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Environment, Health, & Safety Division

5.0    Specific Biosafety Controls

This section further describes biosafety controls, including safe methods, equipment, and facilities that were generally introduced in Section 4.0 of this manual.

5.1       Work Authorizations

LBNL Job Hazards Analyses (JHAs), Subcontractor Job Hazards Analysis and Work Authorizations (SJHAWAs), and Biosafety Work Authorizations document the definition of work, identification of hazards, risk assessments, and controls. Biosafety Work Authorizations include:

  • Biological Use Authorizations (BUAs),
  • Biological Use Registrations (BURs),
  • Biological Use Notifications (BUNs), and
  • Exposure Control Plans (ECPs).

PIs, work leads, workers, Division Safety Coordinators, and Environment, Health, and Safety (EH&S) Division Biosafety Program personnel have access to their BUAs, BURs, and BUNs through the Biosafety Authorization System (BAS) so that controls may be implemented and authorizations updated. Documentation, review, and authorization of new work should be initiated by filling out the Biological Use Application form. See Section 2.0 of this manual and PUB-3000, Section 26.8, for additional information on these work authorizations.

These work authorizations consolidate and document a wide variety of biosafety requirements and controls to meet various biosafety standards (see standards in PUB-3000, Sections 26.4 and 26.10). For example the BUA is also regarded as:

  • the registration document that must be submitted to the LBNL Institutional Biosafety Committee (IBC) as required by the NIH Guidelines for recombinant work (BURs also document such recombinant work),
  • the laboratory-specific biosafety manual required by Biosafety in Microbiological and Biomedical Laboratories (BMBL) when Biosafety Level (BL) 2 work is performed with Risk Group (RG) 2 agents or materials, and
  • the ECP required by the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens (BBP) Standard when BBP agents or materials are used.

5.2       Training, Instruction, and Qualification

This section describes the requirements and administrative systems for institutional and operation-specific training, information, and instruction based on the biosafety-related standards and LBNL policies summarized in PUB-3000, Section 26.7.8.1.

Work leads, supervisors, and principal investigators are responsible for ensuring their workers have sufficient skills, knowledge, and ability to perform their work safely. This includes understanding of the work, hazards, and controls through technical competence, training, instruction, and a commitment to safety in Integrated Safety Management (ISM) terms. Each worker’s competence must be commensurate with his or her responsibilities. This competence is a major component of biosafety containment and includes both required LBNL courses and sufficient operation-specific information and instruction. These courses, information, and instruction provide workers with awareness of the potential hazards, required training, and proficiency in the practices and techniques required for handling biological materials safely and in accordance with laboratory standard microbiological practices and special practices discussed in Section 4.1.

Work leads must provide or arrange for appropriate training and instruction for each person, including but not limited to the:

  • completion of required LBNL courses specified on all work authorization documents, and
  • job- and operation-specific instruction and information.

5.2.1    Job Hazards Analysis

Supervisors, work leads, and staff must use the JHA or Subcontractor Job Hazards Analysis (SJHA) to define work with biological materials, determine the potential for exposure to biological hazards, and establish biosafety controls for each worker or subcontractor (for more information, see PUB-3000, Chapter 32 and Chapter 31, respectively). The Laboratory-wide JHA identifies workers who work with or have potential exposure to biological materials (e.g., BBP materials). The JHA process is based on each individual’s work and activities. It also lists general controls including any required EH&S courses and Biosafety Work Authorizations for work or activities in which the worker participates.

5.2.2    Training Courses and Tracking

Specific biosafety, biohazardous waste, and occupational health courses are developed and maintained by the EH&S Division to meet requirements that can be fulfilled at an institutional level. LBNL course requirements are presented below and summarized in Table 10. See the EH&S Training Web site for additional course information, to register for a course, or to take an online course.

  • Researchers who work with biological material of any risk level (e.g., microorganisms, cells, cell lines, tissue cultures, recombinant nucleic acids, blood, body fluids or tissues, or animals) must complete EHS0739 (Biosafety for Researchers). In addition, EHS0730 (Medical/Biohazardous Waste) is recommended for anyone who works with biological material, and required for anyone who works with medical or biohazardous waste. Principal investigators (PIs) or other leaders of the work activity who have responsibility for overseeing the biosafety of the research must also complete these courses.
  • Anyone who works with or may be exposed to human blood or blood products or to human materials (e.g., cells, tissues, or fluids) defined by the OSHA Bloodborne Pathogens Standard as other potentially infectious materials (OPIM) (see Section 3.3.4 of this manual for more information) must complete bloodborne pathogen training and EHS0745 (Hepatitis B Medical Surveillance). Researchers must initially complete EHS0735 (Bloodborne Pathogen for Researchers), and nonresearchers must complete EHS0738. Bloodborne pathogen training must be renewed annually by completing EHS0738.
  • Principal investigators (PIs) of non-exempt recombinant research must also complete EHS0749 (PI Recombinant DNA Responsibilities).

 

Table 10
Biosafety-Related Training Courses

Work Exposure or Role

EHS0739 Biosafety for Researchers

EHS0730 Medical/ Biohazardous Waste

EHS0735 Bloodborne Pathogen for Researchers

EHS0738 Bloodborne Pathogen Refresher

EHS0745 Hepatitis B Medical Surveillance

EHS0749
PI rDNA Responsibilities

Researchers who use biological materials of any risk level, generate medical/biohazardous waste, or are PIs or leaders of the work activity

X

X

 

 

 

 

Researchers who use or are exposed to bloodborne pathogen materials

X

X

X

X

X

 

Nonresearchers who use or are exposed to bloodborne pathogen materials

 

 

 

X

X

 

PIs of non-exempt recombinant research

X

X

 

 

 

X

Biosafety training course requirements for each worker are identified through each worker’s JHA, and inclusion in the Personnel and Training sections of the Biosafety Work Authorization in the BAS. Each worker’s course requirements and training status are then displayed in the worker’s Training Profile, JHA Profile, and the Biosafety Work Authorization.

5.2.3    Job-Specific Instruction, Information, and Practices

As discussed above in Section 5.2, supervisors and work leads are responsible for ensuring that workers receive job- and operation-specific instructions. These instructions should include:

  • Individual JHA job duties and controls
  • Hazards and controls in authorization documents including BUAs, BURs, BUNs, and ECPs. Controls in these documents include, for example, standard microbiological practices and special practices customized as needed for the work (see Appendix C of this manual). These authorizations must be available and accessible to each worker so that they can understand the work, hazards, and required controls. Each worker has access to their authorization, registration, and notification through the BAS.
  • Good microbiological practices as needed to perform the work safely (see Section 4.1 and Appendix D of this manual)
  • Incident, accident, and emergency response procedures (e.g., LBNL Emergency Response Guide)
  • Any operation-specific safety procedure

Additional instruction or demonstration of proficiency may be needed for work that involves higher hazards. For example, workers must demonstrate their proficiency in standard microbiological practices and special practices before working with RG2 agents (for more information, see Section 4.1 of this manual).

Labels and signs must also be used to advise workers of hazards and controls (see Section 5.5 of this manual).

5.3       Occupational Health and Immunization

LBNL occupational health and immunization policies, programs, and services are provided by the Health Services Group of the EH&S Division under the direction of the Site Occupational Medical Director. These policies, programs, and services are described in the Health Services Web site, policies (e.g., immunization and serum banking), and Chapter 3 of PUB-3000. The occupational health program related to biosafety is designed to proactively identify and prepare workers who may be exposed to certain biological materials or agents, and provide procedures for the treatment and management of workers who have been injured or may have been exposed. Employees who are aware of personal illnesses that may affect their ability to combat infection or receive medications or vaccines should visit Health Services for an evaluation of how this may affect their individual risk for work with biological agents.

Potential exposures to biological agents or materials that generate health concerns or may cause disease are assessed as part of the work review and authorization process discussed above in Sections 3.0 and 5.1. This assessment includes an evaluation and determination of the need for employee medical evaluations, immunizations, serum banking, or other occupational health controls. For research projects, this assessment is conducted by IBC members including the Biosafety Officer and the SOMD. The IBC review includes SOMD recommendations and is the basis of required or recommended occupational health controls for potentially exposed employees. These controls are then documented in the Biosafety Work Authorization.

 
Employee consultation with LBNL Health Services. Source: LBNL EH&S.

Requirements or recommendations for occupational health controls (e.g., vaccinations) for specific agents or materials are discussed in BMBL, Section VIII (Agent Summary Statements). Requirements for BBP materials are provided by the OSHA Bloodborne Pathogens Standard. OSHA requirements and LBNL programmatic policies and systems for implementing these requirements are summarized below:

  • Hepatitis B Vaccination: The OSHA Bloodborne Pathogens Standard requires that the hepatitis B vaccination series must be made available and offered to all LBNL employees who have occupational exposure to BBPs or materials that are regulated based on their potential to contain BBPs (e.g., human blood, tissues, and cells). This requirement is managed at LBNL by ensuring that workers who are potentially exposed to BBP materials are identified in their BUA or ECP and are required to complete EHS0745 (Hepatitis B Medical Surveillance). Each worker fulfills their hepatitis B surveillance requirement when they: 1) complete the online EHS0745 course; 2) indicate on the course’s integral surveillance form that they have been previously immunized, wish to be vaccinated, or wish to decline the vaccination; and 3) complete any required follow-up process (e.g., get vaccinated or document previous vaccination). When a worker indicates that they have been previously immunized, Health Services will work with them to document their vaccination and document the results of such efforts.
  • Post-Exposure Evaluation and Follow-up: The OSHA Bloodborne Pathogens Standard requires that postexposure evaluations and follow-ups must be made available to all employees who have had an exposure incident. Employees who have had an exposure incident must report their exposure to their supervisor and Health Services in accordance with LBNL’s policies on “Incident Review and Reporting” (see PUB-3000, Sections 5.1 and 26.7.12).
  • Sharps Injury Log: The OSHA Reporting and Recording Occupational Injuries and Illnesses Standard requires a Sharps Injury Log for the recording of percutaneous injuries from sharps contaminated with BBP material (see 29 CFR1904.8). The information in the Sharps Injury Log must be recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The Sharps Injury Log must contain the type and brand of device involved in the incident, the department or work area where the exposure incident occurred, and an explanation of how the incident occurred. This log may be maintained on the OSHA 300 Form, provided that the type and brand of the device causing the sharps injury is recorded, and sharps injury records may be easily separated from other types of work-related injuries and illnesses. LBNL maintains sharps injury information on the OSHA 300 Form in accordance with OSHA regulations. In addition, the LBNL Health Services Group maintains a separate, confidential log containing sharps injury information required by OSHA.

Consult the LBNL Health Services Group ((510) 486-6266), Health Services Web site, and PUB-3000 (i.e., Chapter 3 (Health Services)) for additional information. See Section 5.10.2 of this manual for additional information on worker exposure, injury, and illness reporting.

5.4       Personal Protective Clothing and Equipment

Text Box:

Use of safety equipment including personal protective equipment (PPE) is another element of BL1 and BL2 containment. PPE is clothing or equipment worn by workers to protect the body from injury by hazardous agents or materials. PPE may include foot, hand, eye, face, body, and respiratory protection.

PPE must be used, maintained, and disposed of in accordance with federal regulations, biosafety standards, and LBNL-specific PPE policies to prevent the spread of contamination and accidental infection. LBNL policies related to PPE when working with biological materials are described in this section and the following policy documents:

The PPE section of the Chemical Safety Hygiene Plan (CHSP) should also be consulted regarding PPE requirements and guidelines related to work with chemicals.

The following PPE requirements are related to biosafety:

  • Area-specific PPE requirements must be established for all Technical Areas (e.g., laboratories) and must be posted on the LBNL entrance placard. Minimum PPE for laboratories where biological materials are stored or handled includes safety protective eyewear, long pants, and closed-toe shoes. Area PPE requirements apply to the entire Technical Area unless an exception is granted in accordance with the procedure described in PUB-3000, Chapter 19, Appendix A.
  • Activity- or operation-specific PPE requirements are assessed and defined in the Biosafety Work Authorization, which covers what PPE must be used (e.g., gloves, laboratory coats, and safety glasses) and any maintenance (e.g., laundering) or disposal requirements.

General requirements and conditions for use of PPE related to biosafety include:

  • The supervisor or work lead is responsible for:
    • Determining what PPE is required to prevent occupational exposure
    • Providing at no cost to an employee the PPE required by this section or specified in the Biosafety Work Authorization. This PPE must be readily available in appropriate sizes.
    • Ensuring that employees and visitors properly use and store required PPE
  • The EH&S Division is available to assist supervisors or work leads in evaluating work activities and selecting appropriate PPE.
  • Employees and visitors are responsible for using PPE when required and whenever the work poses a reasonable probability of eye injury or exposure.
  • In general, removed PPE must be:
    • Decontaminated when needed, or
    • Disposed of in accordance with LBNL medical/biohazardous, hazardous, and radiological waste management requirements.
  • PPE that protects against exposure to BBP materials is considered appropriate if it does not permit BBP material (e.g., human blood or cell culture solution) to pass through the employee's work clothes, street clothes or undergarments, skin, eyes, or other mucous membranes under normal conditions of use and for the duration of time in which the PPE will be worn.

5.4.1    Body Protection

Text Box:  Protective laboratory clothing is a garment such as a lab coat, gown, smock, or uniform designed to keep personal clothing, forearms, or other exposed bodily surfaces protected from contamination by biological materials or exposure to other hazards. The term "protective laboratory clothing” typically applies to garments worn in the laboratory, but may also apply to garments worn in nonlaboratory work (e.g., health care).

The following biosafety criteria are applicable to wearing protective laboratory clothing:

  • Protective laboratory clothing should be worn to prevent contamination of personal clothing when working at BL1.
  • Protective laboratory clothing must be worn when working at BL2 or when working with RG2 or other hazardous materials. This clothing must be removed and left in the laboratory before leaving for nonlaboratory areas (e.g., cafeteria, library, administrative offices).

Protective laboratory clothing removed after use at BL2 or with biohazardous materials must be handled in one of the following ways:

  • Placed in a laundry bag or container for cleaning by a qualified laundry service
  • Disposed of in accordance with LBNL medical/biohazardous, hazardous, and radiological waste management requirements
  • Stored for reuse if not contaminated. Such clothing stored for reuse should be stored in a manner that would not contaminate other items in case the protective clothing has unknown contamination (e.g., separate coat hook).

Protective laboratory clothing and other laundry contaminated with RG2 materials should be handled as noted below, and laundry contaminated with BBP materials must be handled as follows:

  • Handled as little as possible with a minimum of agitation
  • Bagged or containerized at the location where it was used but not sorted or rinsed in the location of use
  • Placed in bags or containers that have biohazard labels, are red in color, or are identified by an alternative laundry labeling or color-coding system that uses universal precautions
  • Placed and transported in bags or containers that prevent soak-through or leakage of fluids to the exterior if the laundry is sufficiently wet

 Place protective clothing in properly identified laundry bags.

5.4.2    Eye and Face Protection

Text Box:  Eye protection is a safety device such as safety glasses with side shields or goggles worn over the eyes to prevent injury to the eye or exposure to biological agents. Face protection is a safety device such as a face mask, face shield, or other splatter guard worn over all or part of the face to protect the face from injury or exposure to biological agents. Face masks or respirators that are occasionally used for face protection are discussed in Section 5.4.5 of this manual.

Eye and face protection is used by laboratory and other workers to protect the eyes and face from splashes, splatters, or flying debris and hand-eye contact with biological materials. Contact by these means may result in injuries to the eyes and face or accidental inoculation via the eyes, nose, or mouth and subsequent infection and disease.

The risks noted above are prevented by using eye and face protection in accordance with the following requirements:

  • As a minimum requirement, safety glasses with side shields must be worn at all times when in a Technical Area such as a laboratory. Area PPE requirements apply to the entire Technical Area unless an exception is granted in accordance with the procedure described in PUB-3000, Chapter 19, Appendix A. Additional eye or face protection may be necessary when handling chemicals or biological materials (e.g., goggles, face shield).
  • Eye protection must be worn when conducting procedures that have the potential to create splashes of biological agents, biohazardous materials, or other hazardous materials.
  • Eye and face protection (e.g., goggles, face mask, face shield, or other splatter guard) must be used when it is anticipated that splashes, sprays, splatters, or droplets of infectious or other hazardous materials may be generated and could contaminate the eyes, nose, or mouth (e.g., when RG2 microorganisms must be handled outside the biosafety cabinet or containment device). This eye and face protection must be included in the Biosafety Work Authorization risk assessment and disposed of with other contaminated laboratory waste or decontaminated before reuse.

eye protection image 
Eye protection using safety glasses. Source: LBNL EH&S.

LBNL provides prescription safety glasses when needed via the EH&S Health Services Group and a staff optometrist. Personnel who need consultation or require prescription safety glasses should schedule an appointment with the optometrist by calling the Health Services Group at (510) 486-6266.

5.4.3    Hand Protection

Text Box:  Hand protection is a glove or other safety device used on the hand to prevent injury to the hand or direct skin contact with biological materials. Hand protection is used by laboratory and other workers to protect the hands from harmful physical, chemical, biological, radiological, or other agents or hazards. These agents or hazards may cut, lacerate, abrade, or burn the skin; absorb through the skin; pass through breaks in the skin; or be spread as contamination. Although there are relatively few microbes that can penetrate unbroken skin, there are many circumstances that may cause a break in the skin, such as a cut or puncture from a sharp (see sharps in Section 5.6.6.1). In the case of biological materials, gloves prevent the worker’s hands, fingers, and nails from being contaminated. Spread of biological contamination from the worker’s exposed hands or contaminated gloves to the worker’s mucous membranes or other surfaces may also cause infection and disease in the worker or other people.

Glove selection may need to consider protection of the worker from different hazards or serve multiple purposes. For example, gloves used for handling chemical and biological materials may need to be resistant to the chemicals being handled, liquid permeation, and physical damage (see the PPE section of the CHSP). But the remainder of this section is focused only on glove criteria that are important for biosafety and gloves that provide protection from biological materials or liquids.

The following criteria are applicable to glove selection, use, and disposal:

  • In general, gloves should be worn to protect the hands from exposure to biological materials or organisms that may present a biological risk. Gloves must be worn to protect hands from exposure to hazardous materials, including: organisms containing recombinant DNA, recombinant experimental animals, RG2 materials, BBP materials or surfaces and items contaminated with BBP materials, when touching mucous membranes and nonintact skin of patients, and when performing vascular access procedures such as phlebotomies.
  • Glove selection should be based on an appropriate risk assessment. Use of standard nitrile or latex examination gloves is considered adequate for handling most biological materials, and is assumed in the Biosafety Work Authorization. The need for gloves with any additional safety features to handle biological materials should be documented in the Biosafety Work Authorization. The JHA process should be used to assess other hand hazards and glove requirements.
  • Alternatives to latex gloves should be available because some workers are known to develop allergic reactions to latex. Exposures to latex may result in skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.
  • When working at BL1 and BL2, workers should remember the following:
    • Change gloves when contaminated, when their integrity has been compromised, or when otherwise necessary. When working at BL2, wear two pairs of gloves when appropriate.
    • Remove gloves and wash hands when work with hazardous materials has been completed and before leaving the laboratory. Gloves that were used in BL1 or BL2 work must not be worn outside the laboratory.
    • Do not wash or reuse disposable gloves. Dispose of used gloves with other contaminated laboratory waste. Hand washing protocols must be rigorously followed.

5.4.4    Foot Protection

Text Box:  Footwear appropriate to the worker’s work activities and conditions must be worn at all times. In a Technical Area such as a laboratory, or areas where chemical or biological materials are stored or handled, closed-toe shoes must be worn at all times, and open-toe shoes and sandals are not permitted. In some cases, LBNL requires workers to wear safety shoes for other hazards such as falling heavy objects. See PUB-3000, Section 19.3 (Foot Protection), for additional information.

5.4.5    Respiratory Protection, Respirators, and Face Masks

Text Box:

Workers who conduct procedures that may generate aerosols containing harmful levels of infectious agents must use controls such as biosafety cabinets (BSCs), enclosed containment systems, or respirators to avoid inhaling the agents. In general, a BSC should be used as the principal device in laboratories to contain infectious splashes or aerosols generated by numerous microbiological procedures (see Section 5.6.4.2 and Appendix E of this manual for additional BSC information). Other engineered containment devices such as safety centrifuge cups should also be used. When engineering controls are not feasible or appropriate for the work, respirators may be needed to provide respiratory protection (e.g., potential exposure to airborne transmissible disease agents during patient care).

Respirators or face masks are occasionally worn by workers while conducting work with biological materials. There are important differences in design, purpose, and requirements between types of respirators and face masks that may be used for biological materials:

  • A respirator is a device designed and certified to protect the wearer from the inhalation of harmful atmospheres. A respirator may be a required respiratory control or worn voluntarily by the worker. A respirator might also provide face or product protection. Types and examples of some respirators:
    • A negative-pressure, air-purifying respirator is a tight-fitting respirator in which the air pressure inside the facepiece is negative during inhalation with respect to the ambient air pressure outside the respirator, and an air-purifying filter or cartridge removes specific air contaminants. Examples include the following types of cartridge and filtering facepiece respirators:
      • A negative-pressure, air-purifying, cartridge respirator is a respirator that uses a filter, sorbent, or catalyst housed inside a cartridge to remove contaminants from the air. Examples are respirators using an N95 or P100 cartridge particulate filter that is 95% and 100% efficient, respectively.
      • A filtering facepiece respirator is a negative pressure, air-purifying respirator with a particulate filter as an integral part of the facepiece or with the entire facepiece composed of the filtering medium. A filtering facepiece respirator is sometimes incorrectly referred to as a dust mask or an N95 respirator. The term “dust mask” is an inaccurate term because a filtering facepiece respirator is a respirator, not a face mask. In addition, filtering facepiece respirators are not to be confused with N95 respirators, because only cartridge-type respirators use N95 filters.
    • A positive-pressure respirator is a respirator designed to maintain positive pressure inside the facepiece during exhalation and inhalation. Examples include a powered air-purifying respirator or a supplied-air respirator, which are not normally used at LBNL for biosafety purposes.

  • A face mask is a loose-fitting, disposable device that covers the worker’s nose and mouth and is not a respirator. Examples of face masks include products labeled as surgical, medical, dental, or isolation masks. A face mask might be worn in combination with eye protection to protect the nose and mouth from splatters or sprays, or the face mask might prevent the wearer from contaminating a product, patient, lab animal, or surface from particles (e.g., droplets) expelled from the nose or mouth. Face masks are not intended to protect the wearer from inhalation of airborne agents and must not be used for respiratory protection.

Respirators Man wearing respirator        Man   wearing facemask
           Filtering facepiece respirator.                                                    Face mask
      Source: CDC courtesy of Moldex Metric Inc. (April 2009).               Source: CDC (April 2009)

The following requirements are applicable to respirator uses, regardless of why the respirator is worn:

  • The respirator must be issued and worn in accordance with PUB-3000, Section 4.13, which includes the LBNL Respiratory Protection Program document. See these polices for additional information and consult your EH&S Industrial Hygienist. Voluntary use of a filtering facepiece that is not a required respiratory control requires a hazard evaluation and training before use, but unlike other required respirator uses, does not require a medical evaluation or fit-testing.
  • A risk assessment for the respirator must be documented in the Biosafety Work Authorization if the respirator use is related to the handling of biological materials.

5.5       Labels and Signs

Biological materials, agents, waste, potentially contaminated items, and laboratory rooms must be properly identified with labels, signs, or colors. Identification is needed so that responsibilities, material identities, hazards, or controls are communicated to workers, visitors, and others. These labels, signs, and colors must be displayed in accordance with LBNL policies and applicable requirements in the biosafety standards as summarized in this section.

A biohazard label or red color is typically required to provide warning when a biohazardous condition may be present. A biohazard label is a sign that is predominantly fluorescent orange or orange-red. It also contains a biohazard symbol and the word “Biohazard” in a contrasting color. The label shown below displays the required biohazard legend:

Sample 2 Biohazard Symbol
Biohazard label. Source: 29 CFR 1910.1030(g)(1)

The following are biosafety criteria for labels, signs, and colors:

  • Information or labels should be visible on containers of biological materials or agents so that their content can be identified.
  • A biohazard label should be posted as a best management practice on primary equipment that uses, stores, or may be contaminated with RG2 agents or materials.
  • Work with BBP materials requires:
    • Biohazard labels, red containers, or red bags for waste containers, refrigerators, freezers, or other containers used to store, transport, or ship BBP materials
    • Biohazard labels, red containers, or red bags for containers or bags used for laundry that may be contaminated with BBP materials
    • Biohazard labels used to indicate which equipment parts remain contaminated with BBP materials
  • Caution placards and other information must be posted at laboratory entrances, including a biohazard label for BL2 work areas. See additional details in the next paragraph.
  • Consult the Medical and Biohazardous Waste Generator’s Guide (PUB-3095) for details on labels and colors for sharps containers, waste containers, and waste bags in designated red-bag or clear-bag areas. A determination must be made in the Biosafety Work Authorization as to whether the work will generate either regulated medical waste (i.e., red-bag waste that is regulated by the California Department of Health Services) or nonregulated biohazardous waste not (i.e., clear-bag waste).

The following criteria must be implemented when posting an entrance to BL1 or BL2 laboratory area:

  • A Caution placard must be posted at the entrance to a Technical Area as specified in the LBNL CHSP.
  • Area PPE requirements must be included on the Caution Placard as specified Chapter 19 of PUB-3000 (PPE).
  • A biohazard label must be posted (typically on a placard) at the entrance to each BL2 work area to advise entering personnel of potential biological hazards.
  • When infectious agents (i.e., human pathogens) are present or there are organisms that require special provisions for entry (e.g., vaccination), additional biological hazard warning signage is required at the entrance to the laboratory. This signage must incorporate the universal biohazard symbol and include: the laboratory’s biosafety level; the identity of the agent(s) or the words “Infectious Agent(s)”; the name and telephone number of the supervisor, work lead, prinicipal investigator (PI), or other responsible personnel; and any special requirements or procedures for entering and exiting the laboratory. The CHSP Caution Placard will be used to accomplish these additional signage requirements. Any requirements for posting identities of agents or posting special entry and exit procedures will be specified in the BUA.
  • Other LBNL requirements for signage (e.g., radiological) may also apply to the entrance to be posted.

5.6       Facilities, Laboratory Equipment, and Related Practices

This section describes in a topical manner biosafety engineering and work practice controls related to standard facility design and laboratory equipment. Properly designed and used facilities, facility equipment, laboratory equipment, and lab tools provide protection for laboratory workers, persons outside the laboratory, the public, and the environment.

See Sections 4.1, 4.2, and 4.3 of this manual for a general discussion of the principles of standard laboratory practices, equipment, and facilities. See Appendix C of this manual for a summary of standard laboratory practices, equipment, and facilities categorized as BL1 and BL2. See PUB-3000, Section 26.7.6, for a discussion of the facility design process at LBNL related to biosafety.

5.6.1    Cleanable Surfaces and Furnishings

In general, laboratory facilities and furnishings should be designed and maintained so that they are durable, will not trap contamination, and can be easily cleaned. The following BL1 and BL2 laboratory criteria specified by BMBL and apply to this objective:

  • The laboratory should be designed so that it can be easily cleaned or decontaminated.
  • Carpets and rugs in laboratories are not permitted.
  • Laboratory furniture must be capable of supporting anticipated loads and uses.
  • Spaces between benches, cabinets, and equipment should be accessible for cleaning.
  • Benchtops must be impervious to water and resistant to heat, organic solvents, acids, alkalis, and other chemicals.
  • Chairs used in laboratory work must be covered with a nonporous material that can be easily cleaned and decontaminated with an appropriate disinfectant.

BMBL, fifth edition, added the new requirement noted above for chairs used in BL1 laboratory work. This new requirement for BL1 work involves significant costs to replace or modify chairs covered with porous material (e.g., cloth or mesh cushions). LBNL divisions may develop and document a corrective action that specifies a phase-in period to replace chairs with porous cushions used in BL1 laboratory work. During any phase-in period, new chairs used in BL1 laboratory work must meet the requirement to be covered with a nonporous material.

5.6.2    Doors and Windows

Laboratory doors and windows provide a means to control personnel access to the laboratory, control vectors such as insects and rodents, and maintain laboratory air-flow balance. These controls are elements of standard BL1 or BL2 laboratory practices or facilities.

The following biosafety criteria from BMBL and Appendix C are applicable to laboratory doors and windows:

  • BL1 and BL2 laboratories should have doors for access control. BL2 laboratory doors should be self-closing and have locks in accordance with LBNL standards. When the laboratory is unoccupied during nonbusiness hours, access to the laboratory should be controlled (e.g., by locking doors to the laboratory areas and/or doors to the building entrance).
  • BL1 laboratory windows that open to the exterior should be fitted with screens. BL2 laboratory windows that open to the exterior are not recommended. However, if a BL2 laboratory has windows that open to the exterior, they must be fitted with screens.

5.6.3    Plumbing Systems and Equipment

Plumbing-related systems and equipment that have requirements related to biosafety include handwashing sinks, sanitary sewer drains, water systems and backflow protection, emergency eyewash and shower units, and pipes. These systems provide needed utilities and containment when used properly. When used incorrectly, these systems may provide a route of exposure to personnel or the environment.

5.6.3.1 Sinks and Handwashing

BL1 and BL2 laboratories must have a sink with running water for handwashing. In BL2 laboratories, the sink should be located near the exit door and may be manually, hands-free, or automatically operated. Handwashing sinks should be provided with a soap dispenser and paper towel dispenser as a best management practice. When working with BBP materials, the sink facility is called a handwashing facility. A handwashing facility must have an adequate supply of potable running water, soap, and single-use towels or hot-air drying machines.

Personnel working at BL1 or BL2 laboratories must wash their hands a) after working with potentially hazardous materials, recombinant materials, and animals; b) after removing gloves; and c) before leaving the laboratory.

image
Handwashing with soap and water. Source: LBNL EH&S.

When work involves potential exposure to BBP materials outside of the laboratory (e.g., health care) and handwashing facilities (e.g., potable water and a sink) are not feasible, an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes may be provided. When antiseptic hand cleansers or towelettes are used, hands must be washed with soap and running water as soon as possible.

5.6.3.2 Drains and Disposal

Laboratory sinks must typically be drained into the sanitary sewer system. In general and as a best management practice, liquids that contain biological material that is potentially viable or biologically active and not contaminated with other hazardous or radioactive material should be properly decontaminated with a disinfectant before disposal into the sanitary sewer system (see Section 5.7 (Decontamination, Waste, and Decommissioning) below. All biological liquid material considered medical/biohazardous waste must be decontaminated before disposal (see the Medical and Biohazardous Waste Generator’s Guide (PUB-3095)).

5.6.3.3 Water Systems and Backflow Prevention

Backflow-prevention devices are required in building water systems or connection points to prevent contaminated liquid or water from being inadvertently sucked into the potable water system of the building. For example, a backflow-prevention device called a vacuum breaker is often integrated into the gooseneck of the laboratory sink faucet. This device prevents liquids from being drawn up into the faucet’s water system in case a laboratory worker connects tubing to the faucet’s serrated hose end.



Laboratory faucet with backflow prevention device. Source: Grainger (May 2010).

Potable water is typically supplied to each laboratory building. This water supply is separated through backflow-prevention devices in the building’s plumbing system into potable and industrial water systems or sources. Plumbing fixtures that must be supplied with potable water include emergency eyewashes and showers and fixtures used in restrooms, in kitchens, or as drinking sources (e.g., toilets, sinks, or drinking faucets). Water connected to other fixtures or equipment in the laboratory or building must be separated from the fixtures that require potable water by proper backflow-prevention devices. When the water system is correctly designed and labeled, water pipes labeled as industrial water are separated from the potable water system by a backflow-prevention device(s) in the building’s water system. Connection of laboratory sinks, laboratory equipment, or industrial equipment to pipes that also provide water to potable fixtures requires proper installation of a backflow-prevention device. Contact your building’s facilities service provider (e.g., LBNL Facilities) for proper plumbing advice and hardware.

5.6.3.4 Emergency Eyewashes and Showers

Text Box:

Emergency eyewash is a plumbing unit designed to properly flush chemical, biological, or other hazardous agents off the face and out of mucous membranes such as the eyes. Use of an eyewash prevents injury to the eye or exposed body surfaces. It also prevents an agent from penetrating into the body. An emergency eyewash must be readily available to BL2 work areas.

Ready access to a sink and emergency eyewash without strict distance-to-use requirements is normally sufficient for washing biological contamination from the body, because:

  • Intact skin is considered a good barrier to most biological agents;
  • Biological agents do not cause immediate tissue damage to skin or eyes; and
  • An eyewash unit works well to flush the face (e.g., eyes, nose, and mouth areas).

However, in areas where there is also a splash hazard to certain chemicals (e.g., corrosives, eye irritants, chemicals that are toxic via skin or eye contact), the CHSP specifies that a combination emergency eyewash and shower unit must be reachable within 10 seconds via an unobstructed path. When combination eyewash and shower units are provided for potential chemical exposures, the number and placement of units is often sufficient to also meet the biosafety requirement for an emergency eyewash being readily available in BL2 work areas. Installation, maintenance, and use of all emergency eyewash and shower units must comply with the eyewash and shower requirements in the CHSP.

5.6.4    Ventilation and Hoods

Room ventilation and hoods provide for control of potential biological aerosols, other harmful atmospheres, odors, and smoke caused by fires by providing general room air dilution, directional air flow, and enclosure to contain and exhaust airborne agents. Room ventilation and hoods must be designed and maintained to established standards, guidelines, and LBNL policies.

5.6.4.1 Room Ventilation

The volume and balance of laboratory room ventilation are important safety controls. There may be specific ventilation requirements for specific laboratory uses, but the following design requirements generally apply to laboratory rooms that use biological and hazardous materials:

  • Laboratory rooms must be negative in pressure relative to any fire exit corridor.
  • Laboratory rooms should be negative in pressure relative to nonlaboratory rooms (e.g., offices).
  • BL2 rooms should be negative in pressure relative to other areas. If researchers indicate that a BL2 area should be positive in pressure for research purposes (e.g., contamination control), a negative-pressure anteroom leading to the BL2 area may be required, or the risk assessment process may indicate that it is acceptable for air to flow from the BL2 area into another laboratory area.
  • Air exhausted from laboratories should not be recirculated to rooms outside the laboratory.
  • Laboratory exhaust ventilation flow rates must meet minimum requirements (e.g., 1 cubic foot per minute of exhaust air per square foot of laboratory space).

5.6.4.2 Hoods and Biosafety Cabinets

Hoods are enclosures or shaped inlets designed to conduct contaminated air into an exhaust duct system, or a filter that safely captures the contaminant. This section discusses hoods designed to provide for the safety of the worker or the environment such as biosafety cabinets, laboratory fume hoods, exhausted equipment enclosures, gloveboxes, and other local exhaust points. This section does not cover ventilated enclosures such as laminar flow clean benches that are not designed to protect the worker or the environment from contaminated air.

Hoods used for safety must be designed, installed, tested, and surveyed in accordance with LBNL Environment, Safety, and Health (ES&H) standards and policies for all hoods and high-efficiency particulate air (HEPA) filters (see PUB-3000, Section 4.6). The EH&S Industrial Hygiene Group manages the ventilation safety program and records hood locations, surveys, and testing in the Ventilation Database. Supervisors or work leads should ensure that hood safety survey stickers or labels indicate the hood has been surveyed or tested and determined to be safe for use.

fume hood fume hood alarm 
Laboratory hood.                Hood survey label and monitor.           BSC certification label.
Source: LBNL EH&S           Source: LBNL EH&S                            Source: LBNL EH&S

5.6.4.2 (a) Biological Safety Cabinets and Other HEPA-filtered Containment

Text Box:  Biological safety cabinets or biosafety cabinets (BSCs) are hoods with HEPA filters that provide personnel, environmental, and product protection when appropriate practices and procedures are followed. Appendix E of this manual summarizes BSC types and provides additional BSC information. Various types of BSCs and similar hoods are used at LBNL. Listed below are more common types:

  • Typical BSCs used at LBNL are Class II, Type A2 BSCs built by BSC manufacturers. These BSCs discharge exhaust directly though a HEPA filter and into the laboratory.
  • Class II, Type B1 BSCs are used less commonly than Class II, Type A2 BSCs. These BSCs discharge exhaust air through a HEPA filter, but exhaust air is then ducted to the roof so that toxic chemicals that cannot be filtered by the BSC’s HEPA filter are not exhausted back into the laboratory.
  • Researchers sometimes acquire or build equipment such as cell sorters or robotic enclosures that cannot be categorized as a BSC. These specialized pieces of equipment should be tested and managed using many of the same BSC ventilation, testing, and management principles.

BSCs or other safety equipment, PPE, or other physical containment devices (e.g., safety centrifuge cups) must be used whenever procedures with a potential to create infectious aerosols or splashes are conducted, or whenever high concentrations or large volumes of infectious agents are used. Examples of such procedures include pipetting, centrifuging, grinding, blending, shaking, mixing, vortexing, sonicating, opening containers with pressure differentials, or harvesting infected tissues. The BSC is the principal BL2 device used to provide containment of infectious splashes or aerosols generated by many microbiological procedures.

Picture image Picture
Biosafety cabinet. Source: LBNL EH&S

Aerosols and aerosol generation.

Source: unidentified.

BSCs must be:

  • Designed, installed, tested, and surveyed in accordance with LBNL ES&H standards and policies for all hoods and HEPA filters (i.e., PUB-3000, Section 4.6 ).
  • Designed, constructed, installed, operated, used, decontaminated, and tested in accordance with BSC guidelines in Appendix A of BMBL and summarized in Appendix E of this manual.
  • Managed in accordance with the following list of BSC policies:
    • The Biosafety Work Authorization must include specific BSC uses and information, and an assessment of procedures for RG2 materials that have the potential to produce aerosols or splashes.
    • The EH&S Industrial Hygiene Group is responsible for maintaining records of BSC locations, surveys, and testing in the Ventilation Database, and managing surveys, tests, and gaseous decontaminations of BSCs. BSC testing, certification, and gaseous decontaminations are performed by a subcontractor. The EH&S Division normally pays for each BSC’s annual safety test and certification when the BSC is used for safety.
    • Line management owners of BSCs have primary responsibility for paying costs and ensuring the proper purchase, use, maintenance, testing, and decontamination of BSCs.
    • BSCs used for BL1, BL2, or other safety levels must be tested and certified before initial use, after being moved, and on a nominal one-year cycle.
    • BSCs and their filters must be decontaminated with a gaseous decontaminant before being moved or repaired internally, unless an alternative procedure is approved by the Biosafety Officer.
    • BSCs must be installed and operated according to the manufacturer’s recommendations.

When a new BSC is needed or a BSC needs to be moved, contact the EH&S Industrial Hygiene Group or Biosafety Office for assistance with selecting, testing, and decontaminating BSCs.

5.6.4.2 (b) Laboratory and Other Hoods

Other hoods that are not exhausted through HEPA filters are typically used for most nonbiological laboratory airborne hazards or concerns. These hoods are generally used for control of chemical hazards, gas hazards, process emissions, odors, and heat. Examples of such hoods include laboratory-type (“fume”) hoods, gas chromatograph local exhaust points, and autoclave canopy hoods. These hoods can be used for chemicals including biological toxins, but are not adequate for control of potential infectious biological aerosols or toxic particulate.

5.6.5    Food Facilities and Eating  

Text Box:
Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption are not permitted in BL1 and BL2 laboratory areas. Food must be stored outside the laboratory area in cabinets or refrigerators designated and used for this purpose.

5.6.6    Laboratory Tools and Equipment

5.6.6.1 Sharps

This section describes types and hazards of sharps, states requirements from biosafety standards, and outlines LBNL’s policies on sharps related to biosafety. A sharp is an object that can penetrate the skin. A sharp is often a tool, device, or material that typically has a sharp edge or point such as a needle, scalpel, razor, blade, broken glass piece, broken capillary tube, or an exposed wire end.

 
Sharps examples. Source: unidentified.

Sharps may cause cut or puncture wounds. In addition, sharps contaminated with a biological material may result in the parenteral inoculation of a worker with an infectious or recombinant agent that may cause a laboratory-acquired infection or another disease. Parenteral is an adjective that refers to a route of administration that involves piercing the mucous membranes or skin barrier through events such as punctures, lacerations, abrasions, and bites.

Sharp tools are often designed with a built-in safety feature or mechanism that effectively reduces the risk of accidental skin penetration and a biological exposure incident. These tools are called safety-engineered sharps or safety-engineered needles. Examples include devices that blunt, sheath, or withdraw the sharp when the sharp edge or point has been used or is not in use. The OSHA Bloodborne Pathogens Standard has specific definitions and requirements for the use of safety-engineered sharps that are discussed in the next section.

5.6.6.1 (a) Sharps Risk Assessment and Documentation

Use of sharps should be assessed as part of the risk assessment for work with biological materials. The following general process should be followed:

  • The use of sharps is assessed and controls are defined in each:
    • Worker’s JHA for use of sharp tools
    • BUA and ECP for all sharps involved with RG2 and BBP materials
  • The sharps risk assessment that is conducted when developing the BUA or ECP should:
    • Evaluate what sharps may be needed or might be present
    • Evaluate if a safer alternative to the sharp can be used to accomplish the work. For example: Plasticware should be substituted for glassware whenever possible at BL2.
    • Evaluate available sharp tools and pick the safest device that will accomplish the work. For example:
      • Safety-engineered needles rather than needles that cannot be sheathed after use
      • Scalpels with longer handles that are often more controllable than razor blades
      • Razor blade holders rather than unprotected blades
    • Evaluate the machine’s point-of-operation guarding if there is an exposed sharp edge or point on a machine. For example:
      • A cutting blade on a microtome
      • Needles on a colony picking robotic machine

Use of sharps with RG2 materials should be documented in the BUA. In addition, use of sharps with BBP materials must be documented in the BUA or ECP, and the annual review and update of these plans must reflect changes in technology that eliminate or reduce exposure to BBPs (e.g., newly available devices designed to reduce exposure).

In addition, when the BUA or ECP covers medical procedures or devices that involve exposure to BBP material:

  • Sharps with engineered sharps injury protection (ESIP) must be specified and used with a few exceptions. OSHA defines sharps with ESIP as a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. See the OSHA fact sheet on safety needles and needleless systems for additional information. When a needle must be used as described above, a needle device with ESIP must be used unless one of the following four OSHA exceptions is documented in the BUA or ECP:
    • No needleless systems or sharps devices with ESIP are available in the marketplace for the procedure.
    • A licensed health care professional directly involved with a patient’s care determines that available needleless systems or sharps devices with ESIP would compromise the patient’s care or safety.
    • Available needleless systems and sharps devices with ESIP are not more effective in preventing exposure to BBPs than the alternative being used.
    • Sufficient information is not available on the safety performance of needleless systems or sharps devices with ESIP available in the marketplace, and the supervisor or work lead is actively evaluating such devices.
  • The BUA or ECP’s annual review and update must:
    • Reflect changes in technology that eliminate or reduce exposure to BBPs (e.g., newly available medical devices designed to reduce needlesticks).
    • Document consideration and implementation of appropriate, commercially available, effective, and safer medical devices.
    • Document how input was solicited from nonmanagerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls.

5.6.6.1 (b) Sharps Use and Disposal

Sharps must be used and disposed of in accordance with:

  • Laboratory BL1 and BL2 criteria in Appendix C of this manual
  • The Medical and Biohazardous Waste Generator’s Guide (PUB-3095)

When applying force to a handheld sharps tool, the sharp end of the tool should be pointed away from the worker’s body.

 Picture Picture glassware disposal
Syringe with capped needle, needle disposal without recapping in sharps container, and glass sharps container. Sources: unidentified.

5.6.6.1 (c) Sharps Injury Reporting and Log

See Section 5.10 of this manual for requirements and procedures related to injury and accident reporting, and Section 5.3 for requirements and responsibilities related to logging sharps injuries.

5.6.6.2 Centrifuges

Rotational energies involved with most centrifuges can generate two serious hazards: mechanical failure, and dispersion of aerosols or droplets. This section describes general classes of centrifuges, and general operation and maintenance guidelines to minimize centrifuge hazards. Elements of these guidelines may or may not be applicable to specific centrifuge operations. Information in this section was adapted from the University of Minnesota’s “Bio Basics Fact Sheet: Centrifuge Safety.”

There are three general classes of centrifuges:

  • Text Box:Low-speed centrifuges that do not exceed 5,000 rpm are commonly made for benchtop use.
  • High-speed centrifuges that do not exceed 25,000 rpm may include benchtop or floor models.
  • Ultracentrifuges that may exceed 100,000 rpm are often found in core equipment areas. These centrifuges are the most expensive and potentially the most dangerous.

5.6.6.2 (a) Centrifugation Operation Guidelines

Before centrifugation:

  • Each operator should review or be instructed on proper operating procedures and necessary information from the user manual.
  • Use only rotors compatible with the centrifuge. Check the expiration date for ultracentrifuge rotors.
  • Check tubes, bottles, and rotors for cracks and deformities before each use.
  • Make sure that the rotor, tubes, and spindle are dry and clean.
  • Examine O-rings. Replace if worn, cracked, or missing.
  • Never overfill centrifuge tubes (do not exceed three-fourths full).
  • Cap tubes before centrifugation.
  • Balance buckets, tubes, and rotors properly.
  • Check that the rotor is seated on the drive correctly, put lid on rotor, close the lid on the centrifuge, and secure it.
  • When using swinging bucket rotors, make sure that all buckets are hooked correctly and move freely.

During centrifugation:

  • Keep the lid closed at all times during operation. Never open a centrifuge until the rotor has stopped.
  • Do not exceed safe rotor speed.
  • The operator should not leave the centrifuge until full operating speed is attained and the machine appears to be running safely without vibration.
  • Stop the centrifuge immediately if an unusual condition (e.g., noise or vibration) begins, and rebalance the load if needed. If a loud noise indicates significant mechanical failure such as rotor or container breakage, follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills) of this manual. Report other unusual conditions to the work lead. Evaluation by a manufacturer’s representative may be needed.

After centrifugation:

  • Allow the centrifuge to come to a complete stop before opening.
  • Wear gloves to remove rotor and samples.
  •  Check inside of centrifuge for possible spills and leaks. Disinfect centrifuge and rotor thoroughly if necessary.
  • Wash hands after removing gloves.

Centrifuging RG2 materials:
imageFollow the safety procedures noted above plus:

  • Place a biohazard label on the centrifuge.
  • Wear gloves when handling tubes or rotors.
  • Avoid the use of celluloid tubes with biohazards. If celluloid tubes must be used, an appropriate chemical disinfectant must be used to decontaminate them.
  • Use sealed safety cups, safety buckets, or sealed rotors with O-ring as secondary containment.
  • Fill centrifuge tubes, load into rotors, remove from rotors, and open tubes within a biological safety cabinet.
  • Wipe exterior of tubes or bottles with disinfectant prior to loading into rotor or bucket. Seal rotor or bucket, remove outer gloves, and transport to the centrifuge.
  • Wait at least 10 minutes after the run to allow aerosols to settle before opening the centrifuge. Check for possible spills or leaks.
  • Decontaminate centrifuge interior, safety cups or buckets, and rotors if spills or tube breakage occurs. Follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills).

5.6.6.2 (b) Centrifuge Maintenance Guidelines

Moisture, chemicals, strong cleaning agents, and other substances can promote corrosion of centrifuge parts and cause centrifuge failure. Long-term centrifuge use may also cause centrifuge failure. The following are general maintenance recommendations:

  • Follow manufacturer instructions for maintenance and cleaning.
  • Keep the centrifuge clean and dry.
  • Clean up all nonhazardous spills immediately. Follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills), for biohazardous spills.
  • Decontaminate rotors used with biological or radioactive materials (e.g., use 10% bleach for 30 minutes followed by 70% ethanol; let air dry to clean rotors and cups).
  • Never clean rotors and associated parts with abrasive wire brushes.
  • Store the rotor upside down in a dry place, with lids or plugs removed, to prevent condensation.
  • Remove adapters after use. Inspect them for corrosion.
  • Inspect rotors regularly. Remove rotors from use if they show any signs of defects. Report the defective rotors to a manufacturer's representative for inspection.
  • To avoid rotor failure, record the length of time and speed for each high-speed rotor in a log book. Track and discard rotors according to the manufacturer's recommended schedule.

5.6.6.3 Waste Containers

Containers used to hold medical/biohazardous waste, sharps waste, or pathological waste must be placed in biohazardous waste containers and bags in accordance with the Medical and Biohazardous Waste Generator’s Guide (PUB-3095).

5.6.6.4 Equipment Connected to Building Vacuum Systems

House vacuum systems used to evacuate air from containers, enclosures, or lines that contain biological materials should be equipped with a HEPA filter (or equivalent filter) to prevent biological materials or aerosols from being sucked inadvertently into the vacuum line. This is a general guideline for all biological materials, but the BMBL criteria for BL2 laboratory facilities specifically states that vacuum lines should be protected with a HEPA filter or equivalent, the filter must be replaced as needed, and liquid disinfectant traps may be required. Liquid disinfectant traps typically used in conjunction with tissue culture work inside a BSC are further detailed in Appendix E, Section E.3.3, of this manual.

5.7       Decontamination, Waste, and Decommissioning

Work surfaces, work areas, furniture, equipment, materials, and wastes involved in most work with biological materials must be routinely decontaminated during the work, and prior to transfer or disposal. This section 1) discusses principles of decontamination, 2) provides examples of antimicrobials used to decontaminate, and 3) summarizes or references requirements from the standards related to antimicrobials and decontamination of surfaces, equipment, and wastes. See the following policy sections and standards for additional information:

  • Appendix F of this manual for more detailed information on decontamination processes and antimicrobials.
  • PUB-3000, Section 26.5.7, for a summary of decontamination and waste standards and LBNL policies.
  • BMBL, Appendix B, for BMBL guidance on strategies for decontaminating laboratory surfaces, items, and areas.

Text Box:

5.7.1    Decontamination Processes and Antimicrobials

Decontamination is a process that uses an antimicrobial to reduce or inactivate biological contaminants or components to an acceptable level so as to reduce or eliminate the possibility of transmitting pathogens to undesired hosts. An antimicrobial is a chemical or physical agent that is used in a decontamination process to prevent microbial growth. Prevention of microbial growth and pathogen transmission is needed to control contamination of the work, and to prevent disease in hosts such as laboratory workers, the general public, and other organisms in the environment. The decontamination process, level, antimicrobial, frequency, and specific method should be based on the work activity, agents that need inactivation, and decontamination objectives or requirements. Definitions of decontamination processes and levels, along with common examples of antimicrobials and processes, are listed in Table 11 below. Refer to Appendix F of this manual for additional information on decontamination and antimicrobials.

When using a chemical or physical antimicrobial to ensure decontamination is accomplished for biosafety purposes (i.e., protection of workers, public, agriculture, or environment):

  • There should be information indicating that the selected antimicrobial will be effective when used in a certain manner for the biological materials or agents and equipment or surfaces that need to be decontaminated; and
  • The antimicrobial should be used in accordance with its antimicrobial activity capabilities and conditions of use.

Antimicrobial information in Appendix F of this manual, information provided by manufacturers (e.g., labels or technical specifications), and other information may be used for selecting and using the appropriate antimicrobial. Effective decontamination can also be ensured by using an Environmental Protection Agency (EPA)–registered or Food and Drug Administration (FDA)–cleared antimicrobial product within its manufacturer-specified limits. See Appendix F, Section F.2.3, of this manual for additional information on commercial disinfectants and sterilants registered or cleared by the EPA and FDA.


Table 11
Decontamination Processes, Levels, and Antimicrobial Examples*

General Decontamination Process and Level

Antimicrobial
Example

Example Decontamination Process

Sterilization is the process of completely destroying all living microorganisms and viruses.

Wet heat-steam

Autoclave at 121°C (250°F) for 15 minutes or more.

Dry heat

Bake at 171°C for at least 1 hour, or Incinerate.

Wet or dry heat

Place solid waste in a biohazardous waste container for autoclaving or incineration by a licensed LBNL subcontractor.

Disinfection is the process of generally eliminating nearly all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores) on inanimate objects.

Chlorine in sodium hypochlorite

Wipe clean hard work surfaces and equipment with a 1% solution of fresh household bleach, and allow to air dry for intermediate-level disinfection.

Add household bleach to liquid biohazardous spills or liquid waste until a 10% concentration of household bleach is achieved for 20 minutes for high-level disinfection.

Ethyl or isopropyl alcohol

Wipe clean hard work surfaces with a 70% solution of alcohol for low-level disinfection.

Submerge precleaned items in 70% alcohol for 10 minutes for intermediate-level disinfection.

Iodine

Wipe clean hard work surfaces with an idophor such as Wescodyne® for intermediate-level disinfection.

Formaldehyde

Use formaldehyde in water (i.e., formalin) or in alcohol at 1% to 8% for low- to high-level disinfection, respectively.

Ultraviolet (UV) light

UV light inside biosafety cabinet. Not recom-mended as a biosafety control because disinfection is limited, and light damages human tissue.

Sanitization is the process of generally reducing microbes by the use of general cleaning agents.

Soap and water, quaternary ammonium compounds, or disinfectants

Launder clothing or generally clean laboratory, restroom, room, and equipment surfaces.

Antisepsis is the application of a liquid antimicrobial chemical to human or animal living tissue.

Iodine

Wash hands with Betadine® skin cleanser containing povidone-iodine (PVP-I), or apply 10% PVP-I solution in water to the injection site on a research animal.

* See Appendix F of this manual for additional information and specific conditions.

Clorox bottle

The OSHA Bloodborne Pathogens Standard requires that work surfaces contaminated with BBP material (as defined in Section 3.3.4 of this manual) must be cleaned with an “appropriate disinfectant.” Appropriate disinfectants include household bleach diluted to concentrations ranging from 1% (i.e., 1:100) to 10% (i.e., 1:10) in water and certain disinfectants registered by the EPA or FDA. Household bleach at these concentrations is one of the most common and effective disinfectants used in the laboratory. Household bleach is a water-based solution of sodium hypochlorite (NaOCl) with a typical concentration of 5.25% by weight of the active sodium hypochlorite ingredient. In the U.S., Clorox® bleach is the best-known brand. See Appendix F, Section F.3.2.1, of this manual for additional details on the properties and use of bleach.

Steam heat used in autoclaves is also a common laboratory antimicrobial. An autoclave is a piece of equipment with a chamber used to sterilize items by applying wet heat (i.e., high-pressure steam) at temperatures above the normal boiling point of water and pressures above normal atmospheric pressure. Autoclaves are used to sterilize laboratory equipment or materials such as glassware, media, reagents, or waste. See Appendix F, Section F.5, of this manual for general information and guidelines on autoclave principles, operation, and maintenance typically needed to sterilize equipment and ensure operator safety.

5.7.2    Surface and Equipment Decontamination

In general, surface and equipment decontamination guidelines for BL1 and BL2 areas include:

  • The work area should be cleaned and maintained in a sanitary condition.
  • Surfaces or equipment where work with biological materials is conducted should be routinely decontaminated.
  • Surfaces, furniture, or equipment contaminated with biohazardous materials should be decontaminated after spills and before repair, maintenance, or removal from the laboratory.

Picture
Biosafety cabinet surface decontamination. Source: unidentified.

Laboratory standard microbiological practices from BMBL and NIH Guidelines (see Appendix C of this manual) specifically require the following surface and equipment decontamination practices:

  • At BL1 and BL2, work surfaces must be decontaminated with an appropriate disinfectant after completion of work and after any spill or splash of a potentially infectious or viable recombinant material.
  • At BL2, laboratory equipment should be decontaminated on a routine basis and after spills, splashes, or other potential contamination.
    • Spills involving infectious materials must be contained, decontaminated, and cleaned by staff properly trained and equipped to work with infectious material.
    • Equipment must be decontaminated before repair, maintenance, or removal from the laboratory.

5.7.3    Waste Decontamination and Disposal

Laboratory standard microbiological practices and special practices from BMBL and NIH Guidelines (see Appendix C of this manual) for BL1 and BL2 specifically require that all cultures, stocks, and other potentially infectious or viable recombinant materials must be decontaminated before disposal using an effective method. Effective decontamination methods are covered in Section 5.7.1 and Appendix F of this manual. Responsibility for decontamination starts with the waste generator. In some cases, the waste generator performs the actual decontamination. In other cases, the generator selects the decontamination system and then prepares the waste materials for treatment by others.

LBNL uses the term medical/biohazardous waste to describe wastes that are biological materials, or that may be contaminated with biological materials and require inactivation (i.e., decontamination) in an approved manner prior to final disposal. See the Medical and Biohazardous Waste Generator’s Guide (PUB-3095) for LBNL definitions and requirements for disposal of medical/biohazardous waste. Decontamination, collection, and disposal of medical/biohazardous waste will be conducted in accordance with PUB-3095, methods approved or known to inactivate the materials, and any requirements specified in regulatory permits (e.g., U.S. Department of Agrigulture (USDA)) issued to individuals.

image image image
Contaminated items considered medical/biohazardous waste.
Michigan State University, Office of Radiation, Chemical, and Biological
Safety (May 2010).
Labeled biohazardous container lined with a red biohazard bag. Transfer of closed biohazard bag to Source: waste pickup container. Source: LBNL EH&S.

The EH&S Division Waste Management Group manages the disposal of LBNL medical/biohazardous waste. It also manages the contract with a licensed subcontractor that transports, treats, and disposes of LBNL’s solid waste as regulated medical waste. Examples of such solid waste include materials that are placed in lined and labeled biohazardous waste containers, biologically contaminated sharps in sharps containers, and pathological materials such as carcasses.

Although Waste Management Group manages the waste component of the Biosafety Program, it is the responsibility of the waste generator to ensure that medical/biohazardous waste is properly:

  • Inactivated before disposal (e.g., treatment of liquid culture with bleach prior to sanitary sewer disposal), or
  • Contained in durable leakproof containers, labeled, and documented in the work area before further handling by the EH&S Division or the licensed LBNL subcontractor.

The Joint Genome Institute (JGI) is the only LBNL site that does not use a licensed subcontractor to dispose of solid biological waste as regulated medical waste. Instead, JGI uses autoclaves to sterilize solid, recombinant, biohazardous waste prior to disposal as detailed in PUB-3095.

5.7.4    Laboratory and Equipment Decommissioning and Moves

All surfaces and equipment should be cleaned and put into a safe condition prior to vacating laboratory spaces or relocating equipment. The Laboratory’s Space Management Policy in the Regulations and Procedure Manual (§1.20) requires that laboratory and shop spaces be cleared of debris and contamination prior to transfer of ownership. The decommissioning section of the CHSP provides a good general description of requirements and resources for decommissioning laboratories and equipment.

Decommissioning should include decontamination and waste disposal methods appropriate for the biological materials that may be present and the materials or equipment to be decontaminated. Decommissioning may include:

  • Laboratory surfaces and equipment should be decontaminated. Household bleach is commonly used in the concentrations and manners discussed in Appendix F, Section F.3.2.1, of this manual. Appendix F also provides other decontamination methods.
  • Biohazard labels should be posted on any equipment or containers that still contain or may be contaminated with RG2 agents or materials as discussed in Section 5.5.
  • Dispose of medical/biohazardous waste as described in Section 5.7.4.
  • BSCs and their filters must be decontaminated with a gaseous decontaminant prior to being moved, unless approved by the Biosafety Officer (see Section 5.6.4.2 (a)).
  • Custodians of equipment that will be moved by the LBNL Transportation Department must verify that the equipment is free of biological, chemical, and radiological hazards. This verification is accomplished when the equipment custodian places a completed LBNL Transportation Authorization Form on each piece of equipment to be transported (see PUB-3000, Section 5.8.13.1). Transportation Authorization Forms are issued to equipment custodians when they request an equipment move through the Work Request Center.

5.8 Access and Security

Laboratory supervisors and work leads conducting work at BL1 or BL2 must enforce LBNL Institutional policies that control access to the site and to laboratory facilities as described in the LBNL Site Security Plan. Policies and practices include, for example, the hosting of visitors and the issuance of gate passes, badges, and/or keys to control access to the site, building, and/or room based on each individual’s business needs. In addition, laboratory areas should have doors for access control. Consult the Safeguards and Security Web site for security policies and additional information.

In addition to the above access requirements, the following additional controls are applicable when working at BL2:

  • Laboratory doors should be self-closing and have locks designed in accordance with LBNL standards. When the laboratory is unoccupied during nonbusiness hours, access to the laboratory should be controlled (e.g., by locking doors to the laboratory areas and/or doors to the building entrance).
  • All persons entering the laboratory must be advised of the potential hazards and meet any specific entry/exit requirements as communicated through laboratory door postings specified in Section 5.5 of this manual. Minimum biosafety hazard advisories include a required biohazard symbol posted at the entrance to the BL2 laboratory. Any additional biosafety requirements necessary for advising and protecting personnel entering and exiting the area will be specified in the BUA based on a risk assessment.

Additional security assessments and security measures should be considered when select agents, other agents of high public health or agricultural concern, or agents of high commercial value are introduced into the laboratory. In this case, advisory recommendations of Section VI (Principles of Laboratory Biosecurity) of BMBL should be considered. In addition, when a security risk assessment has determined that additional physical security measures are needed to mitigate specific vulnerabilities, the laboratory or facility may be designated a property protection area. Lastly, when the agents are select agents or toxins (see Section 3.3.2.5), then the security requirements of the select agent regulations must be implemented as outlined in a specific security plan for the laboratory or building. The term biosecurity is often used to describe the administrative and physical security measures used to protect higher-consequence microbial agents or toxins from loss, theft, diversion, or intentional misuse.

Text Box:  5.9       Pest Management 

Biosafety level (e.g., BL1 and BL2) criteria in BMBL and the NIH Guidelines require a program to control pests such as insects and rodents. Pests such as flies, cockroaches, ants, or mice can mechanically transmit biological materials and pathogens.

Appendix G of BMBL provides guidance and requirements for Integrated Pest Management (IPM). IPM is a comprehensive program approach that integrates housekeeping, maintenance, and pest control services. The primary goal of IPM is to prevent pest problems by managing the facility environment to make it less conducive to pest infestation. Along with limited applications of pesticides, pest control is achieved through proactive operational and administrative intervention strategies to correct conditions that foster pest problems. Research supervisors, work leads, and LBNL Facilities are each responsible for elements of IPM for each operation.

The LBNL Facilities Division is responsible for the general construction and maintenance of facilities including the design of laboratory buildings, periodic floor cleaning, disposal of general trash, and pest management. Pest management includes maintenance of a contract with a licensed California State/County applicator to provide insect and rodent control services. The licensed applicator conducts preventative services (e.g., periodically spraying the foundation of a building) and controls reported infestations. The Facilities Division also maintains the Facilities Work Request Center (510-486-6274) to track and respond to requests to repair and clean facilities and control infestations.

Research supervisors and work leads must ensure implementation of the following IPM elements:

  • Program area surfaces and equipment can be easily cleaned (see Section 5.6.1) and are routinely cleaned and decontaminated (see Section 5.7.3).
  • Medical/biohazardous wastes are routinely placed in designated waste collection barrels (see Section 5.7.4).
  • The Facilities Work Request Center is contacted if additional services are needed from the Facilities Division to repair or clean the facility, or to control a pest infestation.

The following general guidelines may be used to prevent or control rodent infestations:

  • Use rodent-proof containers with tight-fitting lids for storing food, washed utensils, and garbage so that rodents are not attracted to the building. Dispose of trash as soon as possible.
  • Seal, screen, and cover all building openings greater than a quarter of an inch.
  • Place sheds, wood piles, or other structures and debris away (e.g., 100 feet) from buildings. Cut grass, brush, and dense shrubbery.
  • If a building has been abandoned or closed for long periods, open doors and windows to help ventilate the building, and then wait for at least 30 minutes before entering. Use mechanical ventilation if needed.
  • Use spring-loaded traps or appropriate EPA-approved rodenticides to control the rodent population.

Note Appendix G of this manual for guidelines on the cleanup of small dead animals, nests, or droppings.

5.10     Incident, Accident, and Emergency Response

This section outlines policy-related incident response and reporting. Biosafety-related incidents may include worker exposure to biological material, injuries or illnesses involving or resulting from exposure to biological material, spillage of biological material, or release of biological material outside of biosafety secondary containment. Such incidents may require reporting, medical evaluation and treatment, emergency response, incident review and documentation, and/or corrective actions.

Response to biosafety-related incidents will be managed in accordance with this section and the following guidelines, policies, and authorizations:

  • LBNL Emergency Response Guide
  • PUB-3000, Section 5.1 (Incident Reviewing and Reporting)
  • PUB-3000, Chapter 9 (Emergency Management)
  • PUB-533, Master Emergency Program Plan for LBNL
  • PUB-3000, Chapter 14 (Lessons Learned)
  • PUB-2488, Occurrence Reporting and Processing System (ORPS)
  • Safeguards and Security Program Planning and Management, DOE Manual 470.4-1, Section N (Incidents of Security Concern)
  • applicable Biosafety Work Authorizations (see Section 5.1 of this manual)

5.10.1 General Incident Response and Reporting

Text Box:

Worker instructions for reporting incidents and general emergency response are covered in the LBNL Emergency Response Guide. This guide provides response guidelines for a variety of common emergencies including biological spills and personal injury. It also provides both emergency and nonemergency telephone numbers. The guide is available on the EH&S Emergency Services Web site and as a wall-mountable flip chart. The Emergency Response Guide must be posted in areas wherever work with biological materials is conducted, and emergency response guidelines should be employed when responding to incidents.

Chapter 5, Section 5.1, of PUB-3000 also provides general requirements for incident reviewing and reporting such, as responding to emergencies, and reporting and reviewing incidents and occupational injuries or illnesses.

Division Directors and their designees are also responsible for reporting certain adverse or abnormal occurrences in accordance with the Occurrence Reporting and Processing System (ORPS) polices and system. In addition to ORPS reporting, incidents of security concern must be reported to LBNL Security.

Text Box:

5.10.2 Worker Exposure, Injury, or Illness

Workers are responsible for immediately reporting all occupational injuries, illnesses, and exposures to biological materials of concern to their supervisor and Health Services. The Biosafety Officer must also be notified of exposures to biological materials of concern or any related illness. Health Services will manage the occupational health case and initiate a Supervisor Accident Analysis Report (SAAR). In addition, an incident review team will be assigned to review the case and determine the causes and any needed actions. See PUB-3000, Chapter 5, Section 5.1, for additional information.

Biological materials of concern related to exposures include materials or animals that may contain agents or properties that have known, potential, or unknown health risks. Examples of materials include all recombinant genomic materials, viable biological microbes in research, or Risk Group 2 or higher agents or materials. Examples of worker exposures to such biological materials of concern include:

  • Biological materials in contact with mucous membranes such as eyes, nose, or mouth.
  • Biological materials in contact with an open area of skin (e.g., cut or abrasion).
  • Cuts or punctures with sharp objects that may be contaminated with biological materials.
  • Exposures to humans or animals in research in a manner that is known to transmit disease.
  • Exposure to the blood of other people.

Additional information on biosafety-related accidents, response, and reporting is contained in the applicable BUA or ECP (see Section 5.1).

imageimage5.10.3 Biological Spills and Cleanup 

Supervisors, work leads, and PIs are responsible for ensuring that spill response procedures and materials needed to safely respond to potential biological spills are maintained in operations where biological materials are used.

The Emergency Response Guide, which must be posted in work areas, provides guidance and materials needed to safely respond to and clean up most biological spills at LBNL. Additional guidance regarding a variety of biohazardous spills inside and outside of biosafety cabinets is provided in Appendix G. Any additional guidance or materials needed to safely respond to or clean up biological spills must be included in the operation’s Biosafety Work Authorization (see Section 5.1).

Response to biological spills should be conducted in accordance with applicable guidelines or requirements contained in the “Biological Spill” section of the Emergency Response Guide, Appendix G of this manual, and the operation’s Biosafety Work Authorization.

5.10.4 Additional Biosafety Incident Reporting

Line management, the Biosafety Officer, the Responsible Official, Waste Management, the IBC, and other LBNL employees have various internal and regulatory responsibilities for reporting biosafety-related incidents. The following incidents must be reported to the Biosafety Officer in the EH&S Division:

  • Worker exposure to biological materials of concern (see Section 5.10.2).
  • Injuries or illnesses involving or resulting from exposure to biological materials (see Section 5.10.2).
  • Release occurring outside of secondary biosafety containment of medical/biohazardous waste, biohazardous materials, recombinant genomic materials, or other regulated biological materials that have not been inactivated.
  • Incidents related to select agents or toxins (see definitions in Section 3.3.2.5).
  • Biosafety-related regulatory inspections or findings.

Release outside of secondary containment includes, for example:

  • Spill of a material outside of its laboratory facility and outside of its primary and secondary containers.
  • Medical/biohazardous waste that has not been decontaminated but is disposed of in a sanitary sewer or in trash outside the laboratory where the work is conducted.
  • Environmental release of a viable agent, animal, plant, or pest material that is regulated against release or may cause damage to humans, plants, animals, or the environment.

5.11     Procurement, Transportation, and Transfer

5.11.1  Procurement

Procurement of biological agents, biological toxins, and other selected laboratory equipment or supplies are controlled at LBNL using a graded approach through the procurement process. These controls are designed to screen for biosafety and other hazards. They also provide a means for EH&S to assist requestors in implementing biosafety controls or complying with regulations. The following LBNL procurement controls are related to biosafety:

  • Expenditures for goods and services must be performed in accordance with LBNL procurement policies and through the Procurement and Property Management Department.
  • Only personnel authorized by the Chief Financial Officer or the Procurement and Property Manager may commit the Laboratory to goods or services. These authorized personnel categorize items to be procured so that assigned EH&S personnel will be notified of the procurement.
  • EH&S personnel notification or pre-approval for EH&S-related items that are on the restricted items list. EH&S personnel are notified of items such as, but not limited to, biological agents, biosafety cabinets, hoods, HEPA filters, chemicals, gases, eyewashes, safety showers, respirators, dust masks, and laboratory refrigerators. Items specific to biosafety that are on the restricted items list include:
    • Biological agents – The LBNL Biosafety Officer is sent a notification e-mail that procurement of a biological agent has been initiated, and the Biosafety Officer contacts the requestor if needed.
    • Select agents and toxins – Only individuals in LBNL Procurement may purchase select agents or toxins (see Section 3.3.2.5 and Appendix B, Section B.2, of this manual) with approval from the Biosafety Officer.
    • Biosafety cabinets – Selected EH&S Industrial Hygienists are e-mailed a notification that procurement of a BSC has been initiated, and the hygienist contacts the requestor as needed.

5.11.2  Transportation and Shipping

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Employees who wish to transport or ship a biological material must ensure the material is moved safely and in accordance with LBNL biosafety transportation and shipping policy detailed in Appendix H of this manual. Appendix H should be used to assess if the material is a regulated biological material and how it should be moved. LBNL’s policy for workers handling materials at LBNL is based on biosafety requirements and U.S. and international transportation and shipping regulations. A number of biological materials may be transported directly by LBNL researchers in accordance with LBNL requirements, but all biological materials shipped by a contracted shipping company (e.g., a common carrier such as FedEx or UPS must be moved through LBNL Receiving, Transportation, and Shipping. See Appendix H for additional information.

Borders5.11.3  Import, Export, and Transfer Restrictions           

Materials being transferred (i.e., imported, exported, or transferred) from one location or person to another may be subject to regulatory restrictions or permit requirements. U.S., state, and foreign government agencies restrict and permit the movement of certain biological materials across borders to prevent threats to public health, agriculture, environment, and national security.

The supervisor, work lead, person transferring the biological material, person requesting transfer of the biological material, and permit holder all have LBNL or legal responsibilities for complying with transfer requirements, obtaining any required permits, and following the conditions of the permit. Regulatory requirements, permits, and permit conditions related to the transfer of biological materials should also be included in the Biosafety Work Authorization. The LBNL Biosafety Office and IBC will review the researcher’s assessment and documentation of transfer requirements during the work authorization review process.

Appendix I of this manual provides an outline of U.S.-based regulatory restrictions, permits, and lists related to the transfer (i.e., import, export, or transfer) of biological and related materials. Appendix I may be used by LBNL personnel as a starting point for determining whether biological materials are potentially regulated by U.S. agencies. It may also be used to determine whether there are restrictions or permits applicable to transfer of the material. Contact the LBNL Biosafety Office for additional advice.

General controls for exporting from LBNL are outlined in the Berkeley Lab Export Control Manual. Export controls are based on government rules and regulations that govern the transfer of the following items to non-U.S. entities or individuals, regardless of where or how the transfer takes place:

  • Goods (systems, components, equipment, or materials)
  • Technologies (technical data, information, or assistance)
  • Software/codes (commercial or custom)