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Biosafety Manual

I. Introduction and General Information ………………………….. 4 a. Definition …………………………………………………… 4 b. Responsibilities …………………………………................. 4 c. Concordia University Biosafety Committee (CUBSC) ……. 5 d. Project registration and approval ……………………………. 6 e. Training ……………………………………………………. 6 f. Inspections ……………………………………………………. 7

II. Regulations and Guidelines …………………………………….. 7

a. Risk groups …………………………………………………….. 8 b. Containment levels …………………………………………….. 9 c. Risk assessment …………………………………………….. 10 d. Transportation, importing and exporting …………………….. 10 e. Controlled Goods Directorate program …………………….. 13 f. Medical surveillance ……………………………………………. 14

III. Laboratory Practices and Biological Safety …………………….. 14 a. Handling infectious substances …………………………….. 14

Safe operational practices and procedures WHMIS

b. Human blood and body fluids .....…………………………….. 16 Tissue cultures Universal precautions

c. Recombinant DNA ….…………………………………………. 18 d. Environmental samples ...…..………………………………… 19 e. Animals ………………………………………………………….. 19 f. Transport on campus ………………………………………….. 20

IV. Safety Equipment …………………………………………………. 20 a. Laboratory ventilation …………………………………………. 20 b. Biological safety cabinets ……………………………………. 21

Classes Safe use Maintenance and certification

c. Fume hoods ……………………………………………………. 24 d. Personal protective equipment ……………………………. 24

V. Decontamination …………………………………………………… 25 a. Autoclaves …………………………………………………….. 26 b. Chemical disinfection …………………………………………. 27

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c. Waste handling procedures …………………………………... 27 Biological waste Autoclave waste Mixed waste Sharps Animal carcases

VI. Laboratory decommissioning …………………………………….. 28

VII. Emergencies and Incident Reporting ……………………………. 29 a. Incident/accident hazard reporting procedures ……………. 29 b. Spill response ……………………………………………. 29 c. Biosecurity …………………………………………………….. 30

Appendix - A …………………………………………………………….. 31 Appendix - B …………………………………………………………….. 33 References …………………………………………………………….. 35

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List of Abbreviations

AIHA American Industrial Hygiene Association

BSC Biological safety cabinet

BSO Biosafety Officer

CDC Centre for Disease Control

CGD Controlled Good Directorate

CGR Controlled Goods Regulations

CFIA Canadian Food Inspection Agency

CL1, 2 Containment level 1, containment level 2

CSST Commission de la santé et de la sécurité du travail

CUBSC Concordia University Biosafety Committee

EH&S Environmental Health and Safety

HEPA High Efficiency Particulate Air

IATA International Air Transport Association

ICAO International Civil Aviation Authority

MSDS Material safety data sheet

NIH National Institute of Health

NRC National Research Council

PI Principal Investigator

PWGSSC Department of Public Works and Government Services Canada

PPE Personal Protective Equipment

SOP Safe Operational Practices and Procedures

TDG Transportation of Dangerous Goods

UV Ultra-violet

WHMIS Workplace Hazardous Materials Information System

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Chapter I

Introduction and general information

a) Definition A biohazardous material is defined for the purpose of this manual as any organism, and/or its toxin, that can cause disease in humans or animals, or cause significant environmental or agricultural impact. Biohazardous Infectious/Poisonous material falls under Class D, Division 3 of the Workplace Hazardous Materials Information System (WHMIS), and includes microorganisms such as viruses, fungi, parasites, and bacteria and their toxic metabolites. Blood and body fluids (human and non-human) and certain types of nucleic acids such as DNA derived from pathogenic organisms or human oncogenes, and DNA from transformed cell lines are considered biohazards as well. Biohazardous materials also include human or primate tissues, fluids, cells or cell culture.

b) Responsibilities Principal investigators (PI), faculty members, researchers, instructors, Teaching Assistants and, Technicians in Academic Departments It is the responsibility of any principal investigator, faculty member, researcher, instructor, teaching assistant and, technician in academic departments (in their capacity as supervisor of a class, laboratory or university sponsored activity) to be familiar with and follow the procedures outlined in the University Biosafety Manual and they must ensure that all staff and students working under their supervision and within their laboratories are aware of these procedures. Principal investigators are also responsible for the following:

1. Obtaining the Biosafety Certificate, and informing the Environmental Health and Safety Office (EH&S) of any changes to the conditions of the certificate.

2. Ensuring that the conditions of the certificate are followed. 3. Ensuring that all persons working under their supervision receive the

proper training and work safely with all potentially hazardous materials. Please consult EH&S for a list of available trainings.

4. Providing all the necessary personal protective equipment and standard operating procedures.

5. Reporting to the EH&S office any incidents, accidents, injuries, hazards or exposures.

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The Biosafety Officer (BSO) The Biosafety Officer (BSO) is the individual assigned to manage biological safety issues and is a member of the University Biosafety Committee and the Environmental Health and Safety Office (EH&S). The BSO is responsible for the day-to-day operations of the Biosafety Program.

c) The Concordia University Biosafety Committee (CUBSC) The Concordia University Biosafety Committee (CUBSC) is mandated to fulfill the responsibilities of a “Research Institution Biological Safety Committee” as described in the Health Canada Laboratory Biosafety Guidelines. These responsibilities include verifying that all work with biohazardous agents conducted at the University is in accordance with applicable legislation, guidelines, and recognized codes and standards of practice in ways that best facilitate relevant research or teaching activities of the University. The CUBSC provides advice to the University on matters pertaining to the use of hazardous biological materials. At present, Concordia University has containment level 1 & 2 (as defined by Health Canada guidelines) labs only. The committee will also advise and assist the EH&S Office in developing policies, procedures and manuals that support the academic research mission. The policies, procedures and manuals are intended to protect the University community and the environment from biological hazards. All research projects involving potentially hazardous biological materials will be registered with the EH&S office. Protocols requiring containment level 2 (as defined by Health Canada guidelines) will be reviewed by the committee in order for approval to be granted through the EH&S office. The CUBSC advises the University and recommends policies to guide Principal Investigators and the Environmental Health and Safety Office in carrying out the University’s Biosafety Program. The CUBSC members are appointed by the Vice-President, Services and made up of at least five members with expertise in general issues of laboratory biosafety, use of infectious materials, and recombinant DNA technology. The committee will include faculty and staff, the Biosafety Officer (BSO), and one graduate student with previous biosafety experience. Ex officio members (non-voting) can include representatives of the Office of Research Services and the Environmental Health & Safety Office. The term of membership on the committee is two years. The CUBSC will report to the Vice-President, Services. The CUBSC will meet as necessary, but no less than twice a year. The Chair will submit an annual report of activities and deliberations to the Vice-President, Services.

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The CUBSC is responsible for: 1. Reviewing University projects conducted by faculty, staff, students and/or

visiting scientists which involve biosafety activities that are containment level 2 ( as defined in Health Canada’s Laboratory Biosafety Guidelines).

2. Assisting the EH&S office with the development of policies, manuals, training programs and procedures.

3. Distributing new and relevant biosafety information to laboratories. 4. Making recommendation regarding issues of non-compliance to the

respective department head and to the respective supervising dean or director.

5. Reviewing reported incidents/accidents and exposures and making recommendations for corrections.

d) Project registration and approval The Environmental Health and Safety Office reviews new applications for grants and provides project registration and approval in conjunction with the Office of Research. New researchers are also encouraged to contact the EH&S office and to fill out the Approval Application in order to inform EH&S of their projects. The use or possession of biohazardous materials as defined in Chapter 1 section a) of this manual, as well as radioactive, hazardous materials, lasers or equipment containing lasers and other such materials must be registered or approved by EH&S. The Approval Application form must be completed and returned to EH&S. EH&S will review the application within two business days and provide the necessary Biohazard Certificate as well as any other required certificate based on activities. Activities identified as requiring a biosafety containment level 2 (refer to Chapter 2(b)) will also be reviewed by the CUBSC. To download the Environmental Health and Safety Approval Application: http://web2.concordia.ca/EHS/pdf/hm/approval.application.pdf

e) Training It is the responsibility of any faculty member, researcher, instructor, teaching assistants, technician in academic departments and, principal investigator (in their capacity as supervisor of a class, laboratory or university sponsored activity) to ensure that all those involved with biohazards receive biosafety training. This general biosafety training is available through the Arts & Science Safety Seminar given by the Chemistry department or through EH&S. However, operation-specific training must be provided by the Principal Investigator. All training must be documented and the records available to the EH&S Office and the CUBSC.

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f) Inspections

EH&S annual laboratory safety inspections

EH&S performs annual laboratory safety inspections. The inspections are done in cooperation with the departmental safety officers, in order to conform to all relevant legislation and good laboratory practices. These inspections provide a snapshot of laboratory safety and compliance. The inspection report will be sent to the Principal Investigator and will provide a list of conditions identified during the inspection that require corrective actions. Principal Investigators are required to sign the receipt acknowledgement form confirming receipt of the inspection findings and return it to the EH&S office. Laboratories are also encouraged to carry out their own self-inspections; the monthly inspection checklist can be used as a template and adapted to each lab.

Inspection program document: http://web2.concordia.ca/EHS/pdf/hm/lab.studio.shop.inspection.program.pdf EH&S inspection checklist: http://web2.concordia.ca/EHS/pdf/hm/lab.inspection.checklist.pdf Laboratory inspection checklist guidance document: http://web2.concordia.ca/EHS/pdf/hm/lab.inspection.guide.pdf Laboratory self-inspection: http://web2.concordia.ca/EHS/pdf/hm/inspection_checklist_monthly.pdf

Chapter II

Regulations and Guidelines The Act Respecting Occupational Health and Safety is the law that sets out the rights and obligations of all workers and employers. The Act establishes the terms and conditions to fulfill the law but encourages workers and employers to take responsibility for their own health and safety. As such, the internal responsibility system is the underlying philosophy of occupational health and safety legislation. Its foundation is that everyone in the workplace - both employees and employers - is responsible for his or her own safety and for the safety of co-workers. The Regulation respecting occupational health and safety is the subordinate legislation that establishes standards in the work environment to ensure the

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safety and physical well-being of workers. The Commission de la Santé et de la Sécurité du Travail (CSST) is in charge of applying the laws. However, the Acts and Regulations do not always impose or prescribe the specific steps for compliance. Instead, they hold employers responsible for determining such steps to ensure health and safety of all employees. In terms of biosafety, the Office of Laboratory Security under Health Canada has developed the Laboratory Biosafety Guidelines (2004) to guide government, industry, university, hospital, and other public health and microbiological laboratories in their development of biosafety policies and programs. The guidelines can also serve as a technical document for recommended standards or statements that derive from legislation. Guidelines are self-imposed rules but, are developed to achieve government policy objectives. Following the guidelines is in line with the internal responsibility system promoted by the Act. As such, the Concordia Biosafety manual is based on these guidelines as well as good laboratory practices.

a) Risk Groups In many countries, infectious agents are categorized into risk groups based on their relative risk. Health Canada has published these traditional risk groups in their Laboratory Biosafety Guidelines (2004) manual. There are four risk groups used to categorize the relative hazards of infective organisms based on their particular characteristics, such as:

Pathogenicity Infectious dose Mode of transmission Host range Availability of effective preventive measures Availability of effective treatment

The four risk groups are as follows: Risk Group 1, is a low individual and community risk. These agents will unlikely cause disease in healthy workers or animals. Risk Group 2, is a moderate individual risk and low community risk. These agents are pathogens but are unlikely to be a serious hazard to laboratory workers, the community, livestock or the environment. Effective treatments and preventive measures are available and the risk of spread is limited. Risk Group 3, is a high individual risk and low community risk. These pathogens can cause serious human disease or serious economic consequences but do not

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ordinarily spread by casual contact. Disease will be treatable by antimicrobial or antiparasitic agents. Risk Group 4, is a high individual risk and high community risk. These pathogens produce very serious human disease and are readily transmitted between individuals or from animal to human or vice-versa, directly or indirectly or by casual contact. For more detailed information on the risk groups refer to the Office for Laboratory Security website: http://www.phac-aspc.gc.ca/ols-bsl/lbg-ldmbl/index.html

b) Containment Levels Risk group classifications do not take into account the procedures and manipulations occurring in a laboratory. As such, Health Canada has developed a system of containment levels. The term "containment" is used to describe safe methods for managing infectious agents in the laboratory environment. The purpose of containment is to reduce or eliminate exposure of laboratory workers, other people, and the outside environment to potentially hazardous agents. Containment levels are assigned to establish the safe methods and requirements for handling materials safely in a laboratory. There are two types of containment: primary and secondary. Primary containment is for the protection of personnel and the immediate laboratory environment from an exposure to infectious agents. Primary containment includes both good microbiological techniques and the use of appropriate safety equipment such as biosafety cabinets. Secondary containment is the protection of the environment external to the laboratory. Secondary containment is provided by a combination of facility design and operational practices. The containment system takes into account the pathogenicity of organisms, the facility’s design, lab procedures and practices, and the use of appropriate safety equipment. At Concordia, EH&S will assign the containment levels following a thorough risk assessment (refer to section (c)), in accordance with Health Canada guidelines. The four Health Canada containment levels are described below: Containment Level 1 (CL1) is for basic laboratories. CL1 labs do not require special design features, work can be done on an open bench top using basic microbiology laboratory practices. Biological Safety Cabinets (BSCs) are not required. According to the Health Canada guidelines, general practices are

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required for all laboratories handling infectious substances, please refer to Appendix A.

Containment Level 2 (CL2) applies to laboratories using agents whose primary route of exposure is by ingestion, inoculation, or through mucous membranes. Agents requiring CL2 are not generally transmitted by airborne routes but care should be taken to avoid the generation of aerosols and splashes. General practices recommended by Health Canada are found in Appendix A as well as the recommendations for CL2. Containment Level 3 (CL3), applies to laboratories using agents that may be transmitted by the airborne route and that often have a low infectious dose to produce effects and can cause serious or life-threatening disease. Concordia does not have any such facilities at the moment. Any Principal Investigator wishing to use such agents should contact the EH&S office. Containment Level 4 (CL4) is the maximum containment and requires very specific facilities and containment. CL4 is not presently feasible at Concordia.

c) Risk Assessment A risk assessment is a critical step in the assignment of an appropriate containment level. A risk assessment will be done by the EH&S office in consultation with the Concordia University Biosafety Committee (CUBSC). New research projects should undergo a risk assessment (refer to Chapter 1, section d) Project registration) and obtain approval. The Principal Investigator must also prepare a document outlining safe operational practices and procedures (SOP) describing in details the procedures involved with the agent(s). The following factors are considered and evaluated during a risk assessment:

1. The organism(s) risk group(s). 2. The potential for aerosol generation 3. Quantity and concentration being used 4. The agent’s stability 5. The manner in which the agent is used (e.g. in vitro, in vivo) 6. Use of recombinant organisms

d) Transportation, importing and exporting

Transportation

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The transportation of infectious substances within Canada is administered through Transport Canada and regulated by the Transportation of Dangerous Goods Regulations (SOR/85-77). The regulation defines the labelling, packaging and documentation requirements. Individuals transporting an infectious substance must be trained in the transportation of dangerous goods. Information is available on the Transport Canada website: http://www.tc.gc.ca/tdg/clear/menu.htm Air transportation of infectious substances internationally is regulated by the International Civil Aviation Organization (ICAO). The ICAO regulations define the labelling, packaging, and documentation requirements necessary for international shipping by air. Shipping infectious substances by air is also regulated by the Dangerous Goods Regulations (DGR) of the International Air Transport Association (IATA). For more information: International Civil Aviation Organization (ICAO): http://www.tc.gc.ca/civilaviation/commerce/dangerousgoods/menu.htm International Air Transport Association (IATA) www.iata.org

Importing Human Pathogens: According to the Human Pathogens Importation Regulation (SOR/94-558), Principal Investigators wishing to import a human pathogen requiring a containment level 2, 3 or 4 facility must have a valid Health Canada permit before importation. Pathogens requiring containment level 1 facilities do not require an importation permit. Laboratories importing containment level 2 pathogens must be approved and inspected by EH&S; the requirements and inspection are subject to verification by Health Canada inspectors. Laboratories wishing to import containment level 3 pathogens require a Health Canada certification; contact EH&S for more information. The application to import human pathogens into Canada must be submitted to the Office of Laboratory Security, Public Health Agency of Canada. After evaluation and approval by the Office of Laboratory Security, an importation permit will be issued which must accompany the shipment of the pathogen into Canada. A single- or multiple-entry permit will be issued according to the particular situation. Permits generally require five working days. The permit application can be obtained by contacting:

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Office of Laboratory Security 100 Colonnade Road, Loc.: 6201A OTTAWA ON K1A 0K9 Telephone: (613) 957-1779 Facsimile: (613) 941-0596 Or through the website: http://www.phac-aspc.gc.ca/ols-bsl/pathogen/howto_e.html

Animal Pathogens: The Canadian Food Inspection Agency (CFIA) and Biohazard Containment and Safety Unit (BCS) regulate the importation of animal pathogens under the Health of Animals Act. Permits are required for the importation of all animal pathogens into Canada. An application to import animal pathogens into Canada must be made to the CFIA. After evaluation and approval, an import permit will be issued which must accompany the pathogen into Canada. A single- or multiple-entry permit will be issued according to the particular situation. The import permit will specify the conditions under which the pathogen is to be maintained and work is to be carried out. Laboratories must meet the conditions outlined in the Containment Standards for Veterinary Facilities. The importation of agents of zoonotic or communicable diseases common to humans and animals also requires application to Health Canada under the Human Pathogens Importation Regulations (Please refer to the human pathogen section). The form Application for Permit to Import must be completed and signed by the applicant. Applicants are also required to submit the application form for Facility Certification for the Importation of Animal Pathogens, which must be signed by both the applicant and the institutional safety officer.

Application for Permit to Import: http://www.inspection.gc.ca/english/for/pdf/c5083perimpe.pdf

Facility Certification for the Importation of Animal Pathogens: http://www.inspection.gc.ca/english/for/pdf/c5083apaze.pdf

Exporting: Certain goods and technology and certain destinations, require a federal export permit from the Export Controls Division of the Department of Foreign Affairs and International Trade (DFAIT) before they can legally be exported. DFAIT controls certain toxicological and biological agents as well as their related equipment, components, materials, and technology. A variety of specific goods and

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technology, controlled by the Department of Foreign Affairs and International Trade (DFAIT) require permits for export, regardless of their destination. These goods and technologies are found on the Export Control List (ECL): http://laws.justice.gc.ca/en/E-19/SOR-89-202/index.html or http://www.dfait-maeci.gc.ca/trade/eicb/military/documents/exportcontrols2003-en.pdf Export permits are obtained through DFAIT and require approximately ten working days. The application form is available through the website or any International Trade Centre offices: Application for Permit to Export Goods: http://www.dfait-maeci.gc.ca/trade/eicb/forms/documents/EXT1466.pdf e) Controlled Goods Directorate program The Controlled Goods Directorate (CGD) is a Federal Government agency which administers the Controlled Goods Program (CGP) on behalf of the Department of Public Works and Government Services Canada (PWGSSC). The objective of the CGP is to safeguard controlled goods and technology within Canada and prevent these from being accessed by unauthorized persons. Persons possessing, examining or transferring controlled goods within Canada, or seeking to export controlled goods, must be registered with the CGD. 'Persons' for the purpose of registration are businesses or companies, as defined under the Controlled Goods Regulations (CGR). Concordia University is registered with the CGD; therefore, any Concordia employee, student or visitor involved with Controlled Goods must have security clearance and an approved security plan. Authorization to possess, examine or transfer Controlled Goods must be requested from the Designated Official, currently Dr. Robert Roy, Vice-Provost, Academic Facilities at extension 2087. For the purpose of the CGP, the goods and/or technologies described in Group 2, Group 5 (item 5504 only) and Group 6 of the Export Control List (ECL) published by International Trade Canada are considered controlled. For information about the CGP and link to ECL, please consult the following website: http://www.cgd.gc.ca/cgdweb/text/about/about_e.htm

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f) Medical surveillance The need for medical surveillance will be determined by the risk assessment process of the laboratory and the infectious agents used. Students who work with blood and human tissue in the lab are at increased risk of Hepatitis B virus infection. Hepatitis B vaccine is free for students who work with blood and human tissue. Those who have already been vaccinated should get a blood test to make sure they are protected. The vaccine is available at Concordia Health Services. Please contact Stephanie Johnston, nurse, at Health Services for more information about the vaccine or testing to see whether you are protected.

Chapter III

Laboratory Practices and Biological Safety

a) Handling infectious substances Safe operational practices and procedures

The most important element of containment and of working safely is to adhere to standard microbiological practices and techniques. Prudent practices and good technique are based on sound technical knowledge, experience, common sense and an attitude of courtesy and consideration for others. These are detailed in the "Standard Microbiological Practices" of the CDC-NIH Biosafety in Microbiological and Biomedical Laboratories and the NIH Guidelines for Research Involving Recombinant DNA Molecules, in the National Research Council’s Biosafety in the Laboratory - Prudent Practices for the Handling and Disposal of Infectious Materials (National Academy Press, Washington, D.C., 1989), and in many laboratory safety text and reference books. At a minimum, the Seven Basic Rules of Biosafety (based on NRC Prudent Practices) should be the basis of any personal laboratory work ethic:

• Manipulate infectious fluids carefully to avoid spills and the production of aerosols and droplets.

• Restrict the use of needles and syringes to those procedures for which there are no alternatives; use needles, syringes and other "sharps" carefully to avoid self-inoculation; and dispose of sharps in leak- and puncture-resistant containers.

• Use protective laboratory coats, gloves, and eye protection.

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• Wash hands following all laboratory activities, following the removal of gloves, and immediately following contact with infectious materials.

• Decontaminate work surfaces before and after use and immediately after spills.

• Do not mouth pipette. • Do not eat, drink, store food, apply cosmetics, or smoke in the laboratory.

Other prudent practices to consider are that plastics should replace glass and sharps wherever possible. Only laboratory grade (borosilicate) glass should be used, and any article that is chipped or cracked should be discarded. Hypodermic needles must only be used for parenteral injection and aspiration of fluids from laboratory animals. Procedures which may produce aerosols should be performed in a BSC. Consult Appendix A for the Health Canada general operational practices for laboratories handling infectious substances. Each laboratory should develop safe operational practices and procedures (SOPs) in writing that identify the hazards that will or may be encountered, and that specifies practices and procedures designed to minimize or eliminate exposures to these hazards. Staff and students must be advised of special hazards and should be required to read and follow the required practices and procedures. The Principal Investigator/Researcher is responsible for the conduct of work with any infectious agents or material. When standard laboratory practices are not sufficient to control the hazards associated with a particular agent or laboratory procedure, additional measures may be needed. The Principal Investigator/Researcher is responsible for selecting additional safety practices which are in keeping with the hazards associated with the agent or procedure.

WHMIS Most labs using biohazardous materials will also use chemicals. As such, WHMIS regulations are applicable. WHMIS is established through the Controlled Products Regulations which is a national standard for the classification of hazardous workplace materials. WHMIS is implemented through coordinated federal, provincial, and territorial legislation. Supplier labelling and MSDS requirements are set out under the Hazardous Products Act and associated Controlled Products Regulations. The Hazardous Products Act and its regulations are administered by the Government of Canada Department of Health (Health Canada).

WHMIS consists of three key elements: 1) Material Safety Data Sheets (MSDS) 2) Labels

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3) Education/Training

Everyone working in the laboratory, including the Principal Investigator, should take part in the Concordia WHMIS course, offered in person or via the web. Additionally, the Principal Investigator should provide laboratory hazard specific WHMIS training and ensure the following:

• Up-to-date MSDS for all hazardous materials must be available in the laboratory. MSDS should be updated every 3 years.

• Containers of hazardous materials are to be labelled according to WHMIS legislation.

• All individuals working with, or in close proximity to, hazardous materials should receive the University WHMIS training and/or site specific WHMIS training.

MSDSs for infectious substances are available on the Health Canada website. These MSDSs are produced for personnel working in the life sciences as quick safety reference material relating to infectious micro-organisms: Infectious substances MSDS: http://www.phac-aspc.gc.ca/msds-ftss/index.html

b) Human blood and body fluids Concordia University requires that research or work involving human blood/body fluids and tissues be issued a Biosafety Certificate from the EH&S office prior to the initiation of work. Laboratory practices should be followed on the assumption that all human blood, body fluid and tissues are infectious. As such, Universal Precautions from the Centers for Disease Control (CDC) and National Institutes for Health (NIH) should be followed. The containment level will be determined by EH&S based on the laboratory methods and practices. Universal Precaution standards should also be applied to work with human cells in culture and human serum derived reagents. Bloodborne Pathogens: According to the Centers for Disease Control (CDC) and National Institutes for Health (NIH,) bloodborne pathogens refer to pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Additionally, “Other Potentially Infectious Materials” (OPIM) are included under this standard. OPIM means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva

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in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine and vomitus unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood.

Universal Precautions

“Universal Precautions”, as defined by CDC, are a set of precautions designed to prevent the transmission of bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids are considered potentially infectious for HIV, HBV, and other bloodborne pathogens. However, universal precautions are not only applicable in a health care setting but are also recommended for laboratory workers. Bloodborne disease transmission occurs when an agent enters a person’s general blood circulation. This can be through direct blood-to-blood or indirect, such as infected needle, transmission. Other routes could be via the mucous membranes of the eye, nose or mouth or through breaks in the skin, which can be a result of simple dermatitis, acne, cuts, abrasions or hangnails. Universal precautions recommend using personal protective equipment when handling blood and other fluids mentioned above as well as following prudent laboratory and microbiological practices and common sense as outlined in Appendix B. For more information, consult the CDC website: http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html

Tissue and cell cultures The potential laboratory hazards associated with human cells and tissues include the bloodborne pathogens HBV, HCV, and HIV, as well as agents such as Mycobacterium tuberculosis that may be present in human lung tissues. Other primate cells and tissues also present risks as do cells transformed with viral agents such as SV-40, EBV, or HBV, cells carrying viral genomic material and

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tumorigenic human cells. All these are potential hazards due to the possibility of self-inoculation. Cultured cells which are known to contain or be contaminated with a biohazardous agent (e.g. bacteria or virus) must be assigned the same containment level as the agent. Cell lines which do not contain human or animal pathogens are generally assigned containment level 1. The following list contains cells that should be considered containment level 2:

1. Cells from blood, lymphoid cells, and neural tissue (primate) 2. All primary cell lines (human or primate) 3. Secondary (immortalized) cell lines originating from lymphoid cells or neural tissue 4. Cell lines exposed to or transformed by a human or primate oncogenic virus 5. Pathogen deliberately introduced or known endogenous contaminant 6. Fresh or frozen tissue and all cultured cells new to the laboratory until proven to be free of infectious agents.

All work should be performed in a biosafety cabinet, and all material should be treated as biohazardous. All human blood, blood products, unfixed human tissue, and certain body fluids should be reviewed by EH&S to determine the containment level. Please note that this list is not all-inclusive and individual cases should be evaluated by EH&S as they occur Fixed tissues and tissue sections from human and animal sources that are fixed by treatment with chemical agents should be handled under containment level 1 conditions. Generally, these chemical treatments inhibit all biological activity. Most, but not all, intracellular and intercellular biological agents are inactivated during this treatment. A notable exception is the group of unconventional agents known as ‘prions’. A higher level of containment may be required depending on the source of the material, the nature of the agent, and whether or not it is inactivated.

c) Recombinant DNA In the context of the NIH Guidelines, recombinant DNA molecules are defined as either: (i) 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 (ii) molecules that result from the replication of those described in (i) above. Synthetic DNA segments which are likely to yield a potentially harmful polynucleotide or polypeptide (e.g., a toxin or a pharmacologically active agent) are considered as equivalent to their natural DNA counterpart. If the synthetic

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DNA segment is not expressed in vivo as a biologically active polynucleotide or polypeptide product, it is exempt from the NIH Guidelines. Guidance available to assess potential risks is very general and usually assessed on a case by case basis. However, according to the Health Canada guidelines the following factors should be considered when determining the containment level of a recombinant organism:

1. the containment level of the recipient organism 2. the containment level of the donor organism 3. the replication competency of the recombinant organism 4. the property of the donor protein to become incorporated into the

recombinant particle 5. potential pathogenic factors associated with the donor protein

Some genetic manipulation raise significant possibility of risk and as such each case will need to have its own risk assessment. However, when the source of the DNA being transferred, the vector, and host are all innocuous, the possibility of hazard is remote.

d) Environmental samples Environmental samples, such as water, air, or earth, may contain pathogens and present a hazard to people, animals, or the environment. Environmental samples should be collected using appropriate personal protective equipment. A complete risk assessment will be required to assign the containment level of a sample. Techniques used to enhance and/or culture environmental samples may require containment level 2, such as a biological safety cabinet or fume hood. A sterilized environmental sample may be manipulated under containment level 1. Research involving environmental samples must be registered with the EH&S Office.

e) Animals All aspects of the proposed use of animals in research and the operational procedures for the care and maintenance of animals must satisfy the Guidelines for the Care and Use of Experimental Animals of the Canadian Council on Animal Care. The biosafety level assigned to experiments on animals infected with biohazardous agents will be given the same level as work done with the infectious agent alone.

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The University requires that all Principal Investigators and students who intend to conduct research, testing, or teaching projects involving animals obtain the approval of the University Animal Care Committee before commencing the project. The Principal Investigator must submit the Animal Use Protocol Form which is available through the Office of Research: http://oor.concordia.ca/download/ausf_form.pdf

f) Transporting on campus Transporting biohazardous materials between connected buildings or between labs require safe handling procedures. Precautions must be taken to reduce the risk of spills or leaks. The following precautions are recommended to reduce the risk of breakage and contain the materials in the event of leak or spill.

• Place materials in a leak proof and breakage-resistant container, use screw caps whenever possible.

• Transport the materials on a cart or a handheld carrier bucket. • Use a secondary container with the ability to hold the volume of the

material in the event of a leak or spill. • Freight elevators must be used for moving chemicals and biological

materials. Passenger elevators must never be used for this purpose.

Chapter IV

Safety Equipment

a) Laboratory ventilation General ventilation is used to dilute indoor air contaminants. General ventilation also maintains comfort parameters of temperature, humidity, and air circulation for occupants. The ventilation system is balanced to maintain laboratories under negative pressure relative to adjacent areas (i.e. more air is exhausted than supplied in order to prevent contamination of adjacent areas). However, because the general air supply is not adequate for manipulating hazardous materials on an open lab bench, volatile, corrosive, flammable, odoriferous, toxic, or other dangerous materials should be handled in a chemical fume hood or other appropriate containment device. Concordia Laboratory general ventilation has been set with the following parameters:

Daytime: Occupied labs: 10 air changes per hour

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7AM-11PM Non-occupied: 6 air changes per hour after 15 min without movement

Nighttime: Occupied labs: 10 air changes per hour upon movement

detection Non-occupied teaching labs: 3 air changes per hour Non-occupied research labs: 6 air changes per hour Certain biological agents should only be used in certified biological safety cabinets. The need for a biosafety cabinet will be evaluated during the risk assessment of the research project.

b) Biological safety cabinets Biological safety cabinets (BSCs) reduce the risk of exposure by preventing the escape of biohazardous agents into the laboratory environment. Biological safety cabinets are an effective primary containment for work with human pathogens. BSCs should be used for procedures that potentially produce infectious aerosols and those with high concentrations or large volumes of infectious material. The addition of natural gas to BSCs is not recommended. An open flame in the cabinet can create turbulence, disrupt airflow patterns and can damage the HEPA filter. An alternative is the use of a touch-plate microburner equipped with a pilot light to provide a flame on demand. Classes: There are three classes of BSCs, each providing different levels of containment. Horizontal laminar flow clean benches are not biological safety cabinets and must not be used for handling infectious, toxic, or sensitizing materials. Laminar flow clean benches provide product protection only and are used for the assembly of sterile apparatus or computer parts. Class I Cabinets

• Unrecirculated airflow to protect workers • Air is exhausted to the outdoors through a HEPA filter • Do not protect the material from contamination

Class II, Type A1

• Designed for worker, product, and environmental protection • Provides a “sterile” work area • Air may be recirculated back into the lab or ducted out • Average face velocity of 0.38 m/s (75 ft/min) • Not suitable for work with volatile toxic chemicals and radionuclides

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Class II, Type A2

• Designed for worker, product, and environmental protection • Air may be recirculated back into the lab or ducted out • Average face velocity of 0.5 m/s (100 ft/min) • Suitable for work with minute quantities of volatile toxic chemicals

Class II, Type B1

• Designed for worker, product, and environmental protection • Hard ducted to the outside, no recirculation into the lab • Average face velocity of 0.5 m/s (100 ft/min) • Recirculates 30% of the air within the cabinet • Suitable for work with low levels of volatile toxic chemicals and trace

amounts of radionuclides

Class II, Type B2 • Designed for worker, product, and environmental protection • Hard ducted to the outside, no recirculation into the lab • Average face velocity of 0.5 m/s (100 ft/min) • Does not recirculate air within the cabinet • Suitable for work with volatile toxic chemicals and radionuclides

Class III

• Enclosed and gas-tight with HEPA filtered supply and exhaust air • Designed for work with level 4 pathogens

Safe use of cabinets: Staff and students required to use BSCs must be trained in its correct use. Health Canada (2004) offers the following good practices: Start-up procedures:

1. Turn off UV lights if in use and ensure that the sash is in the appropriate position (UV must be turned off when people are working close by).

2. Turn on fluorescent light and cabinet blower, if off. 3. Check the air intake and exhaust grilles for obstructions. 4. If the cabinet is equipped with an alarm, test the alarm and switch it

to the “on” position. 5. Confirm inward airflow by holding a tissue at the middle of the edge

of the viewing panel and ensuring that it is drawn in. 6. Disinfect the interior surfaces with a suitable, non-corrosive

disinfectant. 7. Assemble all materials required for the procedure and load them

into the cabinet; do not obstruct the air grilles. The working surface can also be lined with absorbent paper with plastic backing.

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Designate separate areas; clean items should be segregated from contaminated items.

8. Wait 5 minutes to purge airborne contaminants from the work area. Working in the cabinet:

1. Put on the necessary personal protective equipment (PPE). 2. Perform operations as far to the rear of the work area as possible. 3. Avoid movement of materials or excessive movement of hands and

arms through the front access opening during use; enter straight on to reduce air turbulence; allow the cabinet to stabilize before continuing work.

4. Keep discarded and contaminated material at the rear of the cabinet; do not discard materials in containers outside of the cabinet.

5. Do not work with open flames inside the cabinet. 6. If there is a spill during use, surface decontaminate all objects in

the cabinet; disinfect the working area of the cabinet while it is still in operation.

Shut-down procedures:

1. Allow the cabinet to run for 5 minutes without activity. 2. Close or cover all open containers before removing them from the

cabinet. 3. Disinfect the surface of objects that were in contact with

contaminated material before removing them from the cabinet. 4. Remove contaminated gloves and dispose of them appropriately;

wash hands. 5. Put on clean gloves, and ensure that all materials are placed into

biohazard bags within the cabinet. 6. Using a suitable non-corrosive disinfectant (i.e. 70% ethanol),

disinfect interior surfaces. 7. Turn off the fluorescent light and cabinet blower when appropriate

(some cabinets must remain on at all times). 8. Turn on the UV light if appropriate (when using at a germicidal

wavelength). Maintenance and certification: BSCs should be installed and then certified annually in accordance with CSA standards. Testing and recertification is also necessary when cabinets are moved or following maintenance or a filter change. Annual certification can be arranged by contacting the Purchasing Department and EH&S.

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c) Fume hoods Procedures involving volatile chemicals and those involving solids or liquids that can result in the generation of toxic aerosols should be conducted in a fume hood and not on an open bench. Fume hoods should be evaluated before use to ensure adequate face velocities. A face velocity of 100 ft/min should be displayed on the side monitor. Generally, fume hoods are inspected and calibrated annually by Facilities Operations. Contact the Service Centre at extension 2400 for any maintenance concerns. For a fume hood to protect laboratory personnel from exposures to hazardous materials, they must be used properly. For a printable fume hood how-to information sheet refer to: http://web2.concordia.ca/EHS/pdf/hm/safework.fumehoods.e.pdf d) Laboratory equipment (sonicators, vortex mixers) The use of equipment that has the potential to produce aerosols must be considered and controlled. Equipment such as vortex mixers should be of the closed type to avoid dispersion of droplets and aerosols. The waste matter should be collected in closed vessels for further autoclaving and/or disposal. All equipment should be disinfected at the end of each session, following manufacturers’ instructions.

e) Personal protective equipment The following personal protective equipment (PPE) must be available for laboratory personnel and students who are working with hazardous materials. Laboratories must provide the necessary personal protective equipment in accordance with the risk. Visitors must wear a laboratory coat and safety glasses. It is recommended to post a sign indicating that eye protection is required where hazardous materials are in use. The EH&S office can assist with recommendations on specific types and uses of protective equipment. Types of PPE that may be required:

• Eye and face protection: Eye and face protection must be worn in the laboratory when there is a potential for contact with hazardous chemicals or other agents such as biohazardous materials and aerosolized material. The type of protection will depend on the hazard; when chemicals are used, approved eye protection is mandatory and chemical splash goggles are recommended. Goggles should be worn over

EHS/SCC/2006 26

eyeglasses or prescription safety glasses with side shields should be worn. Ordinary prescription glasses do not meet these standards. Face shields should be worn when working with an agent that may adversely affect the skin on the face and/or when proper eye protection is not enough.

• Laboratory coats, gloves and other protective clothing: Laboratory coats and closed shoes should be worn when performing laboratory work (open toed-shoes, sandals, flip-flops, clogs, etc. are prohibited). Gloves are also necessary and should be replaced immediately when they are contaminated or torn. Gloves should be carefully selected for their degradation and permeation characteristics to provide proper protection. When working with chemicals, consult the MSDS or the chemical compatibility information that is provided in the manufacturer's catalogs to help you select the proper gloves and other protective clothing. PPE worn inside the lab should not be worn in public areas since all contaminated, potentially contaminated, or the perception of potentially contaminated protective clothing and equipment beyond the lab may create a hazard or project a careless image to both colleagues and visitors.

• Good practices: • Wearing gloves outside the lab should be minimized, except to move hazardous

materials between laboratories. • Gloves should never come in contact with door handles, elevator buttons,

telephones, lavatory faucets, vending machines, bottled-water dispensers, ice making machines, or other surfaces outside the laboratory.

• For the sake of safety, appearances, and courtesy, contaminated, stained, or potentially contaminated lab coats and other research clothing should not be worn outside of the laboratory.

• Chemicals should be transported using a cart or in a bottle carrier with secure handles.

Additional good practices and safety rules can be found in (Appendix A).

Chapter V

Decontamination Decontamination is considered a procedure in the containment barrier to prevent occupational exposure to infectious agents and/or the accidental release of agents. Each laboratory must ensure that materials, equipment, surfaces, rooms, and samples from containment zones are properly decontaminated.

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Decontamination can be achieved by either sterilization or disinfection. Sterilization results in the destruction of all microorganisms, including bacterial spores. Disinfection results in the destruction and removal of specific types of microorganisms on inanimate objects. The choice of the method for decontamination will depend on the nature of the material to be treated. Such materials may include, but are not limited to, equipment, clothing, cultures, and bench tops. Decontamination procedures should be part of all laboratory SOPs and laboratory staff and students must be trained in these procedures. For more disinfection information and product description and comparison see the AIHA website: http://www2.umdnj.edu/eohssweb/aiha/technical/biosafety.htm#Disinfection

a) Autoclaves Autoclaves are effective for the decontamination of biohazardous waste and for sterilizing equipment, glassware, media, and liquids. The effectiveness of decontamination will depend on a number of factors. Temperature and contact time will be determined by how the autoclave is loaded. Steam must contact pathogens in order to destroy them therefore, longer times are needed for larger loads, large volumes of liquid, and denser materials. Autoclaving safety tips:

• Loosen the caps on bottles and tubes. • Bottles with liquids should not be filled more than ¾ full. • Use suitable wrappings when sterilizing clean equipment for reuse. For

example, a complete cover of aluminium foil will not allow the steam to penetrate.

• Waste to be autoclaved should be placed in an orange autoclave bag. The autoclave bags should be placed in a rigid, leak-proof container.

• Avoid spilling liquids in the autoclave chamber. Autoclave bags containing liquids should be placed in Nalgene tubs prior to autoclaving. These shallow tubs are preferable to buckets because the air can be displaced more efficiently.

• Do not seal autoclave bags before autoclaving. If they are closed too tightly, steam will not be able to penetrate.

• Containers that must be tightly closed prior to autoclaving should include additional water to serve as a source of steam to ensure sterilization.

• Autoclave bags should not contain any chemicals, which would evaporate thereby creating hazardous vapours.

• Contaminated Pasteur pipettes must be placed in a puncture-proof “sharps” container.

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b) Chemical disinfection Chemical disinfectants are used for the decontamination of surfaces and equipment that cannot be autoclaved, such as reusable glassware, specimen containers, and spill clean-up. The choice of disinfectant will depend upon the resistance of the microorganisms, practicability, stability, compatibility with the materials, and the health hazards. For more disinfection info and product description and comparison see the AIHA website: http://www2.umdnj.edu/eohssweb/aiha/technical/biosafety.htm#Disinfection

c) Waste handling procedures Hazardous biological waste includes any biological material that, if handled improperly, has the potential to infect and cause harm to persons, animals, or plants. Examples are: human body parts, tissues, blood or blood products, body fluids, cell cultures, spent medium derived from human tissue, animal carcasses, tissue samples, blood, or body fluids from animals. Autoclave waste: Autoclaves are ideal for decontaminating biohazardous

waste prior to disposal with other refuse. Materials such as culture dishes can be autoclaved and disposed of with the regular garbage. Autoclaves are managed by the Biology Department. For more information on autoclaves, contact the Biology Department x3400.

Biohazardous waste that cannot be autoclaved must be disposed of in the designated plastic biohazard containers. These containers are available by contacting the EH&S office at x4356 or by ordering on-line: http://web2.concordia.ca/EHS/hm/wasteform.html.

Contaminated sharps are also collected in the same manner, which include:

- Needles and syringes - Scalpel and razor blades - Clinical glass such as Pasteur pipettes - Any other clinical items that are capable of puncturing

Animal carcasses must be placed in bags that are then stored in the

designated bio-hazardous freezer located in SP-S231-5. Before placing the animals in the bio-hazardous freezer, they should be weighed and the data logged into the appropriate logbook located near the freezer. For more

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information or if the logbook cannot be located, please contact Eric Ambroise, Hazardous Materials/Lab Safety Technician at extension 4356.

Mixed waste - If sharps are contaminated with a mixture of hazardous

components, treat them as follows: - Biohazardous and hazardous chemicals - chemically disinfect the biohazardous agent if possible but do not autoclave and consider as a chemically contaminated sharp. - Biohazardous and radioactive to be disposed as radioactive sharps. - Biohazardous, radioactive, and hazardous chemical should be disposed of as radioactive sharps.

In order to protect lab personnel, as well as the cleaning staff, all broken glass should be disposed of in plastic containers that are clearly marked "BROKEN GLASS". These containers will be emptied by the cleaning staff. To order broken glass containers, contact the Service Centre at x2400.

Chapter VI

Laboratory decommissioning Laboratories working with biological materials should notify the BSO prior to stopping operation in order to ensure that the laboratory has been decontaminated and that all biological materials have been secured or properly disposed of. A walkthrough of the lab can be performed by the BSO and the PI to provide recommendations on the final termination of the biohazardous work in the lab. The BSO will advise the CUBSC and a final lab decommissioning inspection can then be scheduled accordingly. General lab close-out procedures: Biosafety cabinets should be decontaminated with paraformaldehyde and the

outer surfaces cleaned with a suitable disinfectant. BSC paraformaldehyde decontamination must be done by a certified professional.

Storage freezers should be emptied and the contents properly disposed according to waste procedures. Storage freezer surfaces must be decontaminated with a suitable disinfectant.

All biohazardous labels and signage must be removed from surfaces. The outer surface of all equipment and any work surface must be decontaminated with a suitable disinfectant.

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Chapter VII

Emergencies and incident reporting

a) Incident/accident/hazard reporting procedures There are specific reporting procedures at the University, as required by the Act Respecting Occupational Health and Safety and the Act Respecting Industrial Accidents and Occupational Diseases and their regulations. All incidents, accidents, workplace exposures to infectious material, or suspected occupational diseases must be reported to the EH&S office. Forms should be available in each lab or from the EH&S office or on-line. The reports assist in determining the cause of the incidents/accident and in developing measures for preventing recurrence. Hazards can also be reported using this form for the EH&S office to investigate these hazards in order to prevent an incident/accident.

As such, please ensure that everyone working in the laboratory is aware that accidents, incidents, and hazards should immediately be reported to EH&S.

For more information on incident reporting:

http://web2.concordia.ca/EHS/about/answers/faq.procedures1.shtml

To download the incident report form:

http://web2.concordia.ca/EHS/pdf/in/injury.incident.rept.form.e.pdf

b) Spill response Because hazardous materials are used in laboratories, studios, workshops, and service areas, a spill or accidental release may occur anywhere in the University. The University maintains an emergency response policy and procedures for the management of spills or accidental release of hazardous materials, and ensures that these comply with all federal, provincial, and municipal legislation concerning occupational health and safety, and the protection of the environment. Please note that all large spills must be reported immediately to Security by dialing 811. Minor spills: Spill response procedures for minor spills can be established in the laboratory as part of the SOP following the risk assessment of the pathogen(s) in use. As

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such, the proper procedures to deal with biological spills will vary depending on the agent, quantity and location of the spill. To deal with a minor biological spill, laboratories should be equipped with a spill kit. A standard biological spill kit can include: • Concentrated disinfectant, such as chlorine bleach • Packages of paper towels. • Forceps to pick up broken glass. • Household rubber gloves. • Utility gloves. • Several biohazard bags. For spills involving chemicals please refer to the Lab Safety Manual: http://web2.concordia.ca/EHS/pdf/hm/Laboratory_Safety.pdf

c) Biosecurity Biosecurity is the term used for laboratory security and is different from biosafety and laboratory safety. Biosecurity deals with the prevention of theft, misuse, or intentional release of pathogens. A biosecurity plan may be necessary for laboratories using specific agents. According to the Health Canada guidelines, a biosecurity risk assessment should review and list the relevant assets, define the threats, outline the vulnerabilities, and determine the countermeasures or mitigation strategies specific for each facility. The following are aspects to consider:

• Control access to areas where biological agents or toxins are used and

stored and include locked doors. • Restricted access to the laboratory area; knowing who is in the lab and the

personnel suitability/reliability. • Knowing what materials are being brought into the laboratory area;

inventory control. • Knowing what materials are being removed from the laboratory area;

pathogen accountability, inventory control. • Having an emergency plan. • Having a protocol for reporting incidents.

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Appendix A Health Canada general practices for all laboratories handling infectious substances. 1. Documented procedures such as a safety manual must be available for all

staff, students working in the lab. 2. Staff, students working in the lab must receive training on the potential

hazards associated with the work involved and the necessary precautions to prevent exposure to infectious agents and release of material. Training must be documented and signed by both the employee and supervisor with evidence that it was understood.

3. Eating, drinking, smoking, storing of food, personal belongings, or utensils, applying cosmetics, and inserting or removing contact lenses are not permitted in any laboratory. Wearing jewellery is not recommended in the laboratory.

4. Oral pipetting of any substance is prohibited in any laboratory. 5. Long hair should be tied back or restrained to prevent contact with

specimens, containers, equipment or hands. 6. The access to laboratory and support areas should be limited to authorized

students and personnel. 7. Doors must be kept closed and locked (does not apply to open areas within a

laboratory). 8. Any open wound, cut or scratch should be covered with a waterproof

dressing. 9. The storage of materials that cannot be easily decontaminated (i.e. journals,

books) should be kept to a minimum. 10. Laboratory coats must be properly fastened and worn by students, personnel,

trainees, visitors and, others entering or working in the laboratory. Suitable footwear with closed toes and heels must be worn in all laboratory areas.

11. Eye and face protection must be used whenever there is a known or potential risk of exposure to splashes or airborne objects.

12. Gloves must be worn for all procedures that might involve direct skin contact with biohazardous materials or infected animals. Gloves must be removed and hands washed before leaving the laboratory.

13. Lab coats must not be worn in non-laboratory areas; lab coats must be stored separately from street clothing.

14. In the event of a known or suspected exposure, contaminated clothing must be decontaminated before laundering.

15. The use of needles, syringes and other sharp objects should be limited to parenteral infections and aspiration of fluids from laboratory animals and diaphragm bottles. Caution must be used to avoid auto-inoculation and the generation of aerosols during use and disposal. Whenever possible procedures should be performed in a BSC. Needles should not be bent sheared, recapped or removed from the syringe but placed in the designated sharps container.

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16. Hands must be washed after gloves have been removed and, before leaving the laboratory, or any time after handling materials known or suspected to be contaminated.

17. Work surfaces must be cleaned and decontaminated with a suitable disinfectant at the end of the day and after any spill.

18. Contaminated materials and equipment that must leave the laboratory for servicing or disposal must be appropriately decontaminated and labelled.

19. Efficacy monitoring of autoclaves used for decontamination with biological indicators should be done regularly. The records of these results and cycle logs should be kept on file.

20. All contaminated materials, solids, or liquid, must be decontaminated before disposal. Refer to the waste handling procedures in Chapter V section c.

21. Disinfectants effective against the agents in use must be available at all times within the areas where the biohazardous material is handled or stored and must be labelled as such.

22. The transport of infectious materials within a facility must be done in leak-proof containers.

23. Spills, accidents, incidents, or exposures to infectious materials and losses of containment must be reported immediately to the Principal investigator or laboratory supervisor, and to EH&S. Written records of incidents and investigations will be maintained by EH&S.

24. An effective rodent and insect control program is maintained by Facilities Management.

In addition to the above general practices required for all laboratories, the following are the minimum operational practices required for containment level 2: 1. Good microbiological laboratory practices intended to avoid the release of

infectious agents are required of all labs. 2. BSCs must be used for procedures that may produce infectious aerosols and

that involve high concentrations or large volumes of biohazardous materials. These are to be determined following a risk assessment.

3. Appropriate signage must be posted outside each laboratory with the containment level and special entry instructions. Contact information must be available.

4. Entry is restricted and determined by the Principal investigator. The list of authorized individuals must be made available to the Security Department and EH&S. The list shall be updated as required by the Principal investigator.

5. Students and staff working in the containment area must be trained in general biosafety and operational protocols for the projects in process.

6. Emergency procedures for spill clean-up, BSC failure, fire and other emergencies must be written, easily accessible and followed.

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Appendix B

Universal Precautions are derived from prudent laboratory and microbiological practices and common sense and include the following (in no particular order or priority):

• Hands should be washed prior to leaving the facility. • Employees should not shear off, break, bend, recap, or remove contaminated

needles or other sharps for disposal. (Sharps are defined as any sharp object that can puncture or lacerate the skin. This includes hypodermic needles, razor blades, scalpel blades, and Pasteur pipettes, both intact and broken. These materials must be placed in an approved sharps container.)

• The container for storage must be labelled with the universal biohazard symbol and the words "INFECTIOUS WASTE," or "BIOHAZARD WASTE".

• Eating, drinking, smoking, and applying cosmetics are prohibited in work areas where there is reasonable likelihood of an occupational exposure.

• Food and drink must not be kept in refrigerators, freezers, shelves, cabinets, or on countertops where human blood is present.

• All procedures involving human blood must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of aerosols.

• Mouth pipetting or mouth suctioning of human blood, or other biological materials, is prohibited.

• Human blood specimens must be stored, transported, or shipped in a solid container that will not allow the contents to leak out.

• The container for storage, transport, or shipping must be labeled with the universal biohazard symbol as a minimum. The packaging and labeling must conform with all applicable regulations. (Consult the Environmental Health and Safety Office (EH&S) for assistance.)

• If the outside of the primary container becomes contaminated, the primary container must be placed inside a second suitable uncontaminated container.

• Human blood specimens for disposal must be placed in a biohazardous container. • When there is potential for occupational exposure, the Principal Investigator shall

provide and ensure use of, at no cost to the employee, appropriate personal protective equipment (PPE) such as gloves, gowns, laboratory coats, face shields or masks, eye protection, or other safety devices.

• PPE must be used when necessary. • PPE must not permit human blood to pass through to the employee's work or street

clothes, undergarments, skin, eyes, mouth, or other mucous membranes. • If a garment is penetrated by human blood, the garment must be removed as soon

as possible. • All PPE must be removed and placed in the appropriate container prior to leaving the

work area. • Gloves must be worn when the employee may have hand contact with human blood.

Disposable gloves must be replaced immediately if torn or punctured. • Disposable gloves must be disposed of after use; not washed or decontaminated. • Reusable gloves must be decontaminated between uses and discarded if they are

damaged in any way. • Contaminated laundry shall be handled as little as possible with a minimum of

agitation. Contaminated laundry must be placed in a container at the location where it was used and not sorted or rinsed on location. Contaminated laundry must be placed in biohazardous containers or bags.

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• Masks, eye protection, and face shields shall be worn whenever splashes, spray, spatter, or droplets of human blood may be generated and eye, nose, or mouth contamination is anticipated.

• The employee will ensure that the worksite is maintained in a clean and sanitary condition.

• There must be a written schedule for cleaning and method of decontamination. • All equipment and working surfaces shall be cleaned and decontaminated after

contact with human blood. • All contaminated work surfaces shall be decontaminated with a virucidal disinfectant

(such as a 10% solution of household bleach) after completion of procedures, as soon as possible after any spill of human blood, and at conclusion of experiment, if the surface may have become contaminated.

• Plastic wrap, aluminium foil, or other protective coverings used to cover equipment and other surfaces, should be removed and replaced as soon as possible if contaminated.

• All bins, pails, cans, and similar receptacles intended for reuse which may be contaminated, should be inspected and decontaminated on a regular cleaning schedule and when visibly contaminated.

• Broken glassware which may be contaminated shall not be picked up directly by hand but by mechanical means such as brush and dust pan, tongs, or forceps.

• Reusable sharps that are contaminated with human blood shall not be stored or processed in a manner that requires employees to reach by hand into containers where these sharps have been placed.

• Employees who handle contaminated laundry shall wear PPE. • At no time may sharps be discarded in the trash. • Biohazardous bags or containers must be used for all contaminated waste.

Source: Adapted from the University of California, San Francisco

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References Biosafety in microbiological and biomedical laboratories (BMBL), 4th edition. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, and National Institutes of Health. U.S. Government Printing Office, Washington, 1999 (http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm) Control of Biohazards, course manual, Tepper, B.S., Gilpin, R.W. 2004 Laboratory Biosafety Guidelines, 3rd edition. Public Health Agency of Canada, Office of Laboratory Secruity, Ottawa, Canada, 2004 (http://www.phac-aspc.gc.ca/ols-bsl/lbg-ldmbl/index.html). Laboratory Biosafety Manual, 3rd edition. World Health Organization. Geneva, 2004 (http://www.who.int/csr/delibepidemics/WHO_CDS_CSR_LYO_2004_11/en/print.html). Prudent Practices for the Handling and Disposal of Infectious Materials. National Academy Press, Washington, D.C., 1989 Websites: American Industrial Hygiene Association (AIHA): http://www2.umdnj.edu/eohssweb/aiha/technical/biosafety.htm#Biosafety%20Levels Centre for Disease Control (CDC) and National Institute of Health: www.cdc.org www.nih.gov

Health Canada, Workplace Hazardous Materials Information System - Official National Site: http://www.hc-sc.gc.ca/ewh-semt/occup-travail/whmis-simdut/index_e.html Biosafety manuals from various Universities’ were also consulted: McGill University University of Toronto University of New Hampshire University of California, San Francisco