Biosafety Recommendations for Laboratory Testing for TB Thomas M. Shinnick, Ph.D. Associate Director for Global Laboratory Activities, Division of TB Elimination Anticipating Biosecurity Challenges of the Global Expansion of High Containment Biological Laboratories July, 2011 National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of Tuberculosis Elimination

Why is Biosafety Needed in the TB Laboratory? Risk of infection with M. tuberculosis is 3x to 9x higher for TB lab workers than for other lab workers Infection often results from unrecognized production of infectious aerosols containing tubercle bacilli Infection can occur from needle sticks, through broken skin, etc.

Biosafety Level (BSL) Conditions under which an infectious agent can ordinarily be safely handled. Conditions are a combination of: laboratory practices and techniques safety equipment laboratory facilities Recommended BSLs for many of the infectious agents have been developed But different methods for the same agent may require different BSLs So, how does one determine the appropriate BL to use?

GLI Biosafety Guidance Biosafety guidance for TB lab procedures technical consultations, expert meetings GLI, WHO, CDC were the lead agencies Consensus recommendations for minimum biosafety requirements for direct AFB-smear microscopy processing specimens to concentrate bacilli for smear, culture, molecular tests manipulating cultures for smear, subculture, ID, DST, molecular tests

Risk Assessments for TB Procedures Based on likelihood of producing infectious aerosols and the concentration of bacilli Limited risk for infectious aerosols direct AFB smear microscopy Moderate risk for infectious aerosols processing sputum specimens High risk for infectious aerosols processing cultures and suspensions

Direct AFB Smear Microscopy Limited risk of generating infectious aerosols Work can be done on an open bench restricted access to the laboratory separate bench for smear preparation Adequately ventilated laboratory 6–12 ACH, directional airflow natural or mechanical ventilation Proper disposal of infectious material Primary containment or barriers to protect the worker include

Processing Sputum Specimens for Smear, Culture, Molecular Tests – 1 Moderate risk of generating infectious aerosols during specimen manipulation Laboratories must have restricted access and be separated from public areas Impermeable surfaces for easy cleaning Air flows into lab without re-circulation to non-lab areas (directional airflow) 6–12 ACH, closed windows Proper disposal of infectious material

Processing Sputum Specimens for Smear, Culture, Molecular Tests – 2 Class I or II Biosafety Cabinets used for all open manipulation of agents BSCs must be properly installed and certified at least annually BSC exhaust may be ducted to outside using a hard duct or thimble fitting (preferred) recirculated into the room if assured that the BSC is functioning properly Use aerosol-containment rotors Primary containment or barriers to protect the worker include

Processing Cultures for Smear, ID, Subculture, DST, Molecular Tests – 1 High risk of generating infectious aerosols during manipulation of liquid suspensions Work done in a containment lab which has restricted access and a double door entry Impermeable surfaces for easy cleaning sealing room for fumigation is not required Air flows into lab without re-circulation to non-lab areas (directional airflow) 6–12 ACH, mechanical ventilation, sealed windows Autoclave available on site This sort of risk assessment has been done for routine work with a number of infectious agents, and 4 generic biosafety levels developed.

BSCs must be properly installed and certified at least annually Processing Cultures for Smear, ID, Subculture, DST, Molecular Tests – 2 Class I or II Biosafety Cabinet used for all open manipulation of agents BSCs must be properly installed and certified at least annually BSC exhaust may be ducted to outside using a hard duct or thimble fitting (preferred) recirculated into the room if assured that the BSC is functioning properly Use aerosol-containment rotors Primary containment or barriers to protect the worker include

TB Laboratory Biosafety Gaps What are minimum facility requirements? U.S./European-style BSL3? containment room, airflow, BSC? What are suitable laboratory layouts? What are minimum safety requirements for technicians who are HIV+? for areas with high rates of MDR/XDR TB? When should respirators be required? Are Class I BSCs adequate? How to ensure functioning BSCs?

BSL3 – Secondary Containment BSL2 secondary containment plus: Directional inward airflow without re-circulation to non-lab areas; 6-12 ACH Controlled access; separate area Double door entry (airlock) Enclosures for aerosol-generating equipment Walls, floors and ceilings are water resistant for easy cleaning Room penetrations sealed Secondary containment or barriers to protect the environment include

Interim Guidance for XDR TB Clinical specimens from known or highly suspected XDR TB patients BSL2 with full BSL3 practices are highly recommended Manipulation of cultures of XDR TB strains BSL3 practices, containment equipment, and facilities are required. BSL3 practices must include the use of respiratory protection and the implementation of specific procedures and use of specialized equipment to prevent and contain aerosols.

Guidance for Samples from Known or Highly Suspected XDR TB Patients Manipulation of clinical specimens ‘Moderate risk’ facilities with ‘high risk’ practices & PPE are highly recommended Manipulation of cultures ‘High risk’ practices, containment equipment, and facilities are required. Practices must include the use of respiratory protection and the implementation of specific procedures and use of specialized equipment to prevent and contain aerosols.

Acknowledgements Véronique Vincent CN Paramasivan Chris Gilpin Daniela Cirillo Jean Joly Jenny Allen John Ridderhof Jon Crane` Knut Feldmann Moses Joloba Paul Jensen Peter van't Erve Philippe Dubois Sang Jae Kim Shanna Nesby Thomas Shinnick Andrew Ramsay Karin Weyer May Chu Nicoletta Previsani Sebastien Cognat

Thank You National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of TB Elimination