What is the first step in the immediate aftermath of an exposure to a biohazard involving a percutaneous injury through the skin )?

Presentation on theme: "Risk Assessment & Risk Management"— Presentation transcript:

1 Risk Assessment & Risk Management
EMD 545b Lecture #2 Risk Assessment is the most critical factor in Biological Safety. By definition, the risk assessment occurs prior to the initiation of an experiment involving biohazards. It is the process that identifies the most likely risks associated with procedures involving biohazards. Together, with Risk Management, this process can be used to provide the maximum protection for workers prior to engaging in procedures that present a risk to biohazards.

2 Risk Assessment US Airways Magazine, October 1991
This cartoon recreated from a old US Airways Magazine correctly identifies the presence of a risk, the large boulder teetering on the edge of a cliff. One that could potentially harm people or cause damage to items in its path. US Airways Magazine, October 1991

3 Risk Management US Airways Magazine, October 1991
The next part of the cartoon demonstrates what could happen if the risk was never identified or never acted upon. Some of the greatest safety programs or interventions occur in the aftermath of an incident. Appropriate Risk Management measures are implemented prior to an “event.” A good program of Risk Assessment and Risk Management involves all relevant groups to review the proposed risks involved and identifies measures to control them. US Airways Magazine, October 1991

4 Risk Assessment/Risk Management
Risk Identification Adverse events? Risk Estimation Probability of adverse event? Risk Management Control measures? Risk Assessment involves identifying all of the incidents or events that could happen and estimating the likelihood of their occurrence. Probability will give you a range, usually wide and is difficult to determine with the lack of actual data. Generally, the risk estimator will be left with using phrases like low, moderate or high when qualitative approaches are used. Risk Management refers to the steps taken to prevent or minimize the chance of a negative outcome.

5 Risk (Definitions) “Possibility of loss, injury, disease, or death.” Webster's Medical Desk Dictionary (1986) “The probability that exposure to a hazard will lead to a negative consequence.” David Ropeik, George Gray (2002) “To risk living is to risk dying.” Anonymous Various definitions of Risk to provide a perspective on the field. Probability is inherent in the definition of risk, or the chance of a negative outcome. What is also important in the last definition is that virtually nothing is without risk. Each institution, group, or person performing a risk assessment must weigh all of factors and determine if the probability of risk is acceptable and also determine if the control measures are adequate to mitigate the risk and lower the probability to an acceptable level.

6 Risk Assessment The emergent science based on toxicology, epidemiology and statistics that utilizes qualitative and quantitative hazard analysis to provide the public with a reasonable estimate of probability of harm. “Not a scalpel, but a crude tool that allows you to make estimates.” Peter Preuss, US EPA Risk Assessment is a science and involves a variety of disciplines to reach an estimate. In an event out of their control, like a release or spill, the public wants to know how something happened, why it happened, what can happen to them, where they can go for medical assistance if needed, how to get more information, what’s going to be done about it, when will it be done, and how it will be proven that it is safe (and what will be done to prevent this from happening again). Toxicology provides medical information on how much of the toxic material is likely to cause an effect in an exposed individual. Any data, such as the dose required to cause an infection can be used in creating these estimates. Also, being able to calculate the worst case estimate of the amount released, the dilution factor in air (in space or in the environment), the distance to an exposed population, duration of exposure, and individual susceptibilities are a few of the factors involved in determining the risk for the public. The ability to measure the hazardous agent in air, on surfaces, or within bulk water and soil samples after an incident and again after mitigation goes a long way in estimating the potential risk and ensuring the public. For chemical hazards, there are many direct reading instruments that can be used. For Biological agents, such measure rarely exist. Samples could take days to weeks to run after an incident, which is far too long to be useful in the immediate aftermath of biological incidents. Therefore, qualitative measures are generally utilized.

7 Risk Assessment Difficult process (expertise of many fields needed)
Involves uncertainty Range provided (not a specific number) Estimates for society (individual risk may vary) “Reasonable worst-case estimate” (better to overestimate than underestimate risk) Costs and benefits of proposed actions helpful For biohazards, many groups are needed to help determine the risk profile. Principal Investigators, Microbiologists, occupational health and safety professionals (biosafety officers, industrial hygienists, hospital epidemiologists), employee health physicians, molecular biologists, immunobiologists (who can help with the determination of what could happen if the biohazard gets inside the body) legal representatives (who can weigh in on the acceptance of risk for the institution), and administrative officials from an institution (who also weigh in on whether or not the institution should perform this activity) may all be needed to participate in a risk assessment. To determine the likelihood of a bad outcome and whether or not appropriate risk management measures can be used to lower the chance of a negative event. The experience of a group handling biohazards is also an important factor to consider as accidents are more likely to occur when personnel are not trained in good microbiological practices, experienced in handling agents that present that level of risk, and consistently follow prescribed work and containment practices. Worst-case estimates should always be the starting point in a risk assessment and work back from there. The public should always know what can happen, but more importantly what you’ve done to protect them in the rare event that something does happen.

8 4 Steps in Risk Assessment (Jeff Wheelwright, 1996)
1) Identify health hazard 2) Quantify hazard 3) Exposure assessment (from source to at risk person) 4) Determine probability of disease (based on exposure estimate and potency of agent) Simply put by the EPA, the risk assessment process is clearly described here. This is much easier for a chemical than a biological agent. Risks for certain biohazards may not be known and it may be difficult to estimate what level of the agent will be created in an event, especially if associated with new equipment. Determining the risk for a biohazard generally starts with the known agents and those that could potentially be present. Quantification is difficult, but a VERY IMPORTANT piece of the puzzle for biological agents is that they can replicate. Therefore, any amount that gets into the body, if it can evade the immune system, replicate within that host and find an area of the body that it is tropic for, it may be able to grow to concentrations that can cause problems. The quantification is not as important here as it is “built in” to the agent. The route of exposure is an important step, the biohazard must find a way into the host from the release point or work setting. The final step should be determined in advance for the proposed experiment as well as “unknown” exposures are likely to occur with biohazards and all those involved must be able to recognize the signs and symptoms of exposure and incubation periods, as the negative outcome will not occur in the immediate aftermath of the exposure. If the probability of disease is high and the potency of virulence associated with the agent is also high, a question must be asked if this experiment should be conducted. Could a safer agent be substituted in place of the high risk one? Could similar results be achieved with an attenuated agent? If so, these avenues should be pursued first.

9 Biohazard Epidemiology
Incidence of Hepatitis among Danish clinical chemistry workers 7X higher than general population (Skinholj, 1974) Risk of acquiring TB 5X greater among medical lab workers in England than general population (Harrington & Shannon, 1976) Epidemiologists have proven that microbiologists are at greater risk of infection due to increased exposure that the general population. These studies helped to confirm the risk in the absence of quantitative exposure data. Such results pushed containment and control measures to the forefront and helped to protect workers in these laboratories, to reduce the probability of infection with these agents.

10 Hierarchy of Controls Anticipation Recognition Evaluation Control
substitution administrative engineering work practices personal protective clothing facility features Part of the risk assessment process is anticipating what the hazards are associated with a biohazard and the proposed procedures that will be conducted. This recognition of a hazard and risk helps to determine the next step in the process, the evaluation of the risk for those involved. When instruments are available for quantitative measures, trained professionals can monitor the levels of a hazard generated from a procedure and compare those levels to toxic doses or acceptable exposure levels. When such measures cannot be undertaken, qualitative measures take over. How is the agent transmitted, what is the infectious dose, what is the pathogenicity, virulence, incubation period, and assigned Risk Group for the biohazardous agent. Has it been associated with other lab acquired infections, outbreaks, etc. What is the morbidity, mortality of the agent? Are their pre-exposure and post-exposure treatment measures available? Are there individuals who are more susceptible to infection than others? How long can this agent survive in the environment? How to you inactivate or decontaminate this agent on surfaces, equipment, in spill situations? Will the proposed procedures generate an aerosol? Are sharps involved? Animals? Can this be shed by the animal? Can it be transmitted via an animal bite? These are just some of the risk assessment questions to ask. Once you start to get answers to these questions, you can being forming a risk assessment profile. With that profile, you can go along to various control options to lower the risk as much as possible. This lecture will cover the basic elements needed to conduct the risk assessment, raise awareness of some of the laboratory procedures that may involve risk, and introduce the key factors associated with Risk Management when dealing with any hazard (isolation of the hazard with containment barriers and engineering controls, safe handling of the hazard or good work practices, and secondary containment of the hazard to protect others not associated with the work or facility design parameters).

11 Biohazard Risk Assessment
Qualitative exercise (inexact) General guidelines to assess/control risk: agent in use, volumes, concentration proposed practices/procedures proposed location training, experience, health status of worker The first bullet has been touched upon in earlier slides. Additional factors to consider in the risk assessment process is the expected amount of material that will be handled, the types of procedures and the proposed biosafety work practices of the staff. How the agent is handled is critical in controlling exposure or release. The proposed work practices and the experience of the staff are very important. 90% of lab acquired infections are related to a break down in safe work practices. Making sure that the individual handling the agent is healthy, a safe worker, and trained goes along way in mitigating risk.

12 Biohazard Risk Assessment
Use to determine appropriate combination of containment lab practices safety equipment facility design Primary Containment protects handlers and those in immediate vicinity Secondary Containment protects environment and those outside the lab Risk Management logically follows the risk assessment component. Biosafety is predicated upon addressing how agents are handled, using specialized equipment to contain hazards, and ensuring that biohazards are handled in appropriate locations. Primary containment controls hazards at their source or as close as possible to the point of generation. Secondary containment, usually the room serves as the secondary barrier and is the line of secondary containment to confine hazards if released from primary containment. Evaluation of both are critical in any proposed project.

13 Biohazard Risk Assessment Pathway
Principal Investigator (initiates risk review) Biosafety Officer (assists PI) Institutional Biosafety Committee (must review and approve PI’s submission) Assistance through published listings, guidelines (U.S. and abroad) other experts at host institution, local public health other institutions working with same agents Government entities (CDC, NIH, USDA, FDA, etc.) The person proposing work with biohazards is responsible for the initial risk assessment. Those responsible for protection of others within an organization (the Biosafety Officer, the Institutional Biological Safety Committee, the President, CEO, CFO, Provost, Dean, Department Chair, Vice President, Responsible Officials, etc.) must verify that an appropriate risk assessment was completed by the lead researcher. This process also verifies that adequate Risk Management factors are in place for protection of staff, others within the building or within the community. Published Risk Groups are starting points for this process. Experts should be consulted wherever necessary and don’t forget that many government offices are established for public outreach and also may be contacted for assistance before initiating certain projects.

14 Risk Assessment Pathway
Principal Investigator initiates process Qualitative process Agent Virulence, pathogenicity, communicability, environmental stability, dose, route of exposure, availability of therapy Use Risk Group Lists Consider proposed procedures Operations, quantity (volume/concentration), generation of aerosols, sharps, animals Again for biohazards, the risk assessment is primarily a qualitative process. As mentioned previously, the agent, the proposed procedures and materials or animals involved, the supplies and equipment involved all must be evaluated for proposed risk. Knowledge of proposed operations, their associations with prior incidents can be used in this process. For new procedures and equipment, consideration must be given to the potential for release. Procedures can be performed with surrogate organisms, indicator organisms that can be sampled for on surfaces or in the air following the procedure after the creation of aerosols, or dyes that fluoresce under black light to identify potential release points. Safe sharps devices should be employed whenever possible, following an evaluation period that proves their effectiveness and adequate or suitable training on their use for the proposed group of workers. A good take home message to impart to students is that the 1st two elements of the Risk Assessment with biological hazards are the Agent or Pathogen along with the proposed procedures or manipulations involved. Once this information has been gathered and exhaustively detailed and understood by all involved in the risk assessment (Lead Researcher/PI, the Biosafety Officer, and Institutional Biosafety Committee), can the next steps or Risk Management process be initiated.

15 For an interactive exercise, BEFORE SHOWING THIS SLIDE: ASK THE CLASS TO TELL YOU HOW BIOHAZARDS OR PATHOGENS CAN ENTER THE BODY. Hopefully, the collective experience and awareness of the group will be able to identify the 4 routes of exposure for pathogens in the workplace. Through facial mucosal membranes (eyes, nose, and mouth), via inhalation of aerosols, ingestion (eating, drinking in the laboratory, mouth pipetting, poor hygiene), and through intact (needlesticks, animal bites, etc.) and through non-intact skin (dermatitis, eczema, poison ivy). If you have the accident, injury, illness logs from Employee Health or Worker’s Compensation for your institution, you can ask the class to guess which route of exposure is most often reported, or the most prevalent route of exposure over the past so many years, etc. Generally, exposures that you can “feel,” such as percutaneous injuries like needlesticks, cuts, and bites along with splashes to the face will be reported, thus sharps injuries generally lead the list of reportable injuries, usually followed by the “splashing” events. Rarely, will individuals be able to recollect creating an aerosol and inhaling it as they won’t smell, taste, or see the biological aerosol generated. They also may not even be aware of the inadvertent touching of their facial mucous membranes by contaminated hands. If they are eating, drinking, smoking or mouth pipetting in the laboratory, they may not be aware that these bad practices can lead to exposure or simply don’t care. Individuals in this category should not be permitted to work with biohazards or simply not be allowed to work in the laboratory at all.

16 Routes of Exposure to Infectious Agents
Inhalation of aerosols Through intact or non-intact skin (needlestick, injury (broken glass), animal bites or scratches, vector (mosquito, tick, parasite), eczema, dermatitis Mucous membranes of eyes, nose or mouth Ingestion (mouth pipetting) Contact (indirect transfer from hands or contaminated surfaces) Hopefully, the class discussion from the previous slide has covered most of the information provided on this slide. Aerosols were introduced in the first lecture, will be covered again if subsequent slides. But remind the class that is important that all involved in situations that involve exposure to biohazards must be aware of what an aerosol is (a suspension of liquids or particles in air – its weight determines how long it will stay in the air) and how to control and contain them to prevent exposure to the individuals handling them as well as to those around them or in the community. Aerosols represent the greatest risk for exposure to those not exposed if not properly contained. There are so many avenues for skin exposure –ask the class to share experiences or incidents from colleagues involving sharps injuries. One LAI with Hepatitis B Virus that resulted in a fatality involved a clinical microbiologist who worked with human blood in the laboratory during a bout of poison ivy. The tremendous opportunity for access the to bloodstream was the leading cause in this case. Although this case occurred prior to the mandatory offer of the Hepatitis B Virus immunization, the take home message is to ensure that those handling biohazards are aware that they should not perform work with biohazards if they have wounds that cannot be adequately covered with waterproof bandage and two pairs of gloves. Also, many other pathogens may be present in human blood and other clinical materials. For situations involving broken skin, employees should have an evaluation by the Principal Investigator and Employee Health, who share responsibility in assessing the level of risk of exposure for an individual with non-intact skin. It may be easier to simply employ a “do not work with biohazards policy” for employees with non-intact skin. It will depend on the risk involved. Many of the mucous membrane exposures are a result of a failure to recognize that when working with a liquid, regardless of the quantity, that splash or splatter could reach the facial mucous membranes. Appropriate barriers (shields, biosafety cabinets, etc.) should be utilized and full face protection should be utilized when working outside of these barriers. A good take home for the students is that >250,000 HIV virions can fit on the head of a pin, thus even that very little flick of liquid could be carrying a very significant dose of a infectious agent. A review of anatomy is not bad in these slides (respiratory deposition for aerosols can be discussed above in regard to size of aerosol in microns, with those 5 microns or less usually getting to the mid and lower lung – again mention that these are ranges only – larger particles can still bypass our defense mechanisms, but on average, these are the sizes that do). Also, for those working with gastrointestinal pathogens and any other pathogen whose primary route of exposure is ingestion (any of the organisms that are tropic for the gut), it is important to discuss the potential route of entry to the gut via the nasal lachrymal duct. This duct runs from the eyes and can carry contaminants that reach the eye to the rear of the throat, where they are swallowed. Dr. Tom Hamm uses this anatomical lesson for animal handlers who are constantly dealing with contaminants in animal rooms to urge them to always wear their full face protection. So something that can get into the eye, can also get into the stomach, an important “fact” to pass along. Another element to pass along (perhaps in later slides) is that when individuals are interviewed to review their exposure incidents following treatment and evaluation, most are invariably not wearing face protection at all, or usually only covering SOME of the facial mucous membranes – safety glasses will only cover the eyes – a surgical mask will only cover the mouth. From a splash/splatter prevention policy, both must be worn to cover the eyes, nose and mouth. (or a full face shield). Ingestion – most are not taught to mouth pipette any longer, but this is still identified on laboratory inspections. Entomologists, Embryologists, and Electrophysiologists are among the professions still inclined to teach mouth pipetting. All regulations prohibit this practice, even when not working with biohazards, so it is not only dangerous to the individual performing this procedure, but to the institution if this practice is conducted. Contact Transmission is important to emphasize, from a standpoint of contamination control and the importance of disinfection and decontamination. Hepatitis B Virus can survive for 7 days at room temperature on a surface and remain an infection risk. Mycobacterium tuberculosis in a sputum sample left on a surface away from UV light can survive for 6 months (and longer) under similar conditions. Researchers must decontaminate surfaces contaminated by biohazards and others must recognize the potential for inadvertent exposure and keep their hands away from their eyes, nose and mouth.

17 Infectious Agents are Classified by Level of Hazard
4 Agent Risk Group Classifications RG RG RG3 RG4 Low individual risk Moderate individual risk High individual risk Assistance in the Risk Assessment process is provided by the Risk Ranking of biohazards into Risk Group classifications. Many organizations have established Risk Groups for biohazards and each begin with a ranking of lowest risk agents (Risk Group 1 or RG1) to the highest risk agents (Risk Group 4 or RG4). The next set of slides provide examples of the 4 risk groups with samples of agents in each category. The Routes of Transmission are associated with the risk group assignments, although this is not mutually exclusive. The risk groups also presuppose a healthy adult population and do not factor in the immunocompromised, young or old populations. RG1 – not infectious to healthy adults RG2- generally agents that are transmitted via ingestion, through mucous membranes, and through the skin. The severity of disease is not as significant (usually) as high risk agents, and treatment is generally available. Mortality and morbidity is lower than high risk group classifications. RG3-all routes of exposure are in play, especially the AIRBORNE route, severity in terms of morbidity and mortality are elevated and infectious dose is generally lower for RG3 agents. Treatment may/may not be available. RG4- all routes of exposure, much more significant mortality/morbidity than RG3 agent, treatment usually not available. One quick “cute” way to let the class frame Risk Groups from Gwladys Caspar is as follows: “RG1 – Don’t Drink it”; “RG2 – Don’t Touch it”; “RG3 – Don’t Breathe it”; and “RG4 – Don’t do it in Connecticut!” (Enter your state here – Gwladys used to say Massachusetts, but with the proliferation of BSL4 laboratories, this won’t work in every state). High risk to community No risk to community Low risk to community

18 Risk Groups (RG) RG1 RG2 Both RG1/RG2 can be used in a basic lab
Not infectious to healthy adults e.g. E. coli K12 strains, B. subtilis, S. cerevisiae RG2 Infectious agents of varying severity, treatment usually available, predominantly bloodborne, ingestion, and mucous membrane routes of exposure e.g. Salmonella, Shigella, Vibrio, Plasmodium, Hepatitis B Virus, Cryptococcus neoformans Both RG1/RG2 can be used in a basic lab containment equipment to contain aerosols Self-explanatory. Rabies virus is a good example to use of an agent where the Risk Group Classification varies between organizations (some locations have the agent as RG2, and others as RG3). Because there is an effective immunization to protect workers and in nature, Rabies virus is generally transmitted via mucous membranes and through the skin, some organizations put the agent at RG2. However, the first two laboratory acquired infections with Rabies virus have been associated with the inhalation of aerosols from unconfined procedures. There is also documentation of Rabies infection in nature from caves “overloaded” with bat guano that have been associated with aerosol transmission from the inhalation of rabies contaminated airborne “dust.” Given the severity of disease outcome among those not protected, the potential for airborne transmission, RG3 or enhanced RG2 is appropriate. This is also a good time to mention that the “laboratory” can be a more DANGEROUS location than nature. Concentrations (through amplification) of pathogens can reach levels that are not seen in nature. Procedures and manipulations can create avenues of exposure that may not have been identified in nature. THE LABORATORY CAN BE A DANGEROUS PLACE – LOOK AT THE EPIDEMIOLOGY. WE CAN HAVE UNNATURAL INFECTIONS IN THE LABORATORY. Two very good take home messages for students and biosafety professionals.

19 Risk Groups (RG) RG3 potential to cause serious or lethal disease, airborne route of exposure (and others), treatment generally not available, lower infectious dose. Containment Lab 2 doors off general corridor, dedicated air handler, controlled airflow, all work contained e.g. TB, Vesicular Stomatitis Virus, Yellow Fever Virus, Coxiella burneti, Francisella tularensis Many of these agents are in this category not only for their potential to cause serious disease, but for the notable RG3 agents, their ability to infect many from single releases or events. Thus the controls required for RG3 agents are more rigorous. This will be touched upon subsequent course lectures.

20 Risk Groups (RG) RG4 Dangerous, exotic agents with high risk to individual and community. Aerosol transmission along with all other routes. Very low infectious dose, high mortality rates. Building within building approach for research purposes. e.g. Ebola virus, Marburg virus, Junin, Lassa, Machupo, Sabia, Equine Morbillivirus (Hendra-like viruses), Tick-Borne Encephalitis Viruses Agents classified at RG4 have generally been associated with outbreaks that result in elevated morbidity with usually no treatment available. RG4 agents are reserved for Maximum containment facilities that are totally isolated from the Building that it is housed in, with treatment or purification of all of the air, liquids, and solids leaving the facility. Individuals wear fully encapsulating research suits (connected to clean breathing air outside the lab space) that are showered with disinfectant upon exit. Statistical rates of infection and death can be given to the class for some of the agents (roughly 90% of those infected in the first Ebola outbreak died from the infection, etc.)

21 Risk Assessment Pathway
Principal Investigator responsible for completing initial risk assessment Start with risk group for parent organism Consider the proposed procedures Identify Risk Management Procedures Facility design elements Safety or containment equipment Work practices Most of the U.S. and international regulations, standards, or guidelines begin with the primary user’s assessment of risk. They should be “expert” on the biology of the organism that they are handling and understand the risk assessment factors associated with that pathogen. They are also aware of what they wish to do and must list all of the proposed procedures from the receipt of the organism and storage in a freezer through use and final treatment and disposal of the agent. Every piece of equipment to be used in every location, including animal facilities and core equipment rooms must be identified to examine the full range of potential risk and exposures. All of the supplies should be identified and listed. Once this process has been completed, the end user should begin to identify the avenues for potential exposure and then start the implementation of Risk Management or Control measures.

22 Laboratory Safety Containment Levels
4 Laboratory Biosafety Levels BSL1 BSL BSL BSL4 A corollary to Risk Groups, which detail the inherent hazards associated with the agent, are Biosafety Levels (Biocontainment Levels or Containment Levels), which are associated with the level of controls employed to protect those handling agents in the various RG’s. Risk Groups are not Biosafety Levels and Biosafety Levels are not Risk Groups. Risk Groups are associated purely with the pathogen. Biosafety Levels are associated with the confinement or containment of the pathogen (and the proposed procedures associated with the pathogen). Students who have previously worked or studied in a laboratory have already been inside a BSL1 or BSL2 laboratory. The BSL3 laboratory will be reviewed in upcoming lectures and exercises. Another important message to get across to students is that YOU CAN SIMPLY OVERLAY THE RISK GROUPS ON TOP OF THE BIOSAFETY LEVELS AND AUTOMATICALLY SELECT THE CORRESPONDING BIOSAFETY LEVEL. Risk Assessment is required in this process. All of the factors associated with the pathogen and the proposed procedures allow professionals to make an informed decision in the selection of an appropriate Biocontainment Level for the proposed work. A RG1 agent may be moved to BSL2 if the proposed work is large scale (Sacchromyces cerevisiae) if others in the lab are allergic to yeast. Work with an attenuated RG3 agent may be downgraded to BSL2 containment upon verification of attenuation. Work with a RG2 agent, such as Chlamydia trachomatis or Chlamydia pneumoniae may require BSL2-enhanced or BSL3 containment if the procedures have high risk of generating aerosols (ultracentrifugation). Experiments with pathogens in animals can create similar shifting (higher or lower) in the selection of a biocontainment level depending on the disease caused in the animals and the potential for shedding and transmission to other animals and humans. Work with the RG3 agent Venezeulen Equine Encepahlitis (VEE) virus in the laboratory can be safely performed at BSL3 (with enhanced facility features). Work with VEE in horses may require a BSL4 facility to adequately contain an agent that represents both a high risk to both researchers and other animals. Risk Assessment is responsible for extracting this information, gathering the experts to help review the information gathered, and paves the way for the selection of appropriate Risk Management containment measures. Basic laboratory, confine aerosols in biosafety cabinet if needed Containment lab, 2 door separation from general traffic, negative air flow, alarms Maximum containment lab, building w/in building, all features isolated, pos. pressure suits, glove box type isolation

23 Hybrid Biosafety Level
BSL2/BSL3 (BL2+) Creutzfeld Jacob HIV High risk clinical specimens BSL3-Enhanced (HEPA filtered exhaust Lab) Yellow Fever, Rift Valley Fever Virus, VEE Rickettsia rickettsii Risk Assessment also sets a foundation for a rational approach to containment. Some RG3 agents that do not have an airborne route of exposure, such as HIV and Transmissable Spongiform Encephalopathy agents, can be safely handled in BSL2 lab, with strict BSL3 practices and containment equipment. However, before final approval of these designations, your local, state, and federal regulators must be consulted for authorization or endorsement. High risk clinical specimens should be moved up in containment as well. Samples from patients in an “unexplained illness or unexplained death” study warrant elevated precautions. BSL2-enhanced or BSL3 may be needed for such specimens until the pathogen is identified. Regulators may also mandate/specify that facilities have certain control measures before allowing you to work with high risk pathogens. HEPA filtration of exhaust air which may be an option in may BSL3 guidance documents may be required for work with certain RG3 agents. Note: HEPA filtration of exhaust air is becoming an “industry custom” for BSL3 laboratories (especially when there is an airborne route of exposure).

24 Unknown Specimens Facility Evaluation (highest level of protection available) “B.A.R.E” Block All Routes of Exposure Another concept an acronym created by the Yale Biosafety Office for its Principal Investigators is the “BARE” Policy. Block All Routes of Exposure. If the pathogen is known, this is easy, block all of the potential routes of exposure known for the agent. When the pathogen in unknown, BARE is utilized (after risk assessment indicates that the work may be safely performed at your institution) to block all avenues of exposure. Work inside a biosafety cabinet, full face respirator worn by the researcher, eliminate sharps from the procedure, etc.

25 Containment achieved with:
Good microbiological practices Safety Equipment Facility Design Risk Management is generally achieved through a combination of good microbiological work practices, the appropriate utilization of containment equipment and personal protective equipment, and laboratory design.

26 Risk Assessment Pathway
Institutional Biosafety Committee verifies and approves PI Risk Assessment Review of written risk assessment Verification of personnel training and experience Biosafety courses Hands-on experience/proficiency Safety record Inspection of facility and work practices Formal approval of protocol Once the Risk Assessment (and Risk Management process has been completed by the lead researcher or Principal Investigator), the Institutional Biosafety Committee (IBC) must document that an appropriate risk assessment has been completed. In addition, the qualifications of staff, adequacy of the work location and containment equipment must also be checked. If the IBC does not have knowledge of the qualifications of the personnel, arrangement can be made to “watch” the personnel perform the proposed protocol with BSL1 or mock materials first to verify conformity with established work practices. The IBC must also formally document approval of the protocol and communicate their decision to the Principal Investigator. The protocol should not start until the Committee has issued the formal approval.

27 Find Assigned Risk Group for:
Brucella canis Chlamydia trachomatis diagnostic work high concentrations Francisella tularensis diagnostic/clinical work cell culture experiments Coccidioides immitis clinical specimens cultures Prions human prions animal prions Rabies virus HIV/SIV research scale Vesicular Stomatitis virus lab adapted strains Isolates from livestock rDNA, Insertion of oncogene into human cells Vesicular Stomatitis virus-NJ with HIV gp 120 Botulinum toxin INTERACTIVE IN-CLASS EXERCISE. Handouts to provide for the students are: Appendix B from the NIH rDNA Guidelines Agent Summary Statements from the latest Edition of the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories Risk Group Tables from the website of the American Biological Safety Association ( Note: as some of these documents are large, you can provide excerpts for the agents Ask the class to work together to come up with the Risk Groups assigned for the agents on the slide. Ask them to write down their findings from the various resources on the slide adjacent to the agent or description of work below the agent. For the recombinant work – help guide the class through an assessment of what would be a good starting point. Human materials are generally RG2 – oncogenes are that level as well, but require additional containment along with safe sharps precautions. Vesicular Stomatitis-NJ is a lab-adapted strain of VSV, it still represents a risk, but adding an HIV protein doesn’t expand the “infectiousness” of the recombinant molecule, but will create a “new” hazard in that those who are exposed to this may test “false-positive” on an HIV antibody test. Again, safe-sharps precautions and documentation and follow up of all exposures with adequate documentation are required here.

28 Risk Assessment & Risk Management
Prior Planning Prevents Poor Performance The Old Coaches adage – introduce the 5 P’s to the students. Risk Assessment is advanced planning and usually the more “appropriate” preparation can help to minimize or prevent untoward events, such as Laboratory Acquired Infections, spills or releases, or other non-compliance events.

29 Risk Assessment & Risk Management
Pathogen (Agent) Procedures (Protocol) Personnel Protective Equipment Place (Proposed lab facility) Moving over to the 5 P’s of Risk Assessment, again coined by the Yale Biosafety Office for Yale Principal Investigators, we have: Pathogen and the (proposed experimental) Procedures as the two most important factors at the Start of the Risk Assessment/Risk Management Pathway. You can’t have Risk Assessment without Risk Management or Risk Management without Risk Assessment. So start with Risk Group information and the planned operations. Gather all of your info as detailed on the subsequent slides and make decisions on the P’s associated with Risk Management. Once you’ve gathered all of the information needed for Risk Assessment (1st 2 P’s), Focus on the Next Set of P’s for Risk Management: Personnel – associated with the people who will be performing the work (upcoming slides will detail pertinent factors for consideration). Health status, experience, training, education, attitude, safety record, previous exposures, etc. Note: that Procedures are really divided into two segments here, the proposed procedures involved in the experiment AND the PRACTICES (WORK PRACTICES) THAT WILL BE USED BY THE PERSONNEL PEFORMING THE WORK. These proposed biosafety Work Practices must also be evaluated as part of the Risk Management process. Protective Equipment – Engineering controls such as biosafety cabinets, sealed centrifuge rotors, transport containers, biomedical waste containers, needleboxes, etc. and PERSONAL PROTECTIVE EQUIPMENT – worn by the researchers are a big component of Risk Management. Place (Facility Design) – the secondary containment features of the facility represent the final P of the Risk Assessment/Risk Management Pathway. Note: that this P is frequently the one that is the most limiting as the facilities are usually in place prior to the researchers formal request to work with Pathogens.

30 P-1: Pathogen Should this agent be used in this experiment? On this campus? Note: concentration or amplification in lab may present greater hazard than in nature. Very important question that must be asked by an IBC at the outstart. After reviewing the Risk Assessment/Risk Management pathway – if the result of the review indicates that the risks associated with the experiment are too high, then the experiment should not be approved. An IBC is under no obligation to approve every protocol. You could have an adequate facility but inexperienced personnel (the facility is only as good as the people that you put into it). One option is to get training for these personnel, by having the work in another facility under appropriate supervision. You may have experienced people, but inappropriate facilities. One option is to send the trained staff to another institution currently conducting this work (a collaborator) while you develop a plan to upgrade existing lab space. Always remember that the laboratory can be a much more hazardous location than the environment. Higher volumes of material and titers that are not found in nature are part of the framework of laboratory research. In addition laboratories are confined spaces when compared to Nature’s large natural ventilation system. Pathogens can be concentrated in laboratories when released outside of primary containment until cleared by the ventilation system.

31 PATHOGEN Agent Classification (Prior LAI’s) Source of agent
Routes of Exposure Infectious Dose (LD50’s for toxins) Pathogenicity Virulence Antibiotic resistance Find the Risk Group Source: Agents isolated from clinical samples, outbreaks, field sources are likely a greater risk than well characterized materials for biological material repositories. Routes of Exposure: All researchers must be aware of EVERY possible manner in which the agent can get into their bodies AND they must also be KEENLY AWARE of the signs/symptoms of the disease caused by the agent they are handling. Note: The last series of big laboratory acquired infections (those that have made headlines among the biosafety community) – share a lack of awareness of the disease among those infected. Long incubation periods and insufficient training may play a role in this. For higher risk work, the provision of a medical card that contains information to remind researchers of what the signs/symptoms of disease are and whom to contact for evaluation are very important. Site-specific medical cards can be created for each high risk protocol, used for initial training and given to researchers for reference. This “medical” information should be repeated each year at the annual retraining. Infectious Dose: If you have this information, share with personnel. Dose is also a consideration in the assignment of risk. Agents with lower infectious doses can lead to an elevation in RG Classification (not always). Also – Infectious Dose is not used as steadfast as LD50 is with chemical hazards, as infectious agents can “replicate.” Regardless of how many organisms get in your body, there is a chance that it could find cells that they’re tropic for, evade your immune system, establish itself and lead to an infection. Pathogenicity: How infectious is the agent? This will vary among strains and other factors, but is part of the Risk Assessment process. Virulence: How damaging is an infection in a person? Mild fever or meningitis? Mild diarrhea or loss of 20 liters of fluid anticipated? Mild skin rash or debilitating disseminated lesions? Out of work for a day or two or hospitalized for weeks (or worse). Those handling pathogens must be aware of the ramifications of what they will be working with. Researchers must have a high index of suspicion of infection if any of the signs and symptoms of infection are experienced and immediately notify the Employee Health Office for consultation. Antibiotic Resistance. Working with strains that are resistant to treatment regimens will elevate the risk. This will automatically narrow the range of treatment options available. Employee Health must identify additional treatment regimens and ensure that nobody (including emergency responders) are allergic to the other treatment options. This work should be avoided if all possible. The generation of antibiotic or drug resistant strains also require review outside your organization (if funded by the NIH) if part of a rDNA experiment. Also in the U.S., this would represent potential Dual-Use work and would require additional review and registration.

32 Infectious Dose Agent Dose Ebola virus TB Tularemia Anthrax Cholera
Salmonella typhi E. coli Shigella Dose 1 1 - 10 10 >1300????? 10^8 10^5 10^9 Here are a sample of various infectious doses for a few microorganisms to show the range. The Infectious Dose for Anthrax is being reevaluated after the terrorism events of the Fall of 2001 where anthrax spores were placed in letters sent through the U.S. Mail. Extensive samples were taken of the homes of an elderly woman and healthy women who were infected and traces of the organism could not be found. The virulence of the strain (form – pure spores) and other factors have to be accounted for. Also, Dose isn’t as much of a factor as the route of exposure. As infectious agents can replicate, they have the ability to reach the level of infectivity needed within the host.

33 PATHOGEN Quantity/Concentration Incidence in the Community
Immunization/Treatment Communicability Presence of Vectors Environmental Concerns (stability) Data from animal experiments Clinical specimens Quantity/Concentration: What are the expected volumes or anticipated concentrations? What are the maximum levels possible? Spills/releases can result of more concentrated materials elevate the risk for those exposed. Exposures via mucous membranes and through the skin present greater possibility of infection also. Incidence in the Community: Is this pathogen endemic to your neighborhood? Those in your community may not be so accepting of a risk not brought upon themselves. Does your IBC have community members who taken part in the assessment to determine whether this agent can be handled safely at your institution? Are your researchers or those within the community at elevated risk because of this work? Immunization/Treatment: Are pre-and post-exposure prophylaxis available for researchers for the agent in use? Is it on campus? How effective is the immunization? How long does it take before it is protective (how long do you wait before your protected)? Is a booster dose needed? Is so, how often must it be given? How often do you test for antibody titers following the initial immunization. The absence of treatment options tends to elevate the risk for agents that cause more severe disease outcomes. COMMUNICABILITY is another concern for evaluation. Once infected, will others outside the laboratory be at risk from exposure to the infected researcher. Recent outbreaks with SARS virus have started with infected researchers (who were unaware of their infections). VECTORS: Is this disease agent transmitted by ticks, mosquitoes or other vectors? Are you also working with these vectors? Can they survive in the climate outside your laboratory? Are these vectors present in your community? Can this organism be spread from your “infected” researchers following bites from vectors in your community? ENVIRONMENTAL CONCERNS: How long can this organism survive outside the host? On contaminated surfaces, fabric (lab coats), floors, or out in the environment if released? What disinfectants are suitable for inactivation of the agent? What is the chemical, concentration, and contact times? Do you have a reference for the inactivation? DATA FROM ANIMAL EXPERIMENTS: Can this agent be transmitted from animals to other animals in the same cage? To animals in other cages within a room? From animals to humans? CLINICAL SPECIMENS: Are a source that may represent elevated risk

34 Immunizations Vaccinia Tetanus Meningococcal Immunization Typhoid
Botulinum Hepatitis B virus, Hepatitis A virus Yellow Fever, EEE Rabies Employee Health should be involved in the review of all biohazard protocols. Their role is to evaluate if an effective immunization is available for the researchers and whether or not employees have any contraindications prior to receiving it (allergies to components in the vaccine). Is the immunization required? Recommended? Should an individual with contraindications to the vaccine strain be allowed to work with the wild type strain? These are decisions that you must determine in advance for initiating the protocol. The vaccine must be made available to workers free of charge during the work day. Ensure that individuals are sufficiently protected by starting work by checking their protective titers.

35 rDNA Molecules Classification of parent agent Toxins
Antibiotic resistance genes Altered host range or tropism Replication competency Integration into host genome Toxicity, allergenicity, other First step in the evaluation of risk for recombinant DNA molecules is to consider the RG of the vector itself. Adenovirus, Herpesvirus, Retrovirus, Lentivirus, Sindbis, Baculovirus have all been harnessed for the transfer of genes and their respective Risk Groups. Once you have the RG, consider what packaging cell lines are used. Are there additional sequences from the pathogen included here? What is the total percentage of the pathogen’s genome present in the rDNA molecule. If it has been rendered defective, has it been tested to prove that it can’t replicate? What’s the probability of recovering this ability when grown at high titer? The inserted genes are the next area to explore in the assessment of risk. Oncogenic genes, genes that interfere with the cell cycle (inhibitors, regulators, activators), growth factors, etc. will merit additional consideration and precautions for the handlers. The risk of cloning TOXINS is tied to the toxin’s LD50. Toxins with LD50’s < 100 micrograms/kg bodyweight are considered elevated risk and require registration with the IBC (the cloning of toxins with an LD50 <100 ng/kg bodyweight require registration with the Office of Biotechnology Activities and approval from the NIH Director if your institution received NIH funding). Altering the host range or tropism for a rDNA molecule is part of the nature of this research. Doing so can also help the vector infect human cells and potentially deliver the target genes from accidental exposure. This requires evaluation and precautions commensurate with risk. This experiment should also be evaluated for potential “Dual-Use” concerns. Integration into the host genome is a risk associated with retroviruses along with its ability to recombine with endogenous retroviruses within the host.

36 P-2: Personnel Are the proposed researchers capable of safely conducting these experiments? As hand washing is considered the most important work practice among infection control practitioners, the careful selection and evaluation of the people working with biohazards is one of the most considerations in a Risk Assessment. Regardless of the starting point of the hazard, the level of risk, or the inherent dangers of the equipment involved, 90% of the laboratory acquired infections are related to a pure break down in established work practices. Since the IBC and Biosafety Office staff cannot be present within the laboratory 24/7, the Principal Investigator must be aware of her responsibility in ensuring that their researchers are trained, experienced and follow established procedures. Any biosafety program will fall apart if the researchers are not following the SOP approved by the IBC. Following established procedures is so important, all researchers should be informed of the ramifications of non-compliance. The end result of non-compliance including repeated events are the suspension of research privileges. Your biosafety program is only as strong as the most inexperienced person handling biohazards at your institution.

37 PERSONNEL Host Immunity
neoplastic disease/infection immunosuppressive therapy age, race, sex, pregnancy surgery (splenectomy, gastrectomy) diabetes, lupus Reproductive age Contraindications for therapy Again, all workers handling biohazards should be assessed by the Employee Health Office (privately and confidentially) for conditions that may make them more susceptible to infection from the proposed agents. It should not be uncommon to have a research proposal submitted to the IBC with a Principal Investigator and 6 researchers listed, but only have the Principal Investigator and 5 researchers approved by Employee Health. The health status of the employee should be assessed at the start of the protocol and all employees should immediately notify Employee Health in the event of any change in the health status. The take home message is that any condition that permanently or temporarily (i.e. corticosteroid therapy for poison ivy) impacts the immune system should be privately reported to the Employee Health Office for immediate evaluation. If anyone cannot receive therapy, the IBC and Employee Health must jointly evaluate if the risk of allowing them to participate. It may not be prudent to allow this, but any decision must be based on the risk factors involved.

38 PERSONNEL Medical Surveillance prophylactic immunizations
serum storage post-exposure prophylaxis/treatment screening Having a strong Employee Health program that is well staffed and equipped the requisite expertise required by this discipline is an essential supplement to any biosafety program. All researchers handling biohazards must enroll in a medical surveillance program. The completion of a health history questionnaire and medical evaluation should occur at the time or hire followed by periodic surveillance thereafter. Immunizations (if available) should be provided as mentioned previously. The serum storage program should be activated for researchers handling RG3, RG4 and unknown pathogens. Serum storage can also be utilized for individuals working with biohazards in field settings, and for higher risk RG pathogens (such as Eastern Equine Encephalitis). The rationale used in establishing a serum storage program must be communicated to all researchers: The program has been established because there is a known test to demonstrate whether researchers have been exposed; Serum will be collected at time of hire, after any incident, and at termination to have samples on hand to book end the employees exposure to prove later when an individual may have been exposed and infected; As part of an ongoing program of collect and test employees for exposure and seroconversion every 6 months or annually (Institutions working with HIV have utilized periodic testing for their personnel). This is part of a SCREENING PROGRAM – TO FOLLOW EMPLOYEES MEDICALLY FOR THE DURATION OF THEIR EMPLOYMENT AT THE INSTITUTION. Testing an employees serum requires the consent of the personnel. The serum is usually not part of the employees medical record unless they have given their consent for testing. If the serum is tested, that result is part of their permanent medical record. Note: certain institutions, such as government laboratories may require serum storage and testing as a condition of employment. All researchers must be aware of the institution’s incident response program. All must be aware of the post-exposure prophylaxis and treatment regimens for the biohazard in use. Researchers must be aware of the side effects, contraindications, and type of therapy needed at the start of the protocol. Reading drug brochures in the aftermath of an exposure incident to identify if you are contraindicated is the wrong time to gather such information and can also delay the start of post-exposure treatment.

39 PERSONNEL aware of hazards prior documented work experience
microbiological proficiency (observed) comfort/choice The importance of personnel can’t be stressed more. Initial and ongoing training for personnel must continuously raise their awareness of the potential disease outcomes if exposed to and infected with a biohazard. Individuals who handle biohazards must have prior experience with the agent or similar agents. The initial experience is generally gained as a trainee under a competent supervisor. Gone are the days of we’ll figure it out along the way and learn from our infections of the late 1800’s and early 1900’s. Once an individuals is trained, a representative from the IBC or Biosafety Office (or the Principal Investigator in many cases) should schedule a meeting to OBSERVE the proposed work practices to verify conformity with the established SOP. Finally, researchers should not work if they are uncomfortable with the agent or proposed procedures. Nobody should feel coerced into participating in a project, especially if they have an excessive fear of the pathogen. Each program should have a provision for review of such situations by a neutral party (such as Employee Health).

40 PERSONNEL Safety Attitude
Those who have fewer accidents: adhere to safety regulations respect infectious agents defensive work habits able to recognize potential hazards Women Older employees (age 45-64) Health Behavior and Health Education experts have reviewed factors associated with good and poor adherence to safety practices. Attitude is a significant variable in the probability of an accident in the laboratory.

41 PERSONNEL Safety Attitude
Those who have more accidents: low opinion of safety take excessive risks work too fast less aware of risks Men Younger employees (age 17-24) The other side of the coin – poor attitude towards safety provides a greater opportunity for accidents, exposures and infections.

42 P-3: Protective Equipment
Has the Principal Investigator selected the appropriate combination of personal protective clothing and safety equipment for the safe conduct of research? The PI’s selection of protective equipment can be assessed and highlighted in the review of the PI’s written risk assessment and set of standard operating procedures/safe working practices submitted as part of the application. The initial written assessment must be followed up with a check in the actual lab to verify what was meant by a “hood” and a safety “bucket.”

43 Protective Equipment Personal Protective Equipment (clothing)
Containment Equipment Biological safety cabinets Safety centrifuges Sealed sonicators, blenders, homogenizers Sealed tubes, transport carriers Safe sharps, needleboxes, medical waste bags, tongs, forceps, etc. A good biosafety program will introduce the myriad of Personal Protective Equipment (PPE) options and engineering controls available to the researchers. The training should not only focus on the appropriate use (donning and doffing protective clothing) and the principles of operation of the biosafety cabinet and other control devices, but also the limitations of each. The final assembly of protective devices is dependent upon the risk involved in the proposed work. Biological Safety Cabinets will be the major focus of an subsequent lecture and parts of other lectures. They are the primary containment device for the control of aerosols in the laboratory. Safety devices have been created for each of the other high risk laboratory procedures that may involve aerosols. Engineering controls also encompass containers that house medical waste, needles, and disinfectant trays. Finally, devices that move the researchers hands further away from a sharp or a contaminant, such as tongs, or forceps (or two dust pans when picking up glass in a spill situation) further help to isolate biohazards.

44 PERSONAL PROTECTIVE EQUIPMENT
Protect: skin clothing mucous membranes respiratory system Use: gloves (double, kevlar) lab coats, solid-front gowns sleeve covers full face protection respiratory protection Personal Protective Equipment (PPE) is also a focus of an upcoming lecture. Lab acquired infections have been related to the inappropriate use of PPE, utilization of the wrong PPE, and simply the lack of PPE. Although they are referred to as the last line of defense, when used appropriately, PPE can effectively protect researchers from exposure to biohazards. There are a wide variety of gloves that can be utilized and multiple pairs may be worn. Cut-resistant gloves are now made thin to provide the needed dexterity for delicate procedures. Note: Kevlar gloves will help prevent slicing or cutting injuries, but won’t prevent needlesticks that can easily penetrate the open weave of this fabric. A wide variety of reusable and disposable lab coats, gowns, and jump suits are available for use to protect worker’s clothing and skin. Sleeve covers help protect the wrist, which is most often contaminated when the open lab coat pulls away from the gloves while working. Good coverage of the wrists can protect both the skin and the researcher’s clothing from contamination that may not be cleaned during hand washing. Researchers should be reminded that if work is done outside of the biosafety cabinet and splash/splatter potential exist, they should wear full face protection to prevent exposure to facial mucous membranes. If a protocol requires the use of a respirator, researchers must be trained and fit tested and enroll in the campus respiratory protection program.

45 PERSONAL PROTECTIVE EQUIPMENT
Disposable Decontamination Dedicated to area Donning/Doffing Compromised (wet/contaminated/torn) Respiratory Protection Program Most protocols involving high risk experiments utilize disposable protective clothing (gowns, gloves, sleeve covers, and face protection) to provide a clear “end” point for contamination. Reusable protective clothing, gowns and lab coats must be decontaminated after use for higher risk experiments or spot treated to disinfect overt contamination with RG1 and RG2 agents. PPE can also be autoclaved if it will hold up to temperature. PPE should never be worn to non-lab areas, but removed before leaving the laboratory. Researchers should be trained on how to put on (donning) and how to remove (doffing) PPE. They should also understand the policy on contaminated PPE (change as soon as feasible or compromised). Respirators are worn when either the biohazard can’t be adequately confined within primary containment or when working with a high risk pathogen with an airborne route of exposure (can’t discount the potential release from partial containment devices such as the biosafety cabinet)

46 P-4: Place (Facility Design)
Does this research group have (or have access to) a laboratory with the requisite containment features this work? Again, lab design is the focus of a full lecture along with emergency response procedures. However, national and international regulations, standards, and guidelines specify the lab design criteria for the four biosafety containment levels. In many cases this represents the MINIMUM requirements needed for that level of work. If researchers don’t have access to such a facility, the work should not be conducted and unless the institution has received a variance from a competent authority.

47 PLACE – FACILITY DESIGN
Restricted access/Door sign Easily cleanable Hand washing sinks (near exit door) Eye wash Autoclave Vacuum system protection Biosafety Cabinet Research laboratories handling biohazards should be equipped with a door to restrict access and prevent disruption of research. The door sign should identify the types of hazards within the laboratory and also list the entry requirements established by the Principal Investigator. The door should be lockable and always locked when not occupied for security purposes. All surfaces in the lab should be easily cleanable and resistant to the range of disinfectants commonly used in the laboratory. All labs must have hand washing sinks equipped with soap and paper towels. More labs are moving to a hands-free sink, such as foot operated or motion sensors to minimize the spread of contamination. Eye wash stations that meet OSHA and ANSI Standard requirements should be present within the laboratory for immediate response for exposures to biohazards or chemicals used there. Access to an autoclave, preferably on the floor of the research lab, is required for decontaminating medical waste and contaminated reusable supplies. If a house vacuum system is used with biohazards, protect it from aerosol contamination by using either a HEPA or Hydrophobic Filter in between the vacuum source and the overflow and collection flasks. Biosafety cabinets are an essential piece of equipment, but must be positioned in a location within the lab where the minimum amount of interference is encountered. They should be positioned out of major traffic patterns within the room, away from supply air diffusers, away from doors, and not directly across from heavy use equipment such as sinks or other work stations.

48 PLACE – FACILITY DESIGN
Anteroom Negative pressure gradient Airflow monitor Air changes per hour (10-15) Sealed penetrations, coved flooring Facility alarms/interlocks Communication outside the lab Work with RG3 pathogens requires more stringent containment and enhanced facility containment elements. An anteroom off the main corridor serves as a buffer zone between the hallway and the research laboratory. This double door access provides a transition zone for donning and doffing PPE. It also serves as a “safe haven” in the event of a release of biohazards outside of primary containment within the laboratory. Clean air is traveling into the anteroom from the adjacent corridor and then on into the laboratory, keeping any aerosols within the lab. An airflow monitor or other device to measure directional airflow is required for BSL3 laboratories. Researchers must verify that the lab is working adequately before entering to perform work. The monitor provides verification that air is flowing into the laboratory. Air is being exhausted from the laboratory and changing over an average of 10 – 15 times each hour. This changing of air helps to remove smaller sized contaminants from room air that may have a low Vts (terminal settling velocity). These smaller particles could have remained in room air for hours if not directed out of the room through the laboratory exhaust. Alarms should notify researchers of problems with the exhaust system or loss of negative pressure at the entry door. In an alarm condition, all work must cease and either decontaminated or sealed and put away, followed by departure from the laboratory. The Supply and Exhaust fans should be interlocked to ensure that the supply fan also shuts off in the event of an exhaust fan failure. This will keep the BSL3 lab from going “positive” (pushing air out of the laboratory). Researchers should also have an elbow operated intercom or phone system directly to a 24 hour security station or control center to request assistance in emergency situations.

49 P-5: Procedures Has the Principal Investigator outlined all of the proposed steps in the protocol? Has the lab outlined sufficient protective work practices to minimize the risk to those working and those outside the lab? Although this is the 2nd P in Risk Assessment (proposed Procedures planned by the Principal Investigator), it is also linked closely with the biosafety work practices that are required to control biohazards. The Principal Investigator must be aware of the procedures that involve risk and take steps to mitigate opportunities for exposure.

50 PROCEDURES Develop standard written practices (SOP’s) for handling pathogens Job Safety Analysis (JSA) identify each task describe all steps hazard assessment at each step incorporate safety Focus on containing aerosol generating procedures and equipment Traditional Safety professionals utilize a method called Job Safety Analysis to identify risks along with containment measures. Every step in a procedure is detailed along with any associated risk. Once this list has been created, the safety elements are added to ensure a safe protocol.

51 Aerosols Procedures that impart energy into a microbial suspension are a potential source of aerosol (Chatigny, 1974) Many common lab procedures and accidents have capability of releasing aerosols homogenization, sonication, blending, mixing, grinding, shaking, vortexing, spills, opening vials, pipetting, animals excreting agent, opening vials under pressure, etc. Aerosols where discussed fairly significantly in earlier slides. Take home messages from this slide: When asked which Laboratory procedures create aerosols, simply say “All of them.” The amount of energy imparted into the culture of microorganisms determines how many aerosols and which size. Early Biosafety Professionals were keenly aware of the risk of aerosols, especially in association with the early laboratory acquired infections with an UNKNOWN route of exposure. Dr. Arnold Wedum (and later Dr. Karl Johnson) urged conference attendees in 1960 and later in 1995 to “Confine Aerosols As Close As Possible To Their Point of Generation.” The Class II Biological Safety Cabinet is the primary engineering control to assist with the containment.

52 Viable Particles Recovered from Air (Chatigny, 1974)
Procedure sonic oscillator mixing w/ pipette overflow from mixer opening lyophilized vial top removed after blending dropping flask of culture dropping lyophilized culture # Particles/ft3 of air 6 7 9 135 1500 1551 4839 More on the aerosols – this slide shows “viable” organisms recovered with a aerosol sampling device in room air > 30 minutes after the event. This is only from 1 cubic foot of lab air. Small cell culture labs are about 1,000 ft3 in size (so multiply these numbers by 1,000) and you’ll see why it is important to leave lab air immediately after a spill and stay out of the lab until all aerosols have settled. Note the very LARGE NUMBER of aerosols created in the two spill situations, dropping a flask of culture and dropping a lyophilized (freeze dried) culture.

53 Procedures - Sharps Hazards
Syringe/Needle adjusting volume withdrawal from stopper separation from syringe leaking syringe leakage from injection site inappropriate disposal poor work practices There are MANY different sharps and many different ways of getting injured or exposed to sharps. Needles and syringes are a major sharps risk, but the can also be involved in the dissemination of aerosols. Removing a needle from a septum vial can cause vibration that can lead to the formation of aerosols. Tapping a needle and syringe to remove air bubbles and back-pressure associated with a plugged syringe can release contents that can cause splatter/splash and aerosols. Sharps containers, if overflowing can present risks to others during disposal. Sharps containers or needleboxes should be located in the immediate vicinity of arms reach, to facilitate safe disposal. Walking with needles a distance creates additional risk and usually indicates that the needle will need to be handled multiple times (or one more time than needed). Needles should never be bent, broken, NEVER RECAPPED, or otherwise manipulated by hand.

54 Procedures - Sharps Precautions
Syringe/Needle use needle-locking syringes cover with disinfectant soaked gauze animal restraints cleanse inoculation site safe needle practices immediate collection/disposal

55 Procedures - Sharps Precautions
Needle/syringe removal of needle from syringe (hemostat) no recapping, bending, breaking, etc. immediate disposal of intact needle/syringe location of needlebox (vicinity, height) replacement of needleboxes eliminate/minimize use/safe sharp devices avoid glass Pasteur pipettes Sharps safety precautions mentioned earlier – Glass Pasteur pipettes also presents high risk of puncture or cuts – avoid and use plastic alternatives instead to minimize risk.

56 Procedures presenting risk
Microbiological loop streaking plates spreading material on slides cooling loop in media heating loop in an open flame A lot of bacteriological work is done on the bench and not within a biosafety cabinet. Multiple procedures were also evaluated for the dissemination of aerosols which could spread contamination throughout the laboratory and potentially expose workers. Some of the major findings were: Streaking plates can create aerosols, especially if the plates were rough and not smooth (rough plates caused bumps that created more aerosols during this process) Placing a hot loop direction in the media was also associated with contaminant spread via aerosol Flaming a loop in a burner located on an open bench was also associated with the spread of contaminants via aerosol (Hot air rising rapidly carried organisms upward at a high rate minimizing the contact time with the flame which led to its survival and recovery in sampling devices).

57 Precautions in bacteriology
Microbiological loop smooth plates disposable plastic loops well formed loops with short staff glass spreaders electric (walled) micro-incinerators work within a biosafety cabinet Safety measures are detailed here. Electric walled micro-incinerators instead of burners keep aerosols in against a hot wall instead of releasing to the lab air. The easiest containment measure is to move all work within the Biosafety Cabinet.

58 Procedures with general risk
Pipetting mouth pipetting glass Pasteur pipettes blow-out pipettes mixing suspensions spill of droplets onto hard surfaces Eating, drinking, smoking, applying cosmetics Straightforward – Both are prohibited from the laboratories and are high risk in any laboratory.

59 PROCEDURES Pipetting no mouth pipetting disposable plastic pipettes mark to mark pipettes collect within biosafety cabinet work over disinfectant-wet pad Restrict consumption of food or beverage to well defined break areas

60 PROCEDURES Centrifugation Protective Measures broken/leaking tubes
microfuge tubes (snap caps) (flawed/overfilled) Protective Measures check O-rings on rotors (use O-ring tubes) safety cups/sealed rotors load/unload in a biosafety cabinet Centrifugation will be discussed in subsequent lectures, but most manufacturers now make an aerosol containment safety canister, safety bucket or sealed rotor to contain aerosols when working with biohazards. These devices are loaded and more importantly, UNLOADED within the biological safety cabinet.

61 Risk Assessment Example
Hantavirus Protocol Application of 5 P’s Hierarchy of controls Pathogen Personnel Place Procedures Protective Equipment This protocol represented the application of many control measures in minimizing the risk for those involved and those within the building. The first control used was substitution. Seoul virus was used in place of Hantavirus. Seoul virus was associated with much lower mortality compared to Hantavirus, but still a RG3 agent in the same family and capable of providing the same results. Administrative controls: Only the two most experienced researchers within the department were allowed to participate on this protocol. They also had to work together as the project required at least two people at all times to be present within the lab. An enhanced BSL3 facility was selected (equipped with HEPA filtered exhaust air). Researchers did not wear any personal clothing into the facility, a full clothing change, use of scrubs, jump suits or gowns, Powered Air Purifying Respirators w/ HEPA filters were the main PPE used (along with booties and sleeve covers). Animals were housed within microisolator cages and animals were housed within biosafety cabinets during the experiment. The laboratory’s proposed research procedures were initially tested with a surrogate agent, an animal pathogen transmitted via the airborne route. Many cages of sentinel animals were placed in the laboratory while the researchers conducted their proposed work with the surrogate animal pathogen inside the biosafety cabinet. Over the test period, none of the animals were exposed or infected with the pathogen used in the biosafety cabinet. Once this data was compiled, the protocols was approved as originally submitted.

Which is the best step to follow in the immediate aftermath of an occupational exposure?

What is the best recommendation to provide staff who have breaks in their skin but must work with biohazards?

Which of the following is a good work practice when centrifuging biohazards quizlet?

How long should Researchers wash their hands with soap and water after handling biohazards?