Safe Working with

Biological Hazards

Published by the University Safety Office

© University of Newcastle-upon-Tyne

February 2000

1
 Safe Working with Biological Hazards

Contents

Introduction Application 3
Responsibilities 3
Categories of Pathogens and Containment Levels 4
Prohibitions, Restrictions, Risk Assessments and Approvals 4
General Requirements, comprising: 6
Movement of Material out of Laboratory 6
Movement of material out of the University 6
Accidents 6
Large Scale Production 6
Laboratory Coats 6

Accidents and Emergencies

Emergency Procedure for Accidents involving micro-organisms 8

Prevention and Reporting of 'Inoculation' Accidents 10

Health General: BIOCOSHH Risk Assessment 12

Pregnancy 12
Immunisation 13

Specific Codes and Procedures

Precautions against blood-borne viruses (HIV and Hepatitis) 15

Genetic Modification including work with Genetically Modified organisms 16
Disposal Procedures 19

Purchase, Use and Testing of Equipment

Autoclaves 20
Microbiological Safety Cabinets 22
Fumigation 24

Background Information

Cell Cultures 18
Disinfectants: Selection and use 27
Serum or Plasma Treatment 29
Eye-wash solutions 30
University Register of Micro-organisms and Users 31
Departmental Biological Safety Supervisors - Terms of Reference 33
Hazard Groups and Containment Levels 35
The BIOCOSHH Risk Assessment Form 38
Animal Pathogens 42

List of Reference Publications

Interpretation
"Should" is advisory.
"Must" and "Shall" is obligatory: failure to observe such an item may be regarded
as a disciplinary matter.

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Important Sources of information

USO http://www.ncl.ac.uk/internal/safety/ *
USO circulars: http://www.ncl.ac.uk/internal/safety/circular/index.html
HSE http://www.open.gov.uk/hse/hsehome.htm
MAFF http://www.maff.gov.uk/
Categorisation of Biological Agents: http://www.open.gov.uk/hthdir/agents.htm

List of abbreviations

ACRONYM FULL COMMENT

ACDP Advisory committee on dangerous Government body advising on
pathogens containment of pathogens
ACGM Advisory committee on Government body advising on
Genetic Modification containment of GMOs
BIOCOSHH form Biological COSHH form University form to support
biological risk assessments
BSS Biological Safety Supervisor Department/School level
COSHH Control of substances hazardous Legislative structure governing
to health handling of hazardous materials
GM Genetic Modification
GMO Genetically Modified Organism
HSE Health and Safety Executive Government agency charged with
ensuring compliance with safety
legislation
MAFF Ministry of Agriculture Fisheries
and Food
NOH Newcastle Occupational Health Local agency providing
occupational health services on a
contractual basis
UBSO University Biological Safety University Officer providing
Officer advice to the USO on biosafety
USO University Safety Office

* N.B. Updates of this Code will appear on this web site.

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Introduction

Application

These Local Rules form part of the University's arrangements for achieving the standards set
out in the Health and Safety Policy Statement. They apply to all who work with biological
hazards, whether or not the organisms are live. Most of the work for which containment of
biological hazards has to be considered concerns micro-organisms (bacteria, viruses, protozoa
and some helminths). However, regulations also apply to the handling of samples of body
fluids or tissues that may contain pathogenic organisms taken from humans and animals and
to cell cultures. Genetic manipulation (GM) of any kind, whether prokaryotic or eukaryotic
cells are involved, requires explicit permission from the USO before the work can take place.
Finally, we are also required to recognise the potential environmental impact of uncontrolled
release of biological agents that are used in laboratory experiments. This is now a standard
part of genetic manipulation risk assessments but must also be borne in mind with respect to
organisms that may naturally have potential for environmental impact; these may include
certain animals and plants as well as micro-organisms. With the exception of the flow chart,
its accompanying notes and some sections on GM risk, the rest of this document now
concerns the containment of microbiological hazards.

Two key documents apply to working with micro-organisms and genetic manipulation and
staff supervising work in these area should be familiar with them.

1. The ACDP Report 'Categorisation of Pathogens according to hazards and categories

of containment' and subsequent amendments. Current version at time of printing is 4th
edition 1995, as amended by Approved List of Biological Agents, 3rd edition, 1998 (i.e.
USO Circular 22/98).

2. The ACGM compendium of advisory notes (1997)

In everyday life everyone is exposed to micro-organisms, the vast majority of which, in the
numbers normally encountered, present no risk either to the environment or to the average
healthy person. However, when encountered in greatly increased numbers, as in those
laboratories in which work with micro-organisms is undertaken, these harmless micro-
organisms may present a risk. To reduce or eliminate any possible hazard all persons and
laboratories handling or working with any micro-organism or material intimately associated
with any micro-organisms must adhere to the requirements given below.

Responsibilities

Heads of Department/School have overall responsibility for ensuring that adequate

arrangements are in place to comply with the Rules at Departmental level. They are
accountable to the Dean and then the Pro-Vice-Chancellor in this respect.

Individual members of staff are accountable to the Head of Department/School for achieving
the standards defined here in work undertaken by themselves and by those staff and students
under their supervision and charge.

Visitors working in the University are also bound by these rules and Heads of
Department/School must ensure that arrangements are in place to ensure that they understand
and abide by them.

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Categories of Pathogens and Containment Levels

Micro-organisms are classified into four hazard groups (ACDP guidelines), and appropriate
levels of containment are assigned to each hazard group.

Prohibitions, Restrictions, Risk Assessments and Approvals

Before anyone commences work with wild type or genetically manipulated micro-organisms,
a risk assessment must be performed. This can be achieved by consulting ACDP guidance
(document 1 above) and the BIOCOSH form for wild type organisms and/or by performing a
GM risk assessment where appropriate If containment level 2 is required then a “BIOCOSHH
Risk Assessment Form” must be completed. In some circumstances (clearly indicated in the
notes on completing BIOCOSHH forms) the form must be returned to returned to “Newcastle
Occupational Health” (NOH) and they will institute health surveillance procedures if these
are considered appropriate; these must be observed.

Work with pathogens and materials known to contain them must be conducted at the
appropriate containment level. The level may be altered to provide more stringent
containment conditions depending upon the local assessment of risk. Less stringent
containment conditions must not be adopted before a full risk assessment has been made and
agreed by the Microbiological Hazards and Genetic Modification Safety Advisory Sub-
Committee and in the case of category 3 and 4 pathogens until consultation with the HSE
has taken place.

The procedures in these Local Rules are not written for work with Category 3 or 4 Micro-
organisms some of which are bound by more stringent Regulations and are subject to the
prior approval of the Health and Safety Executive.

The authority of the University must be obtained through the Microbiological Hazards and
Genetic Modification Safety Advisory Sub-Committee before any work involving Genetics
Modification work or the use of Category 3 or 4 Micro-organisms (in particular the HIV
virus or the Hepatitis B virus) can be undertaken on University premises.

The overall approach to the regulation of biological hazards is outlined in the accompanying
flow chart.

Notes
1. The intention of the chart is to show the procedures that you may have to follow to gain
approval to work with certain biological hazards. Local Biological Safety Supervisors
should be able to provide guidance and further support can be obtained from the USO and
the UBSO.
2. The three primary routes of progression are identified by different arrow types
Possible human pathogen:
Genetic modification:
Agent with potential for environmental impact:
3. The genetic modification approval process is complex and may require that more than one
approval procedure be followed for a single project. If you do not have a local GM
committee in your Department/School then you will need to discuss your requirements
directly with the USO/UBSO.

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6
General Requirements

Movement of material out of a laboratory

The movement of live micro-organisms or biologically active microbial material out of the
laboratory should be kept to a minimum and be restricted to what is necessary for the work
being done. The Head of the Department or Unit is responsible for instructing those working
in the Department or Unit on what is acceptable practice in this regard.

Movement of material out of the University

Any live micro-organisms or biologically active microbial material sent to outside

establishments via the Postal Service must be packed in accordance with the Post Office
regulations in force at the time. An up-to-date copy of the Post Office Guide, obtained from
local Post Offices or “Customer Care” (235 3211) should be consulted for details. Where
active microbial material is sent via other carriers e.g. road/rail/air, packaging must be in
accordance with the carrier's regulations. (in the case of Securicor, this is their General
Instructions No. 301). In all cases procedures must be compatible with ACDP Category of
Pathogens 1995, Appendix 11. Guidance on suitable packaging for Road and Rail is
available in USO Circular 34/98.

Note that UN Class 6.2 packaging, suitable for road, rail, air or Post office, is available at a
reasonable price from suppliers such as Bibby Sterilin. (Details available from the University
Safety Officer).

Accidents

All incidents or accidents with live micro-organisms or biologically active microbial

material must be reported to the Departmental Biological Safety Supervisor who shall
maintain a record of such incidents and accidents and report them to the Head of the
Department or Unit. Where the accident or incident involved micro-organisms or material
listed in ACDP Guidelines Categories 2, 3 or 4 or personal injury the University Biological
Safety Officer must also be informed.

Large Scale Production

If large scale production of micro-organisms is to be undertaken the University Biological

Safety Officer should be informed prior to commencement.

Laboratory Coats

The wearing of lab coats by lab staff is governed by the general rules set out under
“Containment Levels”.

For students in Containment Level 2 labs, lab coats are worn: to provide protection, to
prevent contamination of other clothing and to prevent uncontrolled/dissemination of lab
organisms outside the lab.

It is therefore not sufficient to provide the lab coat: unless it is disposable (see below) then
adequate provision needs to be made for storage and laundering. Students should be
instructed about fastening the garment, not wearing it outside the lab, and about
storage/laundering/disposal arrangements.

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Where Student Projects are to take place at Containment Level 2, then the student should be
provided with a Howie coat and arrangements made for storage and laundering.

Where Class Practicals are to take place at Containment Level 2, then account may be taken
of the frequency and scale of the activity to achieve a reasonably practicable method of
meeting the objectives set out above. The options are:

1) Provision of a suitable disposable plastic over garment, containing sleeves.

2) Provision of Howie coats as above. These may be issued individually or shared as

appropriate. Where they cannot be stored at the lab, students should be instructed to store
them in closed plastic bags, and not use them for anything other than Containment Level 2
work until they have been adequate laundered.

Visitors should be provided with clean lab coats.

In the case of maintenance staff, cleaners and contractors, the area should be made safe for
them to enter before access is permitted.

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Emergency Procedures
Seek advice from the Departmental Biological Safety Supervisor following all accidents
involving micro-organisms in any ACDP category. If accidents also involve injury, then
advice from NOH ("Occupational Health") should be sought in addition to any other first aid
action.

Details of the management of 4 types of accidents are given below.

Spillage and Breakage of Specimens and Cultures

Cover spill or debris with appropriate disinfectant.

Leave for 30 minutes.

Put on disposable gloves and carefully sweep debris into a suitable container e.g. plastic
bag or box (using disposable cloths or paper towels or a strong piece of card). Do not use
dust pans and brushes unless these can be autoclaved or disinfected.

Place all debris and materials used in the appropriate laboratory discard receptacle.

Swab area with disinfectant.

Spillage of Micro-organisms over Yourself

Autoclave contaminated clothing.

Attempt to wash and disinfect any exposed skin.

If eyes are involved, rinse copiously with eye wash solutions.

If solutions micro-organisms contaminate the mouth, rinse with water without swallowing.

Immediate medical advice should also be sought if mucosal surfaces are contaminated.

Breakage of Tubes in Centrifuges

If a breakage is known or suspected while the centrifuge is running, switch off the motor
and do not open the centrifuge for 30 minutes.

If a breakage is discovered after the centrifuge has stopped, reseal it and leave it closed for
30 minutes.

Inform the Departmental Biological Safety Supervisor.

Strong (e.g. thick rubber) gloves, covered if necessary with suitable disposable plastic
gloves, must be worn for all subsequent operations. Forceps must be used, or cotton
swabs held in forceps to pick up glass debris.

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 Either autoclave or place all broken tubes, glass fragments, buckets, trunnions and the
rotor in a non-corrosive disinfectant known to be effective against the organisms
concerned at use-dilution and leave for 24 hours. Place unbroken, capped tubes in
disinfectant in a separate container and then recover after 60 minutes.

Swab the centrifuge internal surfaces and lid, with the same disinfectant, at appropriate
dilution, leave it overnight and then swab again, wash with water and dry. All swabs must
be treated as infected waste. (Hypochlorites must not be used: they corrode metals).

Sealed buckets containing ACDP Categories 2, 3 or 4 material must be opened in a

microbiological safety cabinet. If a tube has broken the bucket cap must be replaced
loosely and the bucket autoclaved.

Large scale Spillage of Micro-organisms from Fermenters

Evacuate the areas affected, close the laboratory door, and give warning to workers in the
vicinity. Care should be taken to avoid inhalation of any aerosols which may have resulted
from the accident and at least 30 minutes should elapse before re-occupation of the
laboratory.

Depending on the situation and the micro-organisms involved, the spillage should be
disinfected by workers wearing appropriate protective clothing e.g. thick rubber boots;
strong gloves; impermeable gowns; masks and head wear.

If any workers were contaminated, seek advice from the duty MO, the University
Biological Safety Officer, or by using the emergency telephone numbers listed below.

Large scale spillage or organisms in any ACDP category should be notified to

Departmental Safety Officers and the University Safety Officer.

Emergency telephone numbers

24 hour 6666

9am - 5pm

University Safety Officer: (Mr ME Weston) Ext. 6320 or 0207 70930

University Biological Safety Officer: (Dr MR Barer) Ext. 8264

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Prevention and Reporting of Inoculation Accidents

The purpose of this section is to ensure the safety of staff and students with respect to
biologically hazardous material and in particular biohazardous waste.

"Inoculation Accidents"

This phrase includes:

Contact with material suspected of being microbiologically contaminated in one of the

following ways:

1 Injury to skin by a contaminated sharp (e.g. pipette, needle, broken laboratory glassware
etc.).

2 The contamination of an abrasion, burn, eczema or any other break in the skin.

3 Spillage into eyes or mouth.

4 Human or animal bites and scratches.

Preventive Practices

Observe all correct waste disposal procedures: You must observe the following procedures
for your own safety and that of your colleagues.

1 Never re-sheath used needles.

2 Dispose of all needles and sharps immediately into the approved rigid sharps contained
as soon as you have used them.

3 Whenever possible, discard the syringe and needle as one unit, into the sharps container.
Sharps containers should not be overfilled, and should be disposed separately from yellow
bags.

4 Place all biohazardous waste (not sharps) into yellow bags, which should not be used for
general waste.

5 Specimen containers must be leak proof, properly closed and not externally contaminated
by the contents. Transport bags must be properly sealed without using staples or sharp
closures.

6 Where there is a danger of infection e.g. hepatitis risk, HIV risk, both the form and
container must be correctly labelled with Biohazard stickers.

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The following precautions must be observed:-

Regard blood or body fluid from any individual as potentially hazardous.

Ensure that all cuts, abrasions, lesions and eczema are covered with a water-proof dressing
whilst working with micro-organisms.

Wash your hands before and after carrying out procedures.

Wear disposable gloves if exposure to blood or body fluids is anticipated, including

mopping up spillages.

Take great care when cleaning non disposable instruments.

Action to be taken following inoculation injury

1 Encourage bleeding from the site if appropriate.

2 Wash the site immediately with soap or skin antiseptic under running water for five
minutes.

3 If eyes and mouth have been contaminated, rinse with copious amounts of water.

4 Promptly seek advice from Casualty.

5 Report all inoculation accidents to the University Safety Officer by telephone and
subsequently on the University Accident Form. Try to provide as much information as
possible - e.g. location of offending waste bag, identifying marks upon it, originating
Department (if known).

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Health

(a) General

It is important to identify individuals whose medical or physiological condition may place

them or others at risk. The conditions of concern are listed below. None need necessarily
disbar a person from laboratory work: their identification will permit appropriate measures to
be taken to minimise identifiable risks.

Individuals who have any of the listed conditions should inform Occupational Health by
completing and forwarding the appropriate sections of the “BIOCOSHH” Risk Assessment
Form:

(i) before they commence any work subject to these Local Rules or

(ii) as soon as they develop such a condition if already carrying out work subject to these
Local Rules.

Occupational Health will be happy to give confidential advice to the individual.

Occupational Health will also advise the Department concerning work conditions i.e. whether
the individual can work normally, work subject to certain conditions or restrictions, or not
work at all.

The conditions are:

• Medication: Steroids (e.g. prednisolone, but not the oral contraceptive pill);
immunosuppressive agents (e.g. cyclosporin, azathioprine); antimalignancy agents (e.g.
methotrexate).

• Conditions: Chronic pulmonary disease (e.g. cystic fibrosis, bronchiectasis); chronic skin
conditions; diabetes mellitus; epilepsy (any form); HIV; pregnancy (see below).

• Previous surgery: transplant surgery; splenectomy.

• Any condition or therapy that your personal medical adviser considers may place you or
your colleagues at risk when working in the laboratory.

(b) Pregnancy

Farms

Pregnant women must not work with calving cows, farrowing sows, or lambing ewes; and
must not handle cat faeces.

Laboratories

The following is a list of agents that are generally considered to present a special risk in
pregnancy. Work with any agent that causes systemic or severe infection or that localises to
the female genital tract should be considered and risk assessed carefully.

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Bacteria Brucella spp.
Chlamydia psittaci
Chlamydia trachomatis
Listeria monocytogenes
Treponema pallidum

Protozoa Toxoplasma gondii

Viruses Rubella
Cytomegalovirus
Herpes simplex virus 1 and 2
Varicella zoster virus
Parvovirus B19
Mumps virus
HIV

(c) Immunisation

The National Health Service offers an immunisation programme to all citizens, and prudent
employees should avail themselves of this, through their own General Practitioner.

In particular, all staff and students at the University are strongly advised to obtain
immunisation against tetanus. This is particularly important for those whose work may bring
them into contact with soil and animals.

Employees in the categories listed below should be advised which immunisations are
considered to be desirable before work in a specific area is started. Records should be kept of
all immunisations and of refusals to be immunised by the Department/School.

Visiting workers and students will be treated as employees for the purposes of this policy.

Other categorisations for special work will be made as and when the required notifications are
given to the Sub-Committee, together with any special advice or conditions.

Animals

Employees who handle freshly imported (in quarantine) animals are strongly recommended to
be immunised with rabies vaccine.

Laboratory Workers

Laboratory workers processing blood and body fluids will be offered immunisation against
Hepatitis B.

Plumbing Work

Members of staff carrying out plumbing will be offered immunisation against Hepatitis B and
A.

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Sewage

Staff working with sewage will be offered immunisation against Hepatitis A.

Work with mentally handicapped

Staff whose work brings them into contact with the mentally handicapped will be offered
immunisation against Hepatitis A.

Cleaning Staff

Cleaning staff in the Wolfson Unit of Clinical Pharmacology will be offered immunisation
against Hepatitis B.

Moorbank Experimental Ground

Staff tending the gardens at Moorbank Experimental Ground will be offered immunisation
against Hepatitis B.

15
Precautions against blood-borne viruses (HIV and Hepatitis)

Any laboratory working with human blood or blood products must obtain and observe the
precautions in ACDP Publication; “Protection against blood-borne infections in the
workplace: HIV and Hepatitis”. COPIES CAN BE ORDERED THROUGH THE SAFETY
OFFICE (EXT. 6274). (The “BIOCOSHH” Form must be completed for all such work.)
HEPATITIS B IMMUNISATION IS GENERALLY ADVISED AND SHOULD BE
OFFERED TO INDIVIDUALS CONDUCTING SUCH WORK.

16
Genetic Modification

No work involving genetically modified organisms may be carried out by any person on
University premises without prior approval of Microbiological Hazards and Genetic
Modification Safety Advisory Sub-Committee.

Staff and students must also obtain prior approval before undertaking such work at any
other premises.

Background

There are detailed legal requirements and University rules which must be met in connection
with any work involving genetically modified organisms (GMOs). Certain action must be
taken before work starts and, in addition, there are standards which must be met during the
course of the work.

Application of Laws (See “Current Guidance”)

The Regulations apply to operations in which organisms are genetically modified AND
operations in which genetically modified organisms are cultured, used, stored, transported,
destroyed or disposed of.

Definition of Terms

In general:

"genetic modification" means altering the genetic material of any "organism" by a way that
does not occur naturally by mating or natural recombination or both.

"organism" means any biological entity capable of replication or of transferring genetic

material and includes a "micro-organism"

"micro-organism" means a microbiological entity, cellular or non-cellular, capable of

replication or of transferring genetic material including animal or plant cell cultures.

In cases of doubt, the reader should refer to Current Guidance.

Brief Summary of the Legal Requirements for 'Contained' Use (see page 5)

risks to human health and the environment must be assessed.

work must be categorised on the basis of risks taking into account the nature of the
organisms and the type of activity

appropriate levels of containment must be adopted, as must standards of occupational and

environmental safety

17
 retrospective notification must be made to HSE of individual activities involving genetic
modification, and, for some activities, consent must be obtained from HSE before work
proceeds

local (Departmental) genetic modification safety committees must be established to advise

on risk assessments

accidents must be notified and, where appropriate emergency plans drawn up. (See
Section Current Guidance).

NOTE: Anyone contemplating deliberate release of genetically modified organisms must

not proceed without contacting the University Safety Office.

Controls On Genetic Modification

There are 3 tiers of monitoring and control.

The Department

A Department carrying out genetic modification must have its own local Genetic
Modification Safety Committee, constituted in accordance with ACGM/HSE Note 11, to
advise on each experimental proposal and risk assessment and to oversee the standards in the
Department. In some cases small Departments may combine to form one Committee.

The University

The Microbiological Hazards and Genetic Modification Safety Advisory Sub-Committee

(which reports to Safety Committee and to the Pro-Vice-Chancellor responsible for health
and safety) oversees standards across the University.

All correspondence and enquiries should be directed in the first instance to the Secretary of
the Sub-Committee, in the Safety Office.

The Sub-Committee examines all proposals for genetic modification work and is empowered
by the Pro-Vice-Chancellor to approve certain categories of work on behalf of the University.

The Health and Safety Executive

Certain more hazardous categories of work must be submitted to the HSE before work may
commence.

Current Guidance

At the time of printing both the Laws and the Official Guidance are under review.

The current position can be ascertained by reference to: The Departmental Biological Safety
Supervisor, or the Safety Office, or University Web Site.

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Applying for Approval For A Project/Experiment

1 The person proposing the work must :-

a) Prepare a written protocol

b) Classify the work into an appropriate Category, in accordance with Current Guidance.
c) Prepare a written risk assessment covering both risks to human health and to the
environment.

2 The protocol and risk assessment must then be discussed and agreed by a Departmental
GM Committee constituted in accordance with Current Guidance.

3 After local approval, the protocol and risk assessment must then be forwarded together
with the comments of the local GM committee, to the University Safety Office for referral
to the Microbiological Hazards and Genetic Modification Safety Advisory Sub-
Committee.

If the risk assessment and the category is agreed then the Sub-Committee will issue approval
for the work to begin, with referral and notification to the HSE where required by Current
Guidance.

Cell, organ or tissue cultures

The principal concern here is that maintenance of certain cells in vitro may provide the
opportunity for adventitious infectious agents to multiply and be disseminated, even if the
growth of such agents was not intended within the work. Guidance from the ACDP1 clearly
indicates that all cell cultures of human or primate origin should be handled at
containment level 2 or higher. As a consequence, some GM assessments, for which the
assessment indicates that containment level 1 is appropriate, may nonetheless require
containment level 2 because cell cultures of the types indicated are involved.
1
'Categorisation of Pathogens according to hazards and categories of containment' and
subsequent amendments. Current version, under review at time of printing is 4th edition 1995
pp95-97. In cases of doubt, refer to the DBSS, the USO, or the UBSO for further guidance.

19
Disposal Procedures

The safe disposal of waste is an essential component of safe laboratory practice. Producers
of waste have a legal duty of care under the 1990 Environmental Protection Act.

University procedures for biological and other hazardous waste are summarised in the
"Hazardous Waste" poster. Additional guidance is available in Safe Working & the
Prevention of Infection in Clinical Laboratories: HSAC 1991.

In addition, the following points apply:

Unwanted Biological Material (e.g. redundant samples)

Users must arrange for the safe disposal of materials under their control at the earliest
opportunity. Except in exceptional cases this will be when the programme of work is
completed. It is the specific responsibility of each individual who retains material in storage
to ensure that containers are adequate for the purpose and are clearly and permanently
labelled. Overall responsibility for safe storage rests with the Head of Department. Before
any member of staff retires, leaves the University or transfers Departments, the Departmental
Biological Safety Supervisor should review with the individual concerned all biological
material held in store by that individual and arrange for safe disposal.

Before the end of any research project the Supervisor and researcher, in collaboration with the
Departmental Biological Safety Supervisor, should review and safely dispose of unwanted
biological materials.

In addition to the foregoing, each Departmental Biological Safety Supervisor should co-
ordinate a periodic review of biological materials in store to ensure that unwanted material is
safely disposed of and containers and labels remain adequate and secure.

Treatment of Biological Waste prior to Disposal

Before delivery into the disposal system, material should be inactivated whenever it is
reasonably practicable. This may be by disinfectant or autoclave as appropriate.

20
Autoclaves

Purchase

Purchasers should obtain the advice of the University Safety Officer or the University
Biological Safety Officer prior to placing an order.

Use

In all cases, autoclaves must be serviced at 6 monthly intervals by a competent engineer.

Where an autoclave is to be used for the terminal destruction of pathogens the following rules
apply:-

• Carry out a risk assessment so that users can be satisfied that the machine will achieve the
desired result in the circumstances proposed.

• The recommended standard is 121ºC for 20 minutes at the centre of the load. The starting
time is when the thermocouple meter reads 121ºC, because different machines and
different loads take different times to reach temperature. The 121ºC is optimum: a higher
temperature may produce drier steam with a consequentially lower rate of heat transfer.

• Ideally the temperature in the centre of the load should be read using flexible internal
thermocouple probes. If this is impractical, a satisfactory method of calibrating the
machine for the load should be employed, and the penetration time and sterilising
temperature and time for "make safe" cycles should be checked monthly using typical
discard loads.

• Examine the autoclaves weekly for the proper function of all safety devices by one of the
senior technicians responsible for the autoclaves. The inspection should conform to the
protocol below. A log of the results of the examination must be maintained and retained
by the Departmental Biological Safety Supervisor or his/her nominee.

• Monitor door seals in good operating condition. Any escape of steam from the door seal
should be reported immediately to the responsible person.

• Before any material is disposed of from "make safe" cycles the autoclave log book and
autoclave chart should be checked and signed by the senior technician responsible for the
autoclaves.

• Any major changes to the normal type of load (e.g. change in type/size of discard
container) should be preceded by thermocouple testing in a test load of that type.

• Where failure of malfunction of any safety device is detected, it must not be used until
further notice, confirming fault rectified.

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Weekly checks

1 Examine chamber door seals for any build up of dirt or deterioration, and wipe clean if
necessary.

2 Run the autoclave through a complete cycle and closely observe. Check the door lock
indicator. Log the temperature at the end of each cycle stage and the time taken for each
stage of the cycle and compare to previous results.

3 Examine the interior of the chamber for any pools of water being retained.

4 Examine and clean the strainer.

22
Microbiological Safety Cabinets

1 Purchase and Selection

General guidance is available in ACDP "Categorisation of Pathogens according to Hazard

and Categories of Containment" and other publications. Specific guidance is available from
the University Safety Officer and the University Biological Safety Officer.

The following also applies:

All units must be purchased through the Supply Manager, Bursar's Office, who will inform
the Engineer and the University Safety Officer (The purpose is not unduly to inhibit
Departments freedom of choice, but to ensure that appropriate technical arrangements such
as ensuring the balancing of the ventilation systems are made).

Departments should contact the University Safety Officer or the University Biological
Safety Officer for advice concerning types and makes prior to placing a firm order.

In all cases, commissioning must include an Operator Protection (KI disc) test.

Class II cabinets must vent through 2 HEPA filters. Where, by agreement with the
University Safety Officer, they recirculate into the workroom suitable arrangements must
be made for fumigation. This normally entails obtaining the suppliers "fumigation kit"
and arranging for it to vent outside.

2 Use

Existing Class II Cabinets which recirculate through one HEPA filter

These units must NOT be used for:

Work with known pathogens of Category 2 or higher.

Human tissue assigned to Category 3 by ACDP Protection against blood-borne infections

in the Workplace: HIV and Hepatitis B.

Subject to a suitable Risk Assessment, they MAY be used for work on human material. Risk
Assessment forms are available from the University Safety Officer. Note that continuous use
of these units is subject to a satisfactory risk assessment whenever there is a significant
change in the work taking place, and suitable arrangements must be made for fumigation (e.g.
use of the suppliers "fumigation kit").

23
3 Preparation for Servicing and Testing

Cabinets used for known Hazard group 2 pathogens

Routine access and testing: Swab down all interior surfaces with a suitable sterilising
solution.

Dismantling and/or removal of filter requires formaldehyde fumigation.

Cabinets used for known Hazard group 3 pathogens

Access testing and maintenance by anyone other than persons officially designated in the
laboratory access protocol requires formaldehyde fumigation.

Cabinets used for Human Tissue Culture

For the time being, the same procedures should be observed as for cabinets used for known
pathogens.

4 Training

It is a Departmental responsibility to ensure that users are adequately trained. To assist

Departments, an annual training session is organised by the University Safety Officer.

24
Fumigation of Microbiological Safety Cabinets

This Section should be read in conjunction with BS 5726: Part 4: 1992, paragraph 4. Copies
are available from the University Library or the University Safety Officer.

Except in those cases where hazardous material has not been used, fumigation of
microbiological safety cabinets is necessary before testing, before filters are changed, and also
at regular intervals which must be assessed according to the use to which the cabinet is put. It
may also be required to decontaminate equipment or materials before they are removed from
the cabinet.

In all cases the University permit to work form (available from the University Safety Officer)
must be completed before testing or servicing is carried out.

Formaldehyde vapour is most often used but it has limitations. It penetrates poorly and its
effectiveness depends upon the temperature and humidity. The vapour can also combine with
many common substances and under certain conditions will readily polymerise. Use of
excessive amounts may cause deposition of polymers within the cabinet and may contribute
to filter blockage.

The following comments are given as guidance. In the case of spore-forming and other
highly resistant organisms, biological testing may be necessary. Advice is available from the
Biological Safety Officer.

Vapour can best be generated by evaporation of formalin from a proprietary formalin

vaporiser. Alternatively the liquid may be evaporated by a thermostatically controlled
hotplate. There is also a method involving exposure of formalin to potassium permanganate
(35ml to 10g), but users of this method should exercise caution, as control of the reaction may
prove difficult.

Commercial formalin contains varying amounts of methanol. Formaldehyde vapour is

explosive at 7.75% concentration in dry air. The vapour is irritant. Maximum occupational
exposure limit is 2ppm. Persons carrying out fumigation should have immediately available a
respirator approved for use against formaldehyde and should not work alone. Formaldehyde
vapour is most effective at a relative humidity >65% and a temperature above 24ºc. A
concentration of at least 0.05g of formaldehyde per m3 is required. Excessive quantities
should not be used.

The safety cabinet should be sealed before the formaldehyde is generated inside the cabinet
and then allowed to steep for several hours, followed by proper evacuation of all the residual
gas. With recirculation type cabinets, a fumigation adapter kit should be used. The
temporary closure panel (night door) should in addition be sealed using security tape or
similar over the gaskets to reinforce the seal.

25
 Quantities required for evaporation method

Cabinet Amount of formalin

_____________________________________________

Class I 20 ml
Class I/III hybrids 20 ml
Class II (1200 wide) 25 ml
Class II (900 wide) 20 ml
Class II (1800 wide) 30 ml
Class III 20 ml

During the boiling of the formalin the cabinet fans may be briefly run for 10 seconds or so on
a couple of occasions to assist in the dispersal of the gas. When all the formalin has boiled off
(20-30 minutes) the unit should be switched off. The gas should then be allowed to steep
overnight, though it is possible for this time to be reduced to 2 hours in emergencies.

Hang a notice on the front of the cabinet "CAUTION FORMALDEHYDE" and on the door
to the laboratory "Caution, safety cabinet being fumigated" or similar wording.

Following decontamination the Microbiological Safety Cabinet must be purged of all residual
formaldehyde. With recirculation cabinets, the end of the flexible ducting should be placed in
a suitable outlet, e.g. fume cupboard, and the shut-off valve opened. Care must be taken not
to discharge formaldehyde back into the laboratory. The cabinet should be run for 20-30
minutes to allow any residual formaldehyde to be purged.

• Fumigation is best carried out at the end of a working day. Neighbouring laboratories and
offices should be notified and advised to close their windows against any possible re-entry
into the building of formaldehyde fume.

• Fumigated filters should be removed with gloves and put into a polyethylene bag that is
sealed for safe disposal.

Summary

Put correct amount of formalin in vaporiser, replace cap.

Put vaporiser inside cabinet.
Seal up cabinet using tape to reinforce closure gaskets.
Switch on vaporiser.
(Fans may be run briefly after 10-15 minutes)
Allow to soak overnight.
Switch on fans, remove bung or blanking plate.
After 10 minutes, remove night door.
After another 20 minutes cabinet can be opened or used.

26
Ultraviolet disinfection facilities

Ultraviolet disinfection facilities are not recommended unless specifically required for
experimental purposes. While UV radiation is undoubtedly bactericidal on unprotected moist
microbes, it is ineffective on dry organisms and in the presence of dirt.

The lamp must be clean, and after a limited period its germicidal power is lost although the
visible rays remain unchanged. Therefore, lamps should be linked to an elapsed time recorder
or its bactericidal ultraviolet output frequently tested.

27
Disinfectants: Selection and Use

General Rules

Care should be taken when handling disinfectants; either diluted or undiluted they are
potentially hazardous.

Use clear phenolics for most organic matter, tuberculous material and general
bacteriology, but not for blood and viruses.

Use hypochlorites for minimal organic matter, small amounts of blood and viruses but not
for tuberculous material or metals.

Use aldehydes for special purposes only.

Wear disposable gloves when swabbing with any disinfectant.

Do not top up disinfectant containers. Always empty and sterilise them before refilling.

Disinfectants may deteriorate on storage and subsequently lose antimicrobial activity.

CLEAR PHENOLICS e.g. Clearsol, Hycolin, Printol, Stericol, Sudol.

These are not much inactivated by organic matter and do not attack metals. They have a
wide range of activity, are suitable for tuberculous materials but not for viruses or HBsAg.
They kill some bacterial spores. The should be used in general microbiology, for discard
jars etc. and for disinfecting benches. All phenolics are absorbed by rubber and can cause
it to deteriorate. Use all phenolics at the manufacturer's recommended use-dilutions. Do
not store diluted disinfectants. Phenolics are compatible with anionic and nonionic
detergents.

HYPOCHLORITES e.g. Cloros, Domestos, Diversol BX

These are considerably inactivated by organic matter and attack metals to varying degrees
(Diversol BX is said to be non-corrosive). They are suitable for blood and viruses
including HBsAg, but not for tuberculous material and must not be used for centrifuges,
moving parts of machinery or metal surfaces. They kill some bacterial spores. They may
be used in virology, haematology and chemical pathology for discard and pipette jars and
surface disinfection. The commercial products usually contain 10,000 ppm of available
chlorine and should be used as follows:-

General use: Solution containing 1,000 parts per million available chlorine.

For pipette jars: Solution containing 1,500 parts per million available chlorine.

For blood spillage, etc: Solution containing 10,000 parts per million available chlorine.

Information on the parts per million of available chlorine should be readily available for all
commercially available hypochlorite disinfectants.

Hypochlorites are compatible with anionic and non-ionic but not with cationic detergents.

28
 ALDEHYDES
FORMALDEHYDE GAS AND FORMALIN ARE TOO IRRITANT FOR GENERAL
PURPOSES AND SHOULD NOT BE USED EXCEPT FOR FUMIGATION.
Glutaraldehyde (Cidex) is irritant and sensitising and should not be used where effective
alternatives exist. It does not readily penetrate organic matter and should be used only on
clean surfaces. It has a wide range of antibacterial activity. It is an effective but slow
sporicide. It is less irritating than formalin. It is useful in virology, for HBsAg. and for
disinfecting centrifuges and cryostats. For use it is diluted 2-3% with 0.3% bicarbonate
buffer, as it is most efficient at pH 7.0-8.0. It must be discarded after 12 hours as it
deteriorates once made alkaline. Care should be taken in handling glutaraldehyde and
contact with skin should be avoided.

PEROXYGEN COMPOUNDS AND ORGANIC ACIDS e.g. Virkon S.

This compound is a mixture of peroxygen compounds, organic acids, surfactant and buffer.
It is effective against all 17 virus families affecting man and animals including HIV 1 and
Hepatitis A & B. It is also an effective bactericide and fungicide. It can be applied in
powder form directly onto spillage of blood and other body fluids or can be used as a
solution to disinfect surfaces and soak laboratory glassware.

AVOID CONTACT WITH ALKALINE OR COMBUSTIBLE MATERIALS.

1 General cleaning; 0.5 - 1% solution.

2 Aerial disinfection; spray regularly with a 0.2% Virkon solution.

3 Disinfecting instruments and glassware; 1% solution for 10 minutes.

4 Heavy spillages of blood and body fluids; sprinkle Virkon powder over spillage allow
time for reaction, scrape into a plastic bag and dispose of. Them wash/disinfect with a
1% solution of Virkon S.

Germicidal Powder

FICHLOR clearon is a chlorinated iso-cyanuric acid derivative with a wide range of activity,
including viruses (but not mycobacteria) and is manufactured by Fisons Limited,
Agrochemical Division, Hauxton, Cambridge. It is most useful for gross spillages.

Fumigation

If in doubt advice should be sought from the University Safety Officer or Biological Safety
Officer.

29
Serum or Plasma Treatment

Where possible, it is desirable to treat "high risk" samples so that, if present, HIV. Hepatitis B
virus and other pathogens would be inactivated prior to processing. It is not possible to
generalise about the efficacy of the alternative processes so the containment measures
proposed for a particular project still need to be reviewed by the safety office prior to
approval. The following procedures are provided so that workers can evaluate their effect on
the experimental procedure or assay proposed. This preliminary work should be done using
"low risk" samples.

ß-propiolactone (BPL) treatment

BPL is a carcinogen

Well-stoppered samples should be brought to room temperature throughout. Wearing gloves,

BPL should be added to a final concentration of 1:400 and the samples mixed (preferably by
vortexing) then left to stand at room temperature for at least 1 hour.

BPL can be kept at 4ºC for 1-2 months but stocks held for longer should be frozen at -
70ºC.

References for BPL:

1. Advisory Committee on Dangerous Pathogens. Inactivation of viral haemorrhagic fever

specimens with ß-propiolactone. 1988.

2. Ball MJ. and Griffiths D. Effect of chemical analyses of ß-propiolactone treatment of

whole blood and plasma. Lancet 1985, 18 May 1160-1161.

3. Ball MJ and Bolton FG. Effects of inactivating HTLV iii on laboratory tests. Lancet
1985, 13 July, 99.

4. Dooley BJ et al. Effect of ß-propiolactone on routine biochemical investigations. Med.

Lab. Sci. 1985, 42,318.

5. Freeman R, Dodd AA and Selkin JR. Effect of BETA-propiolactone in blood on routine

haematological, biochemical and serological investigations. Lancet 1982, 8 May, 1048-
1049.

6. Ball MJ, Spriggs V, Sutton PM and Chapel H. Effect of ß-propiolactone - an inhibitor of

HTLV III/LAV activity - on immunological analyses. J. Imm. Methods 1986, 95, 113-116.

30
Eye Wash Solutions

The options are either cold water from the main or commercial eye-wash bottles.

Water from the main

The advantages are availability in substantial quantities (particularly important for chemical
burns), and low quantities of organisms in the water.

The water should not be directed into the eye with too much force.

Irrigation direct from laboratory taps creates the risk of eye injury from contact with the
taps, and should therefore be avoided.

Options include the use of length of sterilised rubber tubing or provision of commercial
eyewash units.

Eye-wash Bottles

The possible disadvantages are lack of sufficient volume, and growth of organisms in the
water (principally Pseudomonas aeruginosa, known to have caused eye damage and loss of
sight).

In order to avoid the latter it is important that only sealed commercial bottles are used, that
they are only used once, and that they are replaced before the suppliers' termination date.

Every case of eye injury should be referred immediately for medical attention.

31
University Register of Micro-organisms and Users

This Register is compiled by the Safety Office on behalf of the Microbiological Hazards
and Genetic Modification Safety Advisory Sub-Committee. Its purpose is to maintain a
record of certain pathogenic micro-organisms used at the University and of the staff who
work with them.

Responsibility for maintaining the record is given to the Departmental Biological Safety
Supervisor.

Annual Updating Exercise

Each year, Departmental Biological Safety Supervisors will receive notification forms from
the Secretary of the Sub-Committee (Assistant Safety Officer). There are two forms.

Form A to be used where there is information to report

Form B for NIL returns

What organisms to notify

Any organisms classified in Group 2, 3 or 4 by the Advisory Committee on Dangerous

Pathogens.

Clinical Samples

It is not the purpose of this register to record clinical samples which may or may not be
contaminated with listed micro-organisms.

However, it is important that records are kept by Departmental Biological Safety

Supervisors of those individuals who are exposed to body fluids and pathological samples.

IN ADDITION to the Register details EACH WORKER is required to keep more details of
strains, origin, or other identification of the micro-organism.

These written records must also include, separately, all other strains of micro-organisms held
or worked with by each individual and must be kept readily available for inspection and use
in an emergency.

32
Example of a Model Entry:-
________________________________________________________________________
Name & Status Pathogenic micro- Location Is vaccination If yes, list the
organism required or recom- persons vaccinated
mended by the
Advisory Committee
on Dangerous
Pathogens?
________________________________________________________________________

Dr AN Other Influenza virus Room ABC123 No

________________________________________________________________________

In written records kept by Dr AN Other

Influenza strains*

A/Puerto Rico/8/34 H1N1, Allantoic fluid in ampoules. Passage history unknown. Received
from Professor P White (Birmingham) in 1981.

A/Singapore/1/57. H2N2. Cell culture fluid from baboon kidney cells.

Passage history E24BK4. Received from ATCC in 1982.

∗ It may be argued that the Advisory Committee's list refers only to "recent isolates". While
the University Sub-Committee does not argue for special handling for such originally
pathogenic and epidemic strains, it feels they should be on the register as potential causes
of transmissible disease.

33
Departmental Biological Safety Supervisors

Terms of Reference

1 The ultimate responsibility for health and safety rests with the Head of the Department.
The role of the Departmental Biological Safety Supervisor (DBSS) is to assist the Head of
the Department or Unit in ensuring that the legal requirements and current University
Codes of Practice, appropriate to the micro-organisms being used for teaching, research
and genetic modification are implemented.

2 It is the responsibility of all supervisors and managers working with micro-organisms or

their products or practising genetic modification to ensure:-

a) That they are conversant with the appropriate Regulations and Codes of Practice, and

b) That they are satisfied that their staff and students are competent in the practice of
sound and safe microbiological techniques.

The DBSS should exercise oversight of these requirements and offer guidance and assistance.

3 Register of Staff and Micro-organisms

The DBSS shall maintain a register of all staff in the Department whose work involves the
use of or contact with micro-organisms and their products in Hazard Groups 2, 3 and 4 as
defined by the Advisory Committee on Dangerous Pathogens.

The DBSS shall also maintain a register of those micro-organisms in Hazard Groups 2, 3
and 4 which are stored and/or used in the Department.

Annually, or upon request, and using the form provided, the DBSS shall provide the
Microbiological Hazards & Genetic Modification Safety Advisory Sub-Committee (via its
Secretary) with an up-to-date, revised list of the staff and micro-organisms referred to
above, and shall confirm that no Category 3 or 4 micro-organisms, or their products are
being stored or used in the Department without the prior permission of the University
Biological Safety Officer and the Microbiological Hazards & Genetic Modification Safety
Advisory Sub-Committee.

4 Unwanted Biological Material (e.g. redundant samples)

The DBSS shall co-ordinate periodic reviews of materials in store to ensure that unwanted
material is disposed of and containers and labels remain secure.

5 The DBSS shall compile, upon request and using the form provided, such information on
genetic modification work as may be legally required by the Health & Safety Executive
and forward this to the University Safety Office.

34
6 Accident Procedures, Investigation and Reporting

Departmental Biological Safety Supervisors shall be responsible for investigating and

reporting to the Head of Department, in writing if necessary, upon any accident involving
micro-organisms or their products or the practice of genetic modification, within their
Departments.

The DBSS should also ensure that the standard University accident report form is
completed, sending a copy of the report to the University Safety Officer and the University
Biological Safety Officer. In many cases the accident report form will be a sufficient
written report.

In the event of injury to personnel, the University's nominated Occupational Health Doctor
should be informed.

Departmental Biological Safety Supervisors should be familiar with the University Local
Rules "Emergency Procedure for accidents involving Micro-organisms" contained within
this Handbook.

7 Equipment

The DBSS should exercise oversight of records of inspections of safety equipment such as
autoclaves and microbiological safety cabinets.

8 Co-operation

The DBSS should co-operate with the Radiation Protection Officer and/or Safety Officer
within his/her Department on matters of safety of mutual concern.

9 Liaison with the University Biological Safety Officer and University Safety Officer

The DBSS should maintain a close liaison with the University Biological Safety Officer
and University Safety Officer.

35
Hazard Groups and Containment Levels

Hazard Groups

Group 1 An organism that is most unlikely to cause human disease.

Group 2 An organism that may cause human disease and which might be a hazard to
laboratory workers but is unlikely to spread in the community. Laboratory exposure
rarely produces infection and effective prophylaxis or effective treatment is usually
available.

Group 3 An organism that may cause severe human disease and present a serious hazard to
laboratory workers. It may present a risk of spread in the community but there is
usually effective prophylaxis or treatment available.

Group 4 An organism that causes severe human disease and is a serious hazard to laboratory
workers. It may present a high risk of spread in the community and there is usually no
effective prophylaxis or treatment.

Laboratory containment levels

For the purposes of this model code the terms listed below have the following meaning:

a) laboratory: the room in which the organisms are handled;

b) laboratory suite: one or more laboratories, not necessarily of the same discipline, and
ancillary rooms within a Section or Department with shared use of facilities such as
autoclaves, centrifuges, etc.;

c) laboratory unit: a separate building, or self-contained suite within a building, containing

one or more laboratories and with ancillary rooms such as airlocks, changing rooms,
showers, autoclave room etc.

Laboratory Containment level 1

Laboratory Containment Level 1 is suitable for work with agents in Group 1. Although
defined as unlikely to cause disease by infection, some agents in this group are nevertheless
hazardous in other ways (i.e. are allergenic or may be toxigenic) and due precautions must be
taken. Guidance on respiratory sensitisation is available. Laboratory personnel must receive
suitable and sufficient information, instruction and training in the procedures to be conducted
in the laboratory.

1. The laboratory should be easy to clean. Bench surfaces should be impervious to water
and resistant to acids, alkalis, solvents and disinfectants.
2. Effective disinfectants should be available for immediate use in the event of spillage.
3. If the laboratory is mechanically ventilated, it is preferable to maintain an inward air flow
while work is in progress by extracting room air to atmosphere.
4. All procedures should be performed so as to minimise the production of aerosols.
5. The laboratory door should be closed when work is in progress.
6. Laboratory coats or gowns should be worn in the laboratory and removed when leaving
the laboratory suite.

36
7. Personal protective equipment, including protective clothing, must be:
a) stored in a well-defined place;
b) checked and cleaned at suitable intervals;
c) when discovered to be defective, repaired or replaced before further use.
8. Personal protective equipment which may be contaminated by biological agents must be:
a) removed on leaving the working area;
b) kept apart from uncontaminated clothing;
c) decontaminated and cleaned or, if necessary, destroyed.
9. Eating, chewing, drinking, taking medication, smoking, storing food and applying
cosmetics should be forbidden.
10. Mouth pipetting should be forbidden.
11. The laboratory should contain a basin or sink that can be used for hand washing.
12. Hands should be decontaminated immediately when contamination is suspected and
before leaving the laboratory.
13. Bench tops should be cleaned after use.
14. Used glassware and other materials awaiting disinfection should be stored in a safe
manner. Pipettes, for example, if placed in disinfectant, should be totally immersed.
15. Contaminated materials whether for recycling or disposal, should be stored and
transported in robust and leakproof containers without spillage.
16. All waste material, if not to be incinerated, should be disposed of safely by other
appropriate means.
17. Accidents and incidents should be immediately reported to and recorded by the person
responsible for the work or other delegated person.

Laboratory Containment Level 2

Laboratory Containment level 2 must be used for work with biological agents in Hazard
Group 2. Laboratory personnel must receive suitable and sufficient information, instruction
and training in working safely with agents in Group 2. A high standard of supervision of the
work should be maintained.

1. Access to the laboratory is restricted to authorised persons.

2. There must be specified disinfection procedures.
3. If the laboratory is mechanically ventilated, it must be maintained at an air pressure
negative to atmosphere while work is in progress (see paragraph 17 below).
4. Bench surfaces must be impervious to water, easy to clean and resistant to acids, alkalis,
solvents and disinfectants.
5. There must be safe storage of biological agents.
6. Laboratory procedures that give risk to infectious aerosols must be conducted in a
microbiological safety cabinet, isolator or be otherwise suitably contained.
7. There must be access to an incinerator for the disposal of infected animal carcasses (see
paragraph 24).
8. Personal protective equipment, including protective clothing, must be:
a) stored in a well-defined place;
b) checked and cleaned at suitable intervals;
c) when discovered to be defective, repaired or replaced before further use.
9. Personal protective equipment which may be contaminated by biological agents must be:
a) removed on leaving the working area;
b) kept apart from uncontaminated clothing;
c) decontaminated and cleaned or, if necessary, destroyed.
10. There should be adequate space (24 m3) in the laboratory for each worker.

37
11. The laboratory door should be closed when work is in progress.
12. Laboratory coats or gowns, which should be side or back fastening, should be worn and
removed when leaving the laboratory suite. Separate storage (for example, pegs) apart
from that provided for personal clothing should be provided in the laboratory suite.
13. Eating, chewing, drinking, smoking, taking medication, storing food and application of
cosmetics in the laboratory should be forbidden.
14. Mouth pipetting should be forbidden.
15. Bench surfaces should be regularly decontaminated according to the pattern of the work.
16. When undertaking procedures that are likely to give rise to infectious aerosols, a Class 1
microbiological safety cabinet (BS 5726: 1992 or unit with equivalent protection factor or
performance) should be used. Safety cabinets should exhaust to the outside air or to the
laboratory air extract system. Some other types of equipment may provide adequate
containment in their own right but this should be verified.
17. In most laboratories operating at Containment Level 2 where there is mechanical
ventilation simply to provide a comfortable working environment, it may not be practical
to maintain an effective inward flow of air. The often constant traffic in and out of
Containment Level 2 rooms may interfere significantly with attempts to establish
satisfactory airflow patterns. However, where a laboratory is ventilated specifically to
contain airborne pathogens in the event of an accident, then engineering controls and
working arrangements must be devised so as to counter the risk of airborne transmission
to other areas. Maintaining an inward flow of air is necessary only when work is in
progress. ‘Atmosphere’ in this context (see paragraph 3) may be taken to mean either the
external air and/or other parts of the laboratory suite or building.
18. The laboratory should contain a wash basin located near the laboratory exit. Taps should
be of a type that can be operated without being touched by hand.
19. Hands should be contaminated immediately when contamination is suspected, after
handling infective materials and before leaving the laboratory. When gloves are worn,
these should be washed or preferably changed before handling items likely to be touched
by others not wearing gloves, for example telephones, paperwork. Computer keyboards
and, where practicable, equipment controls should be protected by a removable flexible
cover that can be disinfected.
20. An autoclave for the sterilisation of waste materials should be readily accessible in the
same building as the laboratory, preferably in the laboratory suite.
21. Materials for autoclaving should be transported to the autoclave in robust containers
without spillage.
22. There should be a means for safe collection, storage and disposal of contaminated waste.
23. Contaminated waste should be suitably labelled before removal for incineration.
24. ‘Access to an incinerator’ - see paragraph 7 above, may be taken to mean an incinerator at
another site but whether local or distant, carcasses for incineration must be transported in
secure containers.
25. Used laboratory glassware and other materials awaiting sterilisation before recycling
should be stored in a safe manner. Pipettes, if placed in disinfectant, should be totally
immersed.
26. All accidents and incidents should be immediately reported to and recorded by the person
responsible for the work or other delegated person.

Diagnostic laboratories

The minimum containment requirement is Level 2. All clinical microbiological suites must
contain a microbiological safety cabinet (class 1; BS 5726: 1992, or one with an equivalent
protection factor).

38
The “BIOCOSHH” Risk Assessment Form

i) All laboratory work with potentially living biological material (including work with
tissue, body fluid and cell cultures) must be assigned to the appropriate the Containment
Level as defined in ACDP, ACGM, MAFF and University documents. This form is to be
completed for all work requiring CONTAINMENT LEVEL 2 or above.
ii) Note that containment requirements may be defined by Dangerous Pathogen (ACDP,
MAFF) or Genetic Manipulation (ACGM) legislation and that all GM assessments must
be reviewed at Departmental and University level.
iii) To complete this form, refer to "Guidance Notes on completing 'BIOCOSHH' Forms" on
page 41.

1. DEPARTMENT

LOCATIONS INVOLVED
2. STAFF: Responsible member of staff Position

Laboratory Workers Positions

3. DESCRIPTION OF ORGANISMS/MATERIAL/PROCEDURE

4. PURPOSE OF WORK

5. HAZARDS: Specific personal hazards identified (including infectious, toxic, oncogenic

and allergenic effects)

Route(s) of infection/exposure
Estimate of minimum dose required to produce disease if available
Specific Environmental/Community Hazards Identified
Epidemic potential
Availability of prophylaxis/treatment

6. CONTROL MEASURES: Containment level:

Safety cabinets
Animal work
Protective clothing
Storage and transport
Disinfection
Waste disposal
Other

39
7. EMERGENCY ACTION
Most significant hazards (identify all intended operations that pose hazards significantly
above those of routine stock culture maintenance e.g. large volumes, sonnication etc.):

Are special emergency/containment contingencies (outside the departmental safety policy)

required to cover accidents related to any of the above YES/NO*
If YES, where are these detailed? (if appropriate, details should be provided below)

8. MONITORING & HEALTH

General: Identify any specific monitoring measures required above standard departmental
procedures. (e.g. equipment maintenance, environmental sampling etc.):

Immunisation and Health: (Detail all immunisations and health monitoring proposed - see
Notes):

Is an Occupational Health Assessment required for reasons relating to the organism or

procedure? YES/NO*

Are there any specific symptoms which should trigger an investigation into a possible
laboratory acquired infection (NB where similar symptoms may be common in the local
community it may be of little value to investigate every time they occur). If so give details:

Training and supervision: Are all identified workers adequately trained and informed to carry
out this work? YES/NO*
If NO, indicate programme of instruction and supervision.

9. REVIEW (date/circumstances for/of review)

10. SIGNATURES
Responsible member of staff: Date:
Laboratory workers: Date:

Head of Department (if required by departmental policy) Date:

* delete as appropriate

40
Guidance Notes on Completing “BIOCOSHH” Forms

Electronic versions of the form (with expanding boxes!) can be obtained from the Safety
Office web site http://www.ncl.ac.uk/internal/safety/biohazard.html (rtf format) or on
disk from the Safety Office (Word 6).

General:

A “suitable and sufficient” risk assessment is a statutory requirement for all laboratory
procedures. Where those procedures involve recognised significant levels of hazard “suitable”
means that it must be written. As a matter of policy and in response to specific advice, the
Microbiological Hazards and Genetic Manipulation Advisory Sub-Committee has defined the
threshold at which written risk assessments are necessary as all operations, including genetic
modification work, for which Biological Containment Level 2 or above are required. Note
that work requiring containment level 3 or above requires specific approval from the
Sub-Committee (contact the Safety Office).

Note also that it is pre-requisite that you have ascertained the Containment Level. This
may involve simply checking against the ACDP list for wild strains, or carrying out the
standard assessment and approval procedure for GM work.

The form presents suggested categories under which you should make assessments. It is NOT
intended that you should religiously fill out every section irrespective of its relevance or
utility. The intention is to help you make appropriate assessments. The law requires that such
assessments should be made but does not define their format beyond the elegantly vague
expression - “suitable and sufficient”.

Specific:

3. This may include a group of organisms or procedures that all pose a similar hazard and
that can be contained by a common set of procedures.

5. What defined hazards do the organisms pose. Useful sources of information include
“Control of Communicable Diseases in Man” 16th Edn Benenson AS (Medical Library
614.5) and Mandell et al, 1995 “Principles and practice of infectious diseases “ 4th Edn
(Medical Library 616.9).

6. Disinfection and waste disposal should highlight any differences required from
established (written) departmental policies.

7. You must address “worst case” scenarios here. The HSE consider worker safety and
minimising exposure to be paramount. Emergency procedures should therefore provide
for immediate appropriate care to a worker who has received a hazardous exposure;
containment and disinfection are less immediate priorities.

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8. Health monitoring, may be required:

(a) because the organism poses a significant hazard the effects of which can be
recognised either in terms of specific symptoms or through specific diagnostic tests.
This is especially important if the infectious agent is known to be associated with
chronic (long-term) effects or latency or is a well-recognised cause of laboratory
acquired infection* .

(b) because a particular worker may be particularly susceptible to infection or to its

deleterious effects as a result of established conditions or therapies. See page 7 of
the University's "Safe working with micro-organisms".

In many (hopefully most) cases health monitoring will not be required because the
likelihood of infection is small, effects are minimal and non-specific, and specific
treatment is not generally required. However, where, in spite of appropriate containment
you consider that either or both of (a) and (b) above apply, then an Occupational
Health Assessment is required and therefore a copy of the Biohazard Risk
Assessment should be sent together with contact details for all the individuals
involved to the USO in a sealed envelope marked

“Occupational Health Referral: Confidential”

A response from Occupational Health will then be sent to all individuals concerned.

Where (a) applies, it is the responsibility of the project leader, and where (b) applies
the responsibility of the individual and copy forms may be submitted in confidence.
Note that for work requiring containment level 3, an Occupational Health
Assessment is mandatory.

In general, if in doubt, you should send the form anyway. If monitoring is undertaken, the
specific approach will be developed in discussion with Occupational Health.

9. Review should be carried out wherever there is a significant change. Although

Regulations permit a maximum period of 5 years between reviews, it is recommended
that review be carried out at 12-monthly intervals.

10. The Head of Department is legally responsible for safety matters, and should therefore
make arrangements to monitor that risk assessments are being carried out.

∗ Useful sources:
Collins CH, Laboratory-acquired infections : history, incidence, causes and prevention: Medical Library 614.44
COL.
Sewell DL, Laboratory-associated infections and biosafety. Clinical Microbiology Reviews 8(3):3898-405,
1995)
42
Application to Student Work

1) Risk Assessment

Those activities which take place at Containment Level 2 should be risk-assessed

using the same forms and procedure. Where the activity is a Class Practical which takes
place unchanged on more than one occasion, a single generic risk assessment is
acceptable, subject to review at appropriate intervals. The maximum review interval
permissible under the COSHH Regulations is 5 years.

Activities at Containment Level 3 are not permitted except with prior approval of the
Sub-Committee.

Responsibility for carrying out the Risk Assessment lies with the supervisor for student
projects, and with the course organiser for class practicals.

Each participating student should be provided with a copy of the Risk Assessment.

2) Health Surveillance

There are two ways in which this may become necessary:

a) By virtue of the general risk created by the activity.

In general student work with organisms necessitating health surveillance should be

avoided (such work is summarised in para 8a of the guidance note in USO circular
37/97: i.e. "because the organism poses a significant hazard the effects of which can
be recognised either in terms of specific symptoms or through specific diagnostic
tests. This is especially important if the infectious agent is known to be associated
with chronic (long-term) effects or latency or is a well-recognised cause of
laboratory acquired infection").

b) By virtue of individual susceptibility.

The potential need for health surveillance by virtue of individual susceptibility

should be brought to the attention of all participating students, who should be
advised to contact Occupational Health directly (Tel. 55-24790) if they believe they
are a susceptible individual. (See p7 of "Safe Working with Micro-organisms",
reproduced below).

Animal Pathogens

Users of non-human pathogens should be aware of the Specified Animals Pathogens Order
1998. See USO Circular 10/98 for further information.

Cell Cultures

See page 18.

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Publications

Microbiological Hazards

Supplement to: Categorisation of biological agents according to hazard and categories of

containment (4th Edition, 1995) Appendix 24: Guidance on laboratory work with Hazard
Group 3 enteric pathogens.
HSE Books 1998
ISBN 0 7176 1038 1

Transmissible spongiform encephalopathy agents: Safe working and the prevention of

infection
The Stationery Office, 1998
ISBN 0 11 322166 5

Protection against blood-borne infections in the workplace: HIV and hepatitis.

The Stationery Office, 1996
ISBN 0 11 321953 9

Publications specific to Genetic Modification

Refer to “Current Guidance” page 18.

44