Directions for Completing the Laboratory-Specific Biosafety Manual Template

In addition to complying with federal, local and institutional requirements; each PI conducting research or teaching using biological material, must establish and routinely update a laboratory-specific biosafety manual and written risk assessment. Research and teaching labs assigned BSL2 containment at the University are required by the Biosafety in Microbiological and Biomedical Laboratories (BMBL) guidelines to have a laboratory-specific biosafety manual. To quote: “A laboratory-specific biosafety manual must be prepared and adopted as policy. The biosafety manual must be available and accessible.” This is also a condition of funding by the National Institutes of Health (NIH) for any institution that receives NIH funding and applies to all research and teaching activities, regardless of funding source. Even unfunded programs are subject to these requirements. In order to assist CSUF investigators in these endeavors, this biosafety manual template has been developed.

1. Review all sections of the template to ensure that they accurately reflect lab standards and practices. Text in red italics requires lab specific information.

2. If upon review of the provided information you determine that it fits your lab situation, then simply incorporate it into the body of the document. Unused information may be deleted from the manual as appropriate.

3. For topics where lab specific protocols or training are required; general information has been developed and should be modified to accurately reflect lab activities.

4. Forward completed manual to the CSUF Biosafety Officer at safety@fullerton.edu and rdenman@fullerton.edu. As part of the Biological Use Authorization (BUA) review process, the Biosafety Officer will review and approve manual, or provide recommended revisions.

5. For questions or assistance please contact Rob Denman, CSUF Biosafety Officer: email: rdenman@fullerton.edu, phone: (657) 278-8118.

Note: The biosafety manual template has been designed as a supplement to laboratory Chemical Hygiene Plan (e.g. continue to document trainings, SDSs, injury/illness reports, etc. in the CHP).

The importance of a lab-specific manual rather than a general manual cannot be over emphasized as it is impossible for the EHS Office to anticipate all potential laboratory activities.

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Biological Safety Manual – Bldg. and Lab Room #

I. Introduction.......................................................................................3

II. Purpose.............................................................................................3

III. Biosafety and Hazard Levels.............................................................3

IV. Biohazard Definition..........................................................................5

V. Classification of Infectious Agents.....................................................5

VI. Rules, Regulations & Guidelines .......................................................6

VII. Practices and Procedures..................................................................7

A. Routes of Infections................................................................7B. Administrative Controls..........................................................8C. Safe Housekeeping Guidelines...............................................8D. Engineering Controls..............................................................9E. Personal Protective Practices..................................................12F. Recommended Work Practices...............................................12G. Biological Spill Cleanup Procedures........................................18H. General Guidelines and Policies..............................................20I. Transportation of Biological Materials....................................22J. Decontamination....................................................................23K. Biohazard Waste.....................................................................26

VIII. Investigation, Analysis, Incident and Near Miss Reporting................27

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IX. Recombinant DNA Research.............................................................29

X. General Biosafety References...........................................................29

XI. Appendix A (Product and Pathogen Safety Data Sheets)..................30

XII. Appendix B (CSUF Bloodborne Pathogen Program)...........................31

I. Introduction and Description of Activities Requiring BSL-2 containmentInsert brief description of BSL-2 research or teaching course.

Biological agents/organisms used(Include bacterial, viral, fungal, recombinant, human/non-human primate unfixed tissues or cells)List organisms/biohazards here

Risk AssessmentPlease provide a brief protocol-specific risk assessment. Include consideration of parent and recombinant agent pathogenicity, virulence, infectious dose, route of transmission, host range, and stability, as well as the likelihood of exposure and consequences of exposure. How will identified risks be controlled (e.g. PPE, work practices, etc.)? Note that “replication incompetent” does not mean “non-infectious.”

II. PurposeThe biosafety manual for California State University, Fullerton (CSUF) has been adopted to achieve the following goals:

A. Protect personnel from exposure to infectious agentsB. Prevent environmental contaminationC. Comply with applicable federal, state and local requirements

The biosafety manual provides university-wide safety guidelines, policies and procedures for the use and manipulation of biohazards. Although the implementation of these procedures is the responsibility of the Principal Investigator (PI), its success depends largely on the combined efforts of laboratory supervisors, managers, and employees. Planning for and implementation of biological safety must be part of every laboratory activity in which biohazardous materials are used. In general, the handling and manipulation of biological agents and toxins, as well as recombinant DNA molecules, requires the use of various precautionary measures depending on the material involved. This manual will provide assistance in the evaluation, containment and control of biohazards. However, it is

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imperative that all parties involved or working with these materials seek additional advice and training when necessary.

III. Biosafety and Hazard LevelsBiological safety or biosafety is the application of knowledge, techniques and equipment to prevent personal, laboratory and environmental exposure to potentially infectious agents or biohazards. Biosafety defines the containment conditions under which infectious agents can be safely manipulated. The objective of containment is to confine biohazards and to reduce the potential exposure of the laboratory worker, persons outside of the laboratory, and the environment to potentially infectious agents. It can be accomplished through the following means:

Primary ContainmentProtection of personnel and the immediate laboratory environment through good microbiological technique (laboratory practice) and the use of appropriate safety equipment such as a biosafety cabinet.

Secondary ContainmentProtection of the environment external to the laboratory from exposure to infectious materials through a combination of facility design and operational practices.Combinations of laboratory practices, containment equipment, and special laboratory design can be made to achieve different levels of physical containment.

Biosafety LevelsCurrently four Biosafety Levels (1-4) define the level of containment necessary to protect personnel and the environment. Biosafety Level 1 (BSL-1) is the least restrictive, while Biosafety Level 4 (BSL-4) requires a special containment laboratory or facility, which is not available and CSUF. Teaching, research and diagnostic laboratories at CSUF are conducted at Biosafety Levels 1 and 2, therefore this manual will mainly focus on these two Biosafety Levels.

Table 1. Summary of Biosafety Levels for Infectious Agents (BSL-1 to BSL-2)

Biosafety Level 1 (BSL-1)Agents: Not known to cause disease in healthy adultsPractices: Standard microbiological practicesSafety None required

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Equipment:(Primary Barriers)Facilities:(Secondary Barriers)

Open bench top sink required

Biosafety Level 2 (BSL-2)Agents: Associated with human disease, hazard exposure =

auto-inoculation, ingestion, mucous membrane exposure

Practices: BSL-1 practice plus: Limited access; biohazard warning signs; “Sharps” precautions; biosafety manual defining any needed training, waste decontamination or medical surveillance policies

Safety Equipment:(Primary Barriers)

Biological Safety Cabinet (BSC) or other physical containment devices used for all manipulations of agents that cause splashes or aerosols of infectious materials; Personal Protective Equipment (PPE): Laboratory coat, gloves, eye/face protection, closed-toed shoes

Facilities:(Secondary Barriers)

BSL-1 facility plus: Controlled access. Waste to be classified as medical waste and disposed of following University procedures. Equipment decontamination before removal from laboratory

IV. Biohazard DefinitionInfectious or etiologic (disease causing) agents, potentially infectious materials, certain toxins and other hazardous biological materials are included in the definition of a biohazard.

BiohazardBiological agents and materials which are potentially hazardous to humans, animals and/or plants. Biohazardous agents may include but are not limited to: Certain bacteria, fungi, viruses, rickettsiae, chlamydiae, parasites, recombinant products, allergens, cultured human or animal cells and the potentially infectious agents these cells may contain, including viroids, prions and other infectious agents as outlined in laws, regulations and guidelines.

Biohazards at CSUFBiological hazards can be found in the various teaching, research, diagnostic and support environments on campus. Current activities at CSUF are dealing with infectious agents utilized in BSL-1 and BSL-2

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laboratories only. The information contained in this and other manuals will further increase our ability to maintain a safe place to work, teach and learn.

V. Classification of Infectious AgentsRisk GroupsWorldwide there are several systems for classifying human and animal pathogens according to the hazard they present to an individual and the community. Although these classifications differ from each other, they all are based on the notion that some microorganisms are more hazardous than others. In general, the pathogenicity of the organism, mode of transmission, host range, availability of effective preventive measures and/or effective treatment is some of the criteria taken into consideration when classifying infectious agents. In the U.S., the most current classification is found in the NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules. The human etiologic agents addressed in these guidelines are classified into four risk groups with Risk Group 1 (RG-1) of low or no hazard and Risk Group 4 (RG-4) representing highly infectious agents:

Table 2. Basis for the Classification of Biohazardous Agents by Risk Group

Risk Group Risk to the individual and the communityRisk Group 1 (RG-1)

Agents that are not associated with disease in healthy adult humans.

Risk Group 2 (RG-2)

Agents that are associated with human disease which are rarely serious and for which preventive or therapeutic interventions are often available.

Risk Group 3 (RG-3)

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).

Risk Group 4 (RG-4)

Agents that are likely to cause serious or lethal human disease for which preventive or therapeutic interventions are not usually available (high individual and community risk).

VI. Rules, Regulations and GuidelinesThe following is a brief summary of the regulatory authorities that either regulate or provide guidelines for the use of biological materials, infectious agents and recombinant DNA molecules.

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A. National Institutes of Health (NIH): Guidelines for Research Involving Recombinant DNA Molecules. These guidelines address the safe conduct of research that involves construction and handling of recombinant DNA (rDNA) molecules and organisms containing them. Included in the Guidelines is a requirement of the institution to establish an Institutional Biosafety Program with authority to approve or disapproved proposed rDNA research using the NIH Guidelines as a minimum standard. For more information, please refer to the Recombinant DNA Research section in this manual and the NIH Guidelines for Research Involving Recombinant DNA Molecules.

B. Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH): Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th edition. This document describes combinations of standard and special microbiological practices, safety equipment, and facilities that constitute Biosafety Levels 1-4, which are recommended for working with a variety of infectious agents in various laboratory settings. The BMBL has been revised several times and is commonly seen as the standard for biosafety.

C. California Occupational Safety and Health Administration (Cal OSHA): 8 CCR 5193 - Bloodborne Pathogens Standard. This rule deals with the occupational health risk caused by exposure to human blood and other potentially infectious materials. The regulation includes a combination of engineering and work practice controls, personal protective clothing and equipment, training and medical follow-up of exposure incidents, vaccination, and other provisions.

D. California Occupational Safety and Health Administration (Cal OSHA): 8 CCR 5154.2 – Ventilation Requirements for Biological Safety Cabinets. This regulation provides minimum ventilation flow conditions for the various class and types of biosafety cabinets available to prevent harmful exposure from biohazard agents or biohazardous materials or hazardous substances.

E. Department of Health and Human Services (HHS): 42 CFR 73 - Possession, Use, and Transfer of Select Agents and Toxins. These rules require facilities and institutions to be registered and approved in order to possess, use, or transfer certain biological agents and toxins.

F. Packaging, shipment and transportation requirements for infectious substances, diagnostic specimens and biological products are addressed in the following agencies regulations and guidelines:

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1. International Air Transport Association (IATA): Dangerous Goods Regulations

2. International Civil Aviation Organization (ICAO): Technical Instructions for the Safe Transportation of Dangerous Goods by Air

3. United Nations: Recommendations of the Committee of Experts on the Transportation of Dangerous Goods

4. U.S. Department of Transportation: 49 CFR Parts 171-1785. U.S. Public Health Service: 42 CFR Part 726. U.S. Postal Service: 39 CFR Part 1117. California Occupational Safety and Health Administration:

8 CCR 5193

G. Importation permits are required for certain infectious agents, biological materials and animals as outlined in U.S. Public Health Service: 42 CFR Part 71 - Foreign Quarantine. In addition, the Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) requires permits for importation and transportation of controlled materials, certain organisms or vectors. This includes animal and plant pathogens, certain tissue cultures, foreign or quarantined soils, and live animals. APHIS: 7 CFR Part 340 regulates the importation, interstate movement, or environmental release of genetically engineered organisms.

H. California Department of Public Health (CDPH) Medical Waste Management Program: Medical Waste Management Act HSC 117600-118360. This act provides guidance for treatment and disposal of biohazardous waste generated at the University.

VII. Practices and Procedures

A. Routes of InfectionWorking in a biological research environment like some labs at CSUF, it is not unreasonable to expect that a laboratory person working with infectious materials is more likely to become infected than members of the general community. An infection occurs when disease-causing microorganisms enter the human body in sufficient numbers and by a particular route and overcome the body’s defense system. The following routes of infection have been reported for laboratory-acquired infections:

1. Through the mouth Eating, drinking and smoking in the laboratory Mouth pipetting

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Transfer of microorganisms to mouth by contaminated fingers or articles

2. Through the skin Accidental inoculation with a hypodermic needle, other

sharp instrument or glass Cuts and scratches

3. Through the eye Splashes of infectious material into the eye Transfer of microorganisms to eyes by contaminated

fingers4. Through the lungs

Inhalation of airborne microorganisms

Most of the laboratory – acquired infections reported in literature point to accidents during work with some type of infectious agent. These include spills, splashes and accidents involving needles or other sharp objects. The general laboratory procedures outlined in this manual address those issues and provide guidance in handling infectious or potentially infectious material.

B. Administrative Controls

1. Biohazard Warning SignagePermanent warning signs containing the biohazard symbol, BSL-2 designation and emergency contact information are posted at the entrance to rooms where RG-2 agents are used or stored. The door sign outside of the laboratory is posted and managed by EHS. The Principal Investigator (PI) is responsible for ensuring all areas or equipment within the lab in which RG-2 agents are handled or stored or where BSL-2 procedures are required contain the biohazard symbol. This includes equipment such as refrigerators, incubators, BSCs, lab benches, transport carts and waste containers.

2. TrainingGood microbiological and laboratory practices are essential for a safe work environment. All personnel working with RG-2 agents or in a BSL-2 lab must receive adequate laboratory specific training from the PI or laboratory supervisor. The following trainings are mandatory unless otherwise specified:

Laboratory Safety Fundamentals (available online) Biological Hazard Safety (available online) Bloodborne Pathogens Safety (available online) Animal Care and Handling – If applicable (available online)

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Shipping Biologicals – If applicable (available online) Site specific information on risks, hazards and procedures Laboratory or environment specific BSL-2 procedures as

applicable

C. Safe Housekeeping GuidelinesThe California Occupational Safety and Health Administration General Industry Safety Orders provide regulations for safety in places of employment. Section 3362 (Safe Practices and Personal Protection- General Requirements) specifically addresses housekeeping. Good housekeeping reduces injuries and accidents, improves morale, reduces fire potential, and can even make operations more efficient. Good housekeeping in laboratories is essential to reduce risks and protect the integrity of biological experiments. Routine housekeeping must be relied upon to provide work areas free of significant sources of contamination. Housekeeping procedures should be based on the highest degree of risk to which personnel and experimental integrity may be subjected. Laboratory personnel are responsible for cleaning laboratory chairs, equipment and areas that require specialized technical knowledge.

Specific laboratory housekeeping concerns include:1. Keeping the laboratory neat and free of clutter – surfaces should

be clean and free of infrequently used chemicals, glassware and equipment.

2. Access to fire extinguishers, sinks, eyewash stations, emergency showers and exits must not be blocked.

3. Biological waste and old/unused chemicals should be disposed of promptly and properly.

4. Aisles and corridors should be free of tripping hazards. Remove unnecessary items on floors, under chairs or in corners.

5. Attention should be paid to electrical safety, especially as it relates to the use of extension cords, proper grounding of equipment, overloading of electrical circuits and the avoidance of creating electrical hazards in wet areas.

6. All laboratory equipment needs to be cleaned and certified of being free of hazards before being released for repair or maintenance.

7. Properly secure all compressed gas cylinders.8. Never use fume hoods for storage of chemicals or other

materials.9. Remain in compliance with CSUF’s Chemical Hygiene Plan.

D. Engineering Controls

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1. Biological Safety Cabinets (BSCs)BSCs are designed to provide personnel, environmental and product protection when appropriate practices and procedures are followed. Two kinds of biological safety cabinets, designated as Class I and II have been developed to meet various research and clinical needs. Biological safety cabinets use High Efficiency Particulate Air (HEPA) filters in their exhaust and/or supply systems. Biological safety cabinets must not be confused with other laminar flow devices or “clean benches”; in particular, horizontal flow cabinets which direct air towards the operator and should never be used for handling infectious, toxic or sensitizing materials.

Laboratory personnel must be trained in the correct use and maintenance of biological safety cabinets to ensure that personnel and product protection (where applicable) are maintained.

Class I Biological Safety CabinetThis is a ventilated cabinet for personnel protection with a non-recirculated inward airflow away from the operator. This unit is fitted with a HEPA filter to protect the environment from discharged agents. A class I BSC is suitable for work involving low to moderate risk agents, where there is a need for containment, but not for product protection (e.g. sterility).

Class II Biological Safety CabinetThis is a ventilated cabinet for personnel, product and environmental protection which provide inward airflow and HEPA-filtered supply and exhaust air. The class II cabinet has four designs depending on how much air is re-circulated and/or exhausted and if the BSC is hard-ducted to the ventilation system or not. Class II cabinets may be utilized for low to moderate risk biological agents, minute quantities of toxic chemicals, and trace quantities of radionuclides; however, care must be exercised in selecting the correct class II cabinet design for these purposes.

Biological safety cabinets, when properly used in research and teaching activities involving the manipulation of biohazardous agents, are effective in containing and controlling particulates and aerosols. The correct location, installation, and certification of biological safety cabinets are critical to its performance in containing infectious agents. All BSCs used for RG-1 or 2 and rDNA research are inspected annually and certified by trained

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and certified service personnel according to the National Sanitation Foundation (NSF) Standard 49. Inspection and re-certification is mandatory if the cabinet is relocated, after major repairs, filter changes, etc. Contact the EHS office at x7233 or email safety@fullerton.edu to request certification.

2. Safe and Effective Use of Biosafety Cabinets

General:- Make sure the BSC is certified (NSF-49/Cal OSHA/MFR

SPEC. certification sticker) when it is installed, relocated, repaired and annually thereafter.

- Do not use Bunsen burners in BSCs.- Avoid disrupting the protective airflow pattern of the

BSC. Such things as rapidly moving your arms in and out of the cabinet, people walking rapidly behind you, and open lab doors may disrupt the airflow pattern and reduce effectiveness of the BSC.

- Plan your work.- Minimize the storage of materials in and around the

BSC.- Always leave the BSC running to ensure containment.

Operation:- Turn on cabinet fan 15 minutes before beginning work.

Do not work in a BSC while a warning light or alarm is signaling.

- Before using, wipe work surface with disinfectant suitable for agent(s) in use. Wipe off each item you need for your procedures before placing inside cabinet. Ensure adequate disinfectant contact time.

- DO NOT block or place any objects over the front and rear air intake grilles.

- Segregate contaminated and clean items. Work from “clean to dirty.”

- Place a pan with disinfectant and/or sharps container inside the BSC for pipette discard. DO NOT use vertical pipette discard canisters on the floor outside the cabinet.

- Move arms slowly when removing or introducing new items into the BSC.

- If you use a piece of equipment that creates air turbulence in the BSC (e.g. micro-centrifuge, blender, etc.), place equipment in the back 1/3 of the cabinet; stop other work while equipment is operating.

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- Protect the building vacuum system from biohazards by placing an inline HEPA filter cartridge between the vacuum trap and source valve in the cabinet.

- Cleanup spills in the cabinet immediately. Wait 10 minutes before resuming work.

- When work is finished, remove all materials and wipe all interior surfaces with disinfectant suitable for the agent(s). Ensure adequate disinfectant contact time.

- Remove lab coat, gloves and other Personal Protective Equipment (PPE) and wash hands thoroughly before leaving the laboratory.

3. Safety Equipment Safety Showers provide an immediate water drench of an

affected person for at least 15 minutes. Standards for the location, design and maintenance of safety showers are outlined in the Chemical Hygiene Plan (CHP).

Eyewash Stations are required in all laboratories where injurious or corrosive chemicals are used, stored and where employees perform tasks that might result in splashes of potentially infectious materials. Eye exposure to any of these materials requires drenching for at least 15 minutes. Standards for location, design and maintenance of emergency eyewash facilities are outlined in the CHP.

Ventilation Controls are those controls intended to minimize employee exposure to hazardous chemicals and infectious or toxic substances by removing air contaminants from the worksite. There are two main types of ventilation controls:- General (Dilution) Exhaust: A room or building-wide

system which brings in air from outside and ventilates within. Laboratory air must be continually replaced, preventing the increase in concentration of toxic substances in the air.

- Local Exhaust or Filtration: A ventilated, enclosed work space intended to capture, contain and exhaust or filter harmful fumes, vapors and particulate matter. Fume hoods are to be utilized for containment of hazardous chemicals and BSCs are required for control of infectious agents. For more information ventilation requirements involving hazardous chemicals refer to the CHP.

E. Personal Protective Equipment (PPE)PPE is used to protect personnel from contact with hazardous materials and infectious agents. Appropriate clothing may also protect the experiment from contamination. Personal protective devices and

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safety equipment must be provided to all employees and students under the appropriate circumstances. The individual has the responsibility to properly maintain and use equipment per manufacturer’s directions.

The following PPE is recommended for regular use:1. Eye and Face Protection: Safety glasses are to be utilized at

a minimum in all laboratory work areas. Goggles are required for anticipated splashes, sprays or splatters of infectious or other hazardous materials. Combination of safety eyewear and face shield may be needed to protect the face from flying objects, splashes, sprays, etc.

2. Laboratory Clothing: At a minimum, a laboratory coat is to be worn in all laboratories. Recommend utilizing fire resistant coat for added protection, especially when working with open flame or flammable materials. Additional criteria for selecting clothing are: comfort, appearance, durability, antistatic properties, closure types and location. Protective clothing must be removed and left in the laboratory before leaving for non-laboratory areas. Disposable clothing is available for maintenance and service workers at Material Control in the event it is required.

3. Gloves: It is imperative that the correct gloves be selected based on the hazards involved and the activity to be conducted. Gloves must be worn when working with biohazards, toxic substances, hazardous chemicals and other physically hazardous agents. Temperature resistant gloves must be worn when handling hot material or dry ice. CSUF’s One Glove Policy is to be enforced to help lower the chance of contamination and exposure outside the laboratory.

4. Respirators: The University prefers engineering controls (e.g. BSC, Fume Hood, etc.) be utilized in lieu of respirator, but if needed, CSUF currently has a respirator program in place. Contact the EHS office at x7233 or email safety@fullerton.edu to schedule training and fit testing.

5. Shoes: Always wear comfortable and safe low profile shoes. Open toed shoes, sandals, and flip-flops are prohibited when working in any lab area.

6. Skirts and Shorts: A lab coat should be worn when wearing a skirt or shorts which may expose your bare legs to chemicals or biological agents.

F. Recommended Work Practices

1. Pipettes and Pipette Aids

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Mouth pipetting is strictly prohibited. Mechanical pipetting aids must be used. Confine pipetting of biohazardous or toxic fluids to a biosafety cabinet if possible. If pipetting is done on the open bench, use absorbent pads or paper on the bench. Utilize the following precautions:

Always use cotton-plugged pipettes when pipetting biohazardous or toxic fluids.

Never prepare any kind of biohazardous mixtures by suction and expulsion through a pipette.

Biohazardous materials should not be forcibly discharged from pipettes. Choose a suitable pipette that will “deliver” material rather than those requiring “blowout”.

Do not discharge biohazardous material from a pipette at a height. Whenever possible, allow the discharge to run down the container wall.

Place contaminated, reusable pipettes in a container with enough disinfectant to completely cover them.

Discard contaminated Pasteur pipettes in an appropriate size sharps container.

When work is performed inside a biosafety cabinet, waste containers should be placed inside the cabinet as well while in use.

2. Syringes and NeedlesSyringes and hypodermic needles are dangerous objects that need to be handled with extreme caution to avoid accidental injection and aerosol generation. Generally, the use of syringes and needles should be restricted to procedures for which there is no alternative. Do not use a syringe and needle as a substitute for a pipette.

When using syringes and needles with biohazardous or potentially infectious agents:

Work in a biosafety cabinet whenever possible. Wear gloves. Fill the syringe carefully to minimize air bubbles. Expel air, liquid and bubbles from the syringe vertically into

a cotton pad moistened with appropriate disinfectant.

The University strongly encourages needles not be bent, sheared, replaced in the sheath or guard (capped), or removed from the syringe following use. Although recapping needles is not recommended in the lab, there are times in which it must be done. In the event that needles must be filled in advance of their use, there are safe methods that can be used to "recap" them

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using one hand.  Here are several suggestions for doing this in a safe manner:

“One-handed scoop method”: Place the cap on a flat surface, then remove your hand from the cap. Insert the syringe needle tip deep into the plastic protective cap on the flat surface. Press the tip of the plastic cap against an inanimate object in order to secure it in place. Never use two hands to begin the needle recapping process.

Using a conical tube or Styrofoam rack: Place the uncapped needle inside a conical tube temporarily instead of recapping. Alternatively, put the cap inside an open conical tube or rack so that the needle can be inserted into it and the cap and secured by firmly pushing the needle downward into it. There are also commercial needle recapping devices available for this purpose.

When passing a sharp, place the sharp tip down into a conical tube for the other person to grasp while using common phrases such as “sharps present” or “sharps clear”.

3. Autoclave Equipment Material Preparation

- Ensure material is safe for autoclaving (e.g. plastics that can withstand the temperature set point in the program that is chosen.)

- NEVER AUTOCLAVE FLAMMABLE, REACTIVE, CORROSIVE, TOXIC, or RADIOACTIVE MATERIALS.

- Glassware must be inspected for cracks prior to autoclaving.

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- Prepare and package material suitably. Waste loads should have ½ cup (100 ml) of tap water added to the inside of autoclavable red biohazard bags. Do not fill a waste bag over half full or above its fill line (if present).

- Loosely tie the neck of red biohazard bags with autoclave tape leaving a hole approximately the size of your fist to allow steam to penetrate and pressure to escape.

- Bottles and liquid containers should never be tightly sealed. Do not fill Erlenmeyer flasks more than ½ full.

- Place all items in metal secondary container (tray) to secure and contain spills.

- Dry waste loads should never contain glass, sharps, or any other material that may compromise the bag.

Loading Autoclave- Wear Personnel Protective Equipment (PPE) including

laboratory coat, eye protection, heat-insulating gloves (autoclave gloves), and closed-toe shoes. Caution: Autoclave gloves will absorb liquids that conduct heat energy, which may cause burns to the hands.

- Do not overload; leave sufficient room for steam circulation. Waste bags should be placed in a vertical position to avoid spills.

Operating Autoclave- Choose the appropriate program for the container and

material being sterilized. Consult the autoclave program chart located on autoclave door for assistance in choosing the appropriate cycle.

- Only designated individuals are allowed to set and/or change parameters for the autoclaves.

- Do not attempt to open the door while autoclave is operating.

- If problems with the autoclave are perceived, abort the cycle by pressing emergency stop button and report it to the lab supervisor immediately. You will not be able to retrieve your items until someone with the appropriate key unlocks the emergency stop button and

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ensures that the interior is depressurized and cool enough to open the door.

Unloading Autoclave- Wear PPE including heat-insulating gloves, eye

protection, laboratory coat, and closed-toe shoes. A face shield is recommended when removing liquid loads.

- Carefully unload the contents of the autoclaves, making sure to avoid getting the autoclave gloves wet since they would then lose their insulating properties.

- Ensure that caps remain loosely secured to media bottles when removing and transporting liquids. To avoid possible implosion of media bottles caused by vacuum formation from cooling media, do not fully tighten the caps until media bottles have cooled to near ambient temperature.

Equipment Malfunction- If the autoclave does not operate exactly as expected,

do not attempt to fix the problem.- Abort the cycle by pressing the emergency stop button.- Place “Autoclave Out of Order’ sign on autoclave door.- Report the problem to your lab supervisor.- Record the problem in the autoclave log book.

Spill Cleanup- Spills may occur from a boil-over, a broken liquid

container, or a torn waste bag.- No operation of the autoclave is allowed until all spills

are cleaned up.- Wait unit the autoclave and materials have cooled to

room temperature before attempting spill cleanup.- Spills contained in a metal tray should be taken to

autoclave room sink and cleaned out using household dishwashing liquid (such as Dawn, Palmolive, or a “green” alternative) and a non-abrasive scrubbing device (such as a blue-colored non-scratch scour pad from Scotch-Brite.) Do not use harsh detergents, bleach, abrasive cleansers, steel wool, or abrasive green-colored scour pads. Make sure that the final rinse

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of the autoclave trays is with DI water so as to avoid the accumulation of mineral deposits from tap water.

- Spills not contained in a metal tray require an “Autoclave Out of Order” sign to be placed on the unit, activation of the emergency stop button, and immediate notification of a supervisor. In these cases, staff members will need to assess the nature/extent of the spill and then determine how best to clean the area under the bottom shelf of the autoclave.

4. Centrifuge EquipmentHazards associated with centrifuging include mechanical failure and the creation of aerosols. To minimize the risk of mechanical failure, centrifuges must be maintained and used according to the manufacturer’s instructions. Users must be properly trained, to include a hands-on component provided by faculty or staff.

Aerosols are created by practices such as filing centrifuge tubes, removing supernatant, and suspending sediment pellets. The greatest aerosol hazard is created if a tube breaks during centrifugation. To minimize the generation of aerosols when centrifuging biohazardous materials, the following procedures should be followed:

Use sealed tubes and safety buckets that seal with O-rings. Before use, inspect tubes, O-rings and buckets for cracks, chips, erosion, bits of broken glass, etc. Do not use aluminum foil to cap centrifuge tubes because it may detach or rupture during centrifugation.

Fill and open centrifuge tubes, rotors and accessories in a BSC. Avoid overfilling of centrifuge tubes so that closures do not become wet. After tubes are filled and sealed, wipe them down with disinfectant.

Add disinfectant to the space between the tube and the bucket to disinfect material in the event of breakage during centrifugation.

Always balance buckets, tubes and rotors properly before centrifugation.

Do not decant or pour off supernatant. Use a vacuum system with appropriate in-line reservoirs and filters.

Work in a BSC when suspending sediment material. Use a swirling rotary motion rather than shaking. If shaking is necessary, wait a few minutes to permit the aerosol to settle before opening the tube.

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Small low-speed centrifuges may be placed in a BSC during use to reduce the aerosol escape.

High-speed centrifuges pose additional hazards. Take precautions to filter the exhaust air from vacuum lines; avoid metal fatigue resulting in disintegration of rotors; and use proper cleaning techniques and centrifuge components. Follow manufacturer’s recommendations meticulously to avoid metal fatigue, distortion and corrosion.

Avoid the use of celluloid (cellulose nitrate) tubes with biohazardous materials. Celluloid centrifuge tubes are highly flammable and prone to shrinkage with age. They distort on boiling and can be highly explosive in an autoclave. If celluloid tubes must be used, appropriate chemical disinfectants are necessary for decontamination.

5. AmpoulesOpening ampoules containing liquid or lyophilized infectious culture material should be performed in a BSC to control the aerosol produced. Gloves must be worn. To open, nick the neck of the ampoule with a file, wrap it in a disinfectant soaked towel, hold the ampoule upright and snap it open at the nick. Reconstitute the contents of the ampoule by slowly adding liquid to avoid making an aerosol of the dried material. Mix the container. Discard the towel, ampoule top and bottom as biohazardous waste.

Ampoules used to store biohazardous material in liquid nitrogen have exploded causing eye injuries and exposure to the infectious agent. The use of polypropylene tubes eliminates this hazard. These tubes are available dust free or pre-sterilized and are fitted with polyethylene caps with silicone washers. Heat sealable polypropylene tubes are also available.

6. Loop Sterilizers and Bunsen BurnersSterilization of inoculating loops or needles in an open flame generates small particle aerosols which may contain viable microorganisms. The use of a shielded electric incinerator or hot bead sterilizers minimizes aerosol production during loop sterilization. Alternatively, disposable plastic loops and needles may be used for culture work where electric incinerators or gas flames are not available or recommended. Never use a Bunsen burner in a BSC.

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G. Biological Spill Cleanup ProceduresSpills of BSL2 material that result in injury to personnel or release greater than 1 liter must be reported to your lab supervisor and EHS office at x7233. Since spills of biological materials will happen, it is important to be prepared prior to dealing with the problem. Laboratories working with biohazards must have a basic spill kit ready to use at all times. Materials should be easily accessible to everyone in the lab. If your BSL-2 lab does not have a spill kit, please contact the EHS office.

The following procedures are provided as a guideline to biohazardous spill cleanup and will need to be modified for specific situations. As with any emergency situation, stay calm, call 911 if necessary, and proceed with common sense. Call EHS office to request the spill response team if additional assistance is required, especially if the spill outgrows the resources in the laboratory.

1. BSL-1 Spills Notify others in the area, to prevent contamination of

additional personnel and environment. Remove any contaminated clothing and wash exposed skin

with soap and water.

Clean up of BSL-1 Spill Don disposable gloves, goggles, lab coat and closed-toe

shoes (Recommend utilizing face shield for spills with potential for splashes.)

Pickup any pieces of broken glass or other solid materials in the spill with forceps and place in broken glass waste receptacle.

Cover spill with paper towels or other absorbent material, pour or spray disinfectant around the spill allowing it to mix with the spilled material. Allow at least 10 minutes of contact time (assuming sodium hypochlorite solution is being utilized).

Mechanically scoop up the absorbed spill using scoops or cardboard.

Discard all disposable materials used to clean up the spill into municipal waste receptacle.

Wash hands with soap and water.

2. BSL-2 Spills If agent poses an inhalation risk, quickly leave the room.

Notify others to leave. Most agents used at BSL-2 are not

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airborne pathogens. Close door, and post with a warning sign.

If liquid spill has contaminated clothing, remove contaminated clothing, turning exposed areas inward, and place in a biohazard bag.

Wash all exposed skin with soap and water. Notify Principal Investigator or lab supervisor of incident.

Clean up of BSL-2 Spill Allow aerosols to disperse for at least 30 minutes before

reentering the laboratory (If applicable). Assemble cleanup materials from spill kit and lab

(disinfectant, paper towels or other absorbent, biohazard bags, forceps, etc.).

Don disposable gloves, goggles, lab coat, closed-toe shoes and shoe covers if necessary (Face shield should also be utilized for large spills with potential for splashes.)

Depending on the nature of the spill, it may be advisable to wear an N-95 filtering face piece. The N-95 face piece should only be worn if there is an airborne hazard present, and only by those who have met the requirements of CSUF Respiratory Protection Program.

Pick up any sharp objects with forceps or tongs and discard in a sharps container. Smaller pieces of glass may be collected with cotton or paper towels held with forceps.

Cover the area of the spill with paper towels or other absorbent material sufficient to soak up the liquid, and then carefully pour or spray disinfectant around the spill. Avoid enlarging the contaminated area. Use more concentrated disinfectant as it is diluted by the spill. Allow at least 20 minutes of contact time (assuming sodium hypochlorite solution is being utilized).

Using mechanical means, scoop up the absorbed spill material and discard in red biohazard bags.

Spray and wipe surrounding areas (where the spill may have splashed) with disinfectant and wipe up with paper towels. Place all contaminated paper towels and any contaminated clothing into a biohazard bag.

Remove and discard gloves, then wash hands and exposed skin areas with soap and water.

All BSL-2 waste is to be is to be disposed at biohazard waste bin located at DBH loading dock.

3. Spill within a Biological Safety Cabinet (BSL-2)

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Leave the BSC blower on and begin cleanup immediately. While wearing lab PPE, cover the spill area with paper

towels or disinfectant soaked paper towels. Do not place your head in the cabinet to clean the spill, keep your face behind the view screen.

If necessary, flood the work surface as well as the drain pans and catch basins below the work surface with disinfectant. Be sure the drain valve is closed before flooding the area under the work surface.

Wipe cabinet walls, work surfaces, and inside the view screen with disinfectant.

Lift the front intake grill and work surface; wipe all surfaces with disinfectant. Be sure no paper towels or soiled debris are blown into the area under the spill tray.

If the work surface, as well as drain pans and catch basins under the work surface have been flooded, soak up disinfectant on work surface. Place container under the drain valve and drain the disinfectant under the work surface into a container.

Wipe the areas under the work surface to remove residual disinfectant.

Collect all cleanup materials and used gloves in a biohazard bag.

Wash hands and exposed skin with soap and water. Notify Principal Investigator or lab supervisor of incident. All BSL-2 waste is to be disposed at biohazard waste bin

located at DBH loading dock.

H. General Guidelines and Policies1. Biological Risk Assessment

The assessment of risk is an essential element of safety in the laboratory. For most situations, guidelines, rules and regulations have clearly defined the procedures and practices to be followed in order to achieve safety in the work place. However, the newly isolated agent or toxin, or new procedure never before employed needs further evaluation. Questions concerning the appropriate safety equipment, training, and waste disposal need to be addressed as well as safe procedures and practices. Something is considered safe if the risk associated with it is judged to be acceptable. However, since individual judgment involves both personal and social values, opinions on what is safe or not can vary significantly. In order to find a common ground of an acceptable risk assessment, the “rule of reason” needs to be applied. The following factors should be considered for the determination of reasonableness:

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Custom of usage (or prevailing professional practice) : Many laboratory procedures involve the maintenance of sterility and cleanliness. These procedures are commonly considered safe, since adverse effects would have been obvious over time. However, because a procedure has been used for many years does not necessarily imply that it is safe. The best example is mouth pipetting, which was used for centuries and finally considered a very dangerous procedure and habit.

Best available practice, highest practicable protection, and lowest practicable exposure: It should be common practice in the microbiological laboratory to use the best available procedures with the highest level of protection. This not only provides for a safe work environment, but also fosters excellence in scientific conduct.

Degree of necessity and benefit : The common question to ask is, are the benefits worth the risk? There is no need to use a human pathogen causing severe gastroenteritis in a teaching laboratory when principal microbiological practices can be taught with an organism that is not considered to be infectious.

No detectable adverse effects : This can be a very weak criterion since it involves uncertainty or even ignorance.

Principal knowledge : A lot of times, existing procedures are modified, involving the same or similar pathogenic agents. For that reason, similar safety procedures should be applied. If new agents are isolated, we need to ask what we know about the close relatives. Many agents of known etiologic character are already categorized in risk groups allowing for the selection of the appropriate biosafety level. New isolates from infected animals or humans with known infectious relatives warrant at a minimum the same level of protection.

Taking the above mentioned factors, as well as others into consideration will allow for a reasonable approach to a new challenge. CSUF’s Biosafety Officer is available to assist in this process and should be contacted for questions concerning biological safety. Once a risk assessment is completed, the results should be communicated to everyone involved in the process. Written standard operating procedures (SOPs) should be established and distributed.

2. Guidelines for Working with Tissue Cultures/Cell Lines

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When cell cultures are known to contain an etiologic agent or an oncogenic virus, the cell line can be classified at the same biosafety level as that recommended for the agent.

The Centers for Disease Control and Prevention (CDC) recommend that all cell lines of human origin be handled at BSL-2. Per Cal OSHA, all employees (faculty, staff, volunteers, etc.) working with or handling these materials need to be included in CSUF’s Exposure Control Plan.

Cell lines which are non-primate or are of normal primate origin, which do not harbor a primate virus, which are not contaminated with bacteria, mycoplasma or fungi and which are well established may be considered Class I cell lines and handled at BSL-1. Appropriate test should confirm this assessment.

Primate cell lines derived from lymphoid or tumor tissue, all cell lines exposed to or transformed by a primate oncogenic virus, all clinical material (e.g. samples of human tissues and fluids obtained after resection or autopsy), all primate tissue, all cell lines new to the laboratory (until shown to be free of all adventitious agents) and all virus and mycoplasma containing primate cell lines are classified as RG-2 and should be handled at a Biosafety Level 2.

3. Guidelines for Preventing the Transmission of TuberculosisRecently, drug resistant strains of Mycobacterium tuberculosis have become a serious concern. Outbreaks of tuberculosis, including drug resistant strains, have occurred in healthcare environments. Several hundred employees have become infected after workplace exposure to tuberculosis, requiring medical treatment. A number of healthcare workers have died.

In December 2005, CDC published its Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities. The guidelines contain specific information on ventilation requirements, respiratory protection, medical surveillance and training for those personnel who are considered at risk for exposure to tuberculosis.

4. Guidelines for Clinical LaboratoriesClinical laboratories receive clinical specimens with requests for a variety of diagnostic services. The infectious nature of this material is largely unknown. In most circumstances, the initial

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processing of clinical specimens and identification of microbial isolates can be done safely at BSL-2.

A primary barrier, such as a BSC should be used: When it is anticipated that splashing, spraying or

splattering of clinical materials may occur, for initial processing of clinical specimens where it is suggested that an agent transmissible by infectious aerosols may be present (e.g. M. tuberculosis), to protect the integrity of the specimen.

The segregation of clinical laboratory functions and restricting access to specific areas is the responsibility of the laboratory director. It is also the director’s responsibility to establish standard written procedures that address the potential hazards and the required precautions to be implemented. Additional recommendations specific for clinical laboratories may be obtained from the National Committee for Clinical Laboratory Standards (NCCLS).

I. Transportation of Biological MaterialsAll biological materials should be transported in a way that maintains the integrity of the material during normal transport conditions, as well as prevents any accidental release, endangerment to the public or environment.

1. Transportation in or between buildings on campus:All samples transported intra and inter buildings are to be secured in durable leak proof containers of polycarbonate which meets Cal OSHA CCR, Title 8 Section 5193.

2. Transportation and shipment via carrier off campus:The shipment of diagnostic and clinical specimens, biological products, infectious agents and recombinant DNA molecules is regulated by Department of Transportation (DOT) for packages shipped by road and International Air Transport Association (IATA) for packages shipped by air. This includes specific procedures for the correct packing and packaging of these materials, necessary documentation and labeling and permits. Contact the EHS office at x7233 or email safety@fullerton.edu for assistance shipping these materials.

J. Decontamination

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Methods of Decontamination: Decontamination is defined as the removal or inactivation of biological agents by physical or chemical means. Methods applied to reach this goal can vary and most often include disinfection or sterilization. Generally speaking, disinfection is used when the acceptable level of microorganisms is defined as being below the level necessary to cause disease. This means, that viable microorganisms are still present. In contrast, sterilization is defined as the complete killing of all organisms present. Depending on the circumstances and tasks, decontamination of a surface (e.g. lab bench) is accomplished with a disinfectant, while decontamination of biomedical waste is done by sterilization in an autoclave.

In order to select the proper method and tools, it is important to consider, for example, the following aspects:

Type of biohazardous agents, concentration and potential for exposure

Physical and chemical hazards to products, materials, environment and personnel

Physical and chemical means of decontamination fall into two main categories:

Heat Liquid Chemicals

1. Heat:In order to kill microbial agents, heat can be applied in dry or wet form. The advantage of wet heat (steam sterilization in an autoclave) is a better heat transfer to and into the biological material resulting in overall shorter exposure time and lower temperature. Steam sterilization uses pressurized steam at 250-270°F (121-132°C) for 30 or 40 minutes. This type of heat kills all microbial cells including spores, which are normally heat resistant. In order to accomplish the same effect with dry heat in an oven, the temperature needs to be increased to 320-338°F (160-170°C) for periods of 2 to 4 hours.

2. Liquid Chemicals Used as Disinfectants:The appropriate liquid disinfectant should be chosen after carefully assessing the biohazardous agent and the type of material to be decontaminated. Liquid disinfectants are preferably used for solid surfaces and equipment. They vary greatly in their efficiency, depending on the chemical constituents and the agents involved. Variables to remember when disinfecting:

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Nature of surface being disinfected – Porous or smooth; the more porous and rough the surface requires increased concentration and/or contact time.

Number of microorganisms present – Higher concentrations requires a longer application time and/or higher concentration of disinfectant.

Microorganism resistance – Microbial agents can be classified according to increasing resistance to disinfectants (see Table 3).

Presence of organic material – The proteins in organic materials such as blood, bodily fluids, and tissue can prevent or slow the activity of certain disinfectants.

Duration of exposure (i.e. contact time) and temperature – Increased exposure time increases the effectiveness of disinfectants. Low temperatures may slow down the activity requiring more exposure time.

Table 3. Resistance to Chemical Disinfectants

Least Resistant

Most Resistant

Examples

LIPID OR MEDIUM-SIZE VIRUSES

Herpes simplex virusCytomegalovirusRespiratory syncytial virusHepatitis B virusHuman Immunodeficiency virus

VEGETATIVE BACTERIA

Pseudomonas aeruginosaStaphylococcus aureusSalmonella choleraesuis

FUNGITrichophyton sp.Cryptococcus sp.Candida sp.

NON-LIPID or SMALL VIRUSES

PoliovirusCoxsackievirusRhinovirus

MYCOBACTERIAMycobacterium tuberculosisMycobacterium bovis

BACTERIAL SPORES Bacillus subtilisClostridium sporogenes

There are many different liquid disinfectants available under a variety of trade names. In general, these can be categorized as

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halogens, acids or alkalies, heavy metal salts, quaternary ammonium compounds, aldehydes, ketones, alcohols and amines. Unfortunately, the most effective disinfectants are often very aggressive (corrosive) and toxic. Some of the more common ones are discussed below:

Alcohols: Ethyl or isopropyl alcohol in concentration of 10% to 70% are good general-use disinfectants. However, they evaporate fast and therefore have limited exposure time. They are less active against non-lipid viruses and ineffective against bacterial spores. Concentrations above 70% are less effective.

Formalin: Formalin is 37% solution of formaldehyde in water. Dilution of formaldehyde to 5% results in an effective disinfectant. Formaldehyde is a human carcinogen and creates respiratory problems at low levels of concentration.

Glutaraldehyde: This compound although chemically related to formaldehyde, is more effective against all types of bacteria, fungi, and viruses. Vapors of glutaraldehydes are irritating to the eyes, nasal passages and upper respiratory tract. They should be used always in accordance with the instructions on the label and appropriate personal protective equipment.

Phenol and Phenol Derivatives: Phenol based disinfectants come in various concentrations ranging mostly from 5% to 10%. These derivatives including phenol have an odor, which can be somewhat unpleasant. Phenol itself is toxic and appropriate personal protective equipment is necessary during application. The phenolic disinfectants are used frequently to disinfect contaminated surfaces (e.g. walls, floors, bench tops, etc.). They effectively kill bacteria including Mycobacterium tuberculosis, fungi and lipid-containing viruses. They are not active against spores or non-lipid viruses.

Quaternary Ammonium Compounds (Quats): Quats are cationic detergents with strong surface activity. They are acceptable for general-use disinfectants and are active against Gram-positive bacteria and lipid-containing viruses. They are less active against Gram-negative bacteria and are not active against non-lipid –containing viruses. Quats are easily inactivated by organic materials, anionic detergents or salts of metals found in water. If Quats are mixed with phenols, they are very effective disinfectants as well as cleaners. Quats are relatively nontoxic and can be

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used for decontamination of food equipment and for general cleaning.

Halogens (Chlorine and Iodine): Chlorine-containing solutions have broad spectrum activity. Sodium hypochlorite is the most common base for chlorine disinfectants. Common household bleach (5% available chlorine) can be diluted 1/10 to 1/100 with water to yield a satisfactory disinfectant solution. Diluted solutions should be kept no longer than one week, assuming maintained in closed containers and protected from light. It is recommended to use freshly prepared solutions for spill clean-up purposes. Chlorine-containing disinfectants are inactivated by excess organic materials. They are also strong oxidizers and very corrosive. Always use appropriate personal protective equipment when using these compounds. At high concentrations and extended contact time, hypochlorite solutions are considered cold sterilants since they inactivate bacterial spores.

Iodine has similar properties to chlorine. Iodophors (iodine in combination with a surfactant) are recommended disinfectants. They are most often used as antiseptics and in surgical soaps and are relatively nontoxic to humans.

K. Biohazard WasteAt CSUF, the term biohazardous waste is used to describe different types of waste that might include infectious agents and/or medical waste. Currently, any waste meeting the California Medical Waste Management Act definitions listed below are to be considered biohazardous waste:

Infectious Agent “Infectious agent” means a type of microorganism, bacteria, mold, parasite, or virus, including, but not limited to, organisms managed as Biosafety Level II, III, or IV by the federal Centers for Disease Control and Prevention, that normally causes, or significantly contributes to the cause of, increased morbidity or mortality of human beings.

Medical Waste (a) “Medical waste” means any biohazardous, pathology, pharmaceutical, or trace chemotherapy waste; sharps and trace chemotherapy wastes generated in a health care setting in the diagnosis, treatment, immunization, or care of humans or animals; waste generated in autopsy or necropsy; waste generated during preparation of a body for final disposition such as cremation or interment; waste generated in research pertaining to the production or testing of microbiologicals; waste generated in research using human

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or animal pathogens; sharps and laboratory waste that poses a potential risk of infection to humans generated in the inoculation of animals in commercial farming operations; waste generated from the consolidation of home-generated sharps; and waste generated in the cleanup of trauma scenes. (B) Laboratory waste such as human specimen cultures or animal specimen cultures that are infected with pathogens that are also infectious to humans; cultures and stocks of infectious agents from research; wastes from the production of bacteria, viruses, spores, discarded live and attenuated vaccines used in human health care or research, discarded animal vaccines, including Brucellosis and Contagious Ecthyma, as defined by the department; culture dishes, devices used to transfer, inoculate, and mix cultures.

General Packaging and Disposal Procedures The responsibility for proper characterization, storage and disposal of waste lies with the PI or lab supervisor.

All biohazardous waste needs to be packaged, contained and located in a way that protects and prevents the waste from release at any time in the lab prior to ultimate disposal.

If not stated otherwise, most biohazardous waste will be disposed of in red autoclavable biohazard bags. CSUF requires the use of red biohazard bags that includes the biohazard symbol.

Solid waste meeting any of the definitions at the beginning of this section (K) is considered regulated waste and cannot be treated onsite (i.e. autoclaved) and disposed in municipal trash receptacle. Waste of this type is to be disposed in approved biohazard waste bin (e.g. DBH Loading Dock waste bin).- See BSL-2 Waste Disposal SOP for detailed instructions

on proper disposal method. Liquid waste meeting any of the definitions at the

beginning of this section (K) is considered regulated waste and must be decontaminated per method prescribed in section (J). Waste can then be disposed down sanitary sewer drain with liberal amount of water.

Biological waste not meeting the above definitions can be autoclaved at PIs discretion, then placed in blue bag and discarded in municipal dumpster. Liquid waste is to be disposed in sanitary sewer while diluting with plenty of water.- See Autoclave Usage and Disposal of Waste SOP for

detailed instructions on proper disposal method.

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All biohazard sharps must be placed in a red rigid, puncture resistant, closeable and leak proof container, which is labeled with the biohazard symbol.

All non-biohazard sharps must be placed in a clear rigid, puncture resistant, closeable and leak proof container, which is labeled with the words “NON-INFECTIOUS Sharps”.

VIII. Investigation, Analysis, Incident/Near Miss Report and Corrective Action

A. Scope of Investigation and AnalysisA near miss incident is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage. Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm, and should be the focus of improvement. Other familiar terms for these events is a “close call”, or in the case of moving objects, "near “collision”. The often misunderstood phrase is so-called to stress that not only had things gone remotely off course towards danger, but they had actually only “barely missed” catastrophe. Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus capturing near misses provides an inexpensive means of learning and can enhance the University’s Biosafety Program by creating a behavior shift, responsibility sharing, awareness, incentives, etc.

1. A near miss is a cheaper learning tool than learning from an actual injury or property loss accident.

2. A key to any near miss report is the “lesson learned”. Near miss reporters are in a position to describe what they observed about genesis of the event, and the factors that prevented loss from occurring.

3. The events that caused the near miss are subjected to root cause analysis to identify the defect in the system that resulted in the error and factors that may either amplify or ameliorate the result.

4. To prevent the near miss from recurring, the organization must institute teamwork training, feedback on performance, and a commitment to continued data collection and analysis; a process called continuous improvement.

B. General process of investigation and analysis for documenting a corrective actionInjury/Illness report forms are the most critical part of successful corrective action, because it directs the corrective action at the root of the problem. That is to say, it is effective solutions we seek, not root

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causes. Root causes are secondary to the goal of prevention, and are only revealed after we decide which solutions to implement.

1. Define the problem.2. Gather data/evidence through reports, interviews and

investigation of laboratory or facilities involved in the incident.3. Ask why and identify the causal relationships associated with the

defined problem.4. Identify which causes if removed or changed will prevent

recurrence.5. Identify effective solutions that prevent recurrence, that are

within your control, meet goals and objectives and do not cause other problems.

6. Implement the recommendations.7. Observe the recommended solutions to ensure effectiveness.8. Apply root cause analysis to aid investigation.

C. Analysis Tool for Investigation (Root Cause Analysis)Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. However, it is recognized that complete prevention of recurrence by a single intervention is not always possible. Thus, RCA is often considered to be an iterative process, and is frequently viewed as a tool of continuous improvement. Root cause analysis is not a single, sharply defined methodology; there are many different tools, processes, and philosophies of RCA in existence. However, most of these can be classed into five, very-broadly defined “schools” that are named here by their basic fields of origin: safety-based, production-based, and failure-based and system based.

1. Safety-based RCA descends from the fields of accident analysis and occupational safety and health.

2. Production-based RCA has its origins in the field of quality control for industrial manufacturing.

3. Process-based RCA is basically follow-on to production-based RCA, but with a scope that has been expanded to include business processes.

4. Failure-based RCA is rooted in the practice of failure analysis as employed in engineering and maintenance.

5. Systems-based RCA has emerged as an amalgamation of the preceding schools, along with ideas taken from fields such as risk management and systems analysis.

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D. Incident Reporting and Procedures1. All injuries/illnesses/near misses should be reported to the PI or

lab supervisor immediately (Please use common sense and reasonableness in evaluation of a near miss.) For clarification of a near miss please refer back to the previous section (Scope of Investigation and Analysis).

2. The PI or lab supervisor is to begin the incident reporting process by instructing the injured/ill or reporting person to complete Part 1 of CSUF Injury/Illness report.

3. Part 2 of the form is to be completed by PI or lab supervisor within 24 hours of knowledge of the incident.

4. Completed form is to be distributed to Risk Management (CP-700), a copy sent to EHS (T-1475) and retain a copy for the department.

5. The EHS office will evaluate report, and if needed, perform additional investigation, root cause analysis and assist with implementation of proposed corrective actions.

IX. Recombinant DNA ResearchAll recombinant DNA/RNA, Select Agent and GMO research must be approved by Institutional Biosafety Committee (IBC) prior to bringing material to the University.

Notice pertinent to the April 2016 revisions of the NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules (NIH Guidelines) can be found at: https://osp.od.nih.gov/wp-content/uploads/NIH_Guidelines.html

X. General Biosafety References

A. CDC Workplace Health Promotion: https://www.cdc.gov/workplacehealthpromotion/index.html

B. The National Institute for Occupational Safety and Health (NIOSH) Database:https://www.cdc.gov/niosh/chemicals/dbsandtools.html

C. Cal OSHA Occupational Exposure to Hazardous Chemicals in Laboratories:https://www.dir.ca.gov/title8/5191.html

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D. Cal OSHA Personal Protective Equipment Standard:https://www.dir.ca.gov/Title8/3380a.html

E. American Biological Safety Association (ABSA International):https://absa.org/

F. Cal OSHA Permissible Exposure Limits for Chemical Contaminants:https://www.dir.ca.gov/title8/5155table_ac1.html

XI. Appendix A: Product and Pathogen Safety Data Sheets

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XII. Appendix B: CSUF Bloodborne Pathogen ProgramCSUF Bloodborne pathogen program can be accessed at: https://ehs.fullerton.edu/programs/safety.php

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