspection Reports − EHS performs annual biosafety inspections and provides a report to the

Principal Investigator. Please make this report available to laboratory personnel. Principal Investigators may also perform their own self-inspection using the Biosafety Inspection Checklist.

5. Lab-Specific Biosafety Training Checklist − All personnel in the lab should fill out this document and keep copies available.

6. Biological Inventory − Each laboratory should maintain a list of all biological organisms that may be present, including known hazards for each organism. Biological material safety data sheets (MSDS) or

fact sheets provided by the manufacturer should also be provided when available.

7. HBV Vaccine Declination Forms − Personnel who work with human blood, human blood products, or any unfixed human tissue must be provided Hepatitis B Virus vaccinations, free of charge. If personnel

decline the vaccination, the HBV Vaccine Declination Form must be signed and maintained. 8. Emergency Contacts − A list of all laboratory personnel and contact information should be recorded and

made available.

9. Standard Operating Procedures (SOPs) − SOPs relevant to the laboratory must be written and made available to lab personnel. Examples include the Biosafety Cabinet SOP and Autoclave Operation SOP.

Other SOPs may be developed for Emergency Spill Clean-up, Biohazardous Waste Disposal, Accident/Incident Reporting, Transporting Biological Materials, Safe Handling of Sharps, Post-exposure

Medical Surveillance, or use of specific equipment in the lab.

Please keep these materials in your laboratory and available to all lab personnel. Annual biosafety inspections will

require the laboratory to produce these documents in accordance with federal regulations. If you have any questions about your Lab-Specific Biosafety Manual, please contact [email protected].

http://www.asu.edu/uagc/EHS/documents/biosafetymanual.pdf

http://oba.od.nih.gov/rdna/nih_guidelines_oba.html

http://www.asu.edu/uagc/EHS/forms/biosafety_inspection_checklist.pdf


http://www.asu.edu/uagc/EHS/forms/hbv_declination_form.pdf

http://www.asu.edu/uagc/EHS/forms/hbv_declination_form.pdf

http://www.asu.edu/uagc/EHS/documents/asu-bsc-sop.pdf

http://www.asu.edu/uagc/EHS/documents/autoclave-sop.pdf

mailto:[email protected]

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Appendix C: Special Considerations for Select Agents and Toxins

SELECT AGENT AND TOXIN REGULATORY INFORMATION

The ASU Biosafety Manual is applicable to all laboratories, research, service and support activities that use or

store select agents or toxins that are regulated by DHHS and/or the USDA. The information presented in this

manual reflects the requirements and guidelines of federal regulations. Each Principal Investigator will supplement this information with written procedures, instruction and guidance regarding specific practices and

procedures unique to the work being done in the laboratory with select agents and toxins.

REGULATORY REQUIREMENTS

Registration Process at ASU

Arizona State University is prohibited from possessing, using, receiving, or transferring select agents or toxins

unless ASU has been granted a certificate of registration by the DHHS Secretary or the USDA Secretary. If a PI from any ASU laboratory would like to apply for a certificate of registration, the PI must contact the Office for

Research Integrity and Assurance (ORIA) and complete the Proposal Routing and Approval Form in addition to

completing the 112C form. These are submitted through a process to the IBC, Animal Care (if required), EH&S, and ORIA. The request to conduct research with a select agent is a lengthy one and involves a requirement for a

compliant facility as well as completion of a site-specific security plan and an agent specific safety plan. These templates and procedures exist, and the EH&S department is ready to assist a PI to navigate this process.

Once approved by the ORIA/IBC, the ASU Responsible Official (RO) will begin the process to obtain a registration

application number from the DHHS or USDA secretary and will submit the application once it has been completed

by the RO in conjunction with the PI. The information requested by DHHS or USDA will be used to determine whether or not ASU will be allowed to conduct activities with the select agent or toxin.

Once the application is approved, the certificate of registration will be valid only for the specific select agents

and/or toxins, and the specified activities and locations that are consistent with the information provided by ASU

upon which the certificate of registration was granted. The RO must promptly notify the DHHS or USDA Secretary, in writing, if a change occurs in any information previously submitted to the DHHS or USDA Secretary.

This includes modifications to the list of individuals approved, changes in area of work, protocols, or objectives of studies.

The certificate of registration will cover activities at only one general physical location (a building or a complex of buildings at a single mailing address). Unless terminated sooner, a certificate of registration will be valid for up to

three years. To obtain a new certificate of registration, ASU must submit a new application.

Security and Emergency Response Requirements

Security and emergency response are very important components of the select agents and toxins regulations and must be an integral part of storing and handling these agents and toxins. Requirements regarding the items in

the following list can be found in the appendix of this manual titled ASU Laboratory Security Guidance for

Laboratories Working with Select Agents:

Physical security;

Data and IT system security;

Security policies for personnel;

Policies for accessing select agent areas;

Specimen accountability;

Receipt of select agents into the laboratory;

Transfer or shipping of select agents from the laboratory (refer to the previous section);

Emergency response plans (refer to the section on emergency response procedures;

Reporting of incidents, injuries, and breaches; and

Recordkeeping



http://researchadmin.asu.edu/forms


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Training

The PI, in conjunction with the RO, must provide information and training on safety and security for working with biohazardous and select agents and toxins to each individual approved for access to his/her laboratory and each

unapproved individual working in, or visiting, areas where select agents and toxins are handled or stored. The PI must ensure that all individuals who work in, or visit, the areas understand the hazards of select agents and

toxins present in the area. This training program must be included as part of their Lab-Specific Biosafety Manual and be documented with a signature and date to indicate that each individual was trained. Training records will

kept on file for 3 years.

The PI must provide information and training at the time of an individual's initial assignment to a work area

where select agents or toxins are present and prior to assignments involving new exposure situations. The PI must provide refresher training annually and when there are any changes in processes or procedures.

Audits and Compliance

The Responsible Official, or his or her designee, will conduct regular inspections, at least annually, of each laboratory where select agents or toxins are stored or used to ensure compliance with the procedures and

protocols of this manual. Inspection reports will document violations and be directed to the PI. The results of these inspections with select agents and toxins will be documented and kept on file with the Responsible Official.

Program Evaluation

Program evaluation is conducted annually based upon the effectiveness of this plan. The Select Agent and Toxin Program measurements must be reviewed, performance tested and updated annually. The plan must also be

reviewed and revised as necessary after any incident. Any program evaluation report for laboratories containing select agents and toxins is written by the RO.

Biosafety Manual - Arizona State University

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