1. __________________________________________________________WSLH 1 Laboratory Biosafety WSLH Teleconference June 27, 2007 Peter A. Shult, Ph.D. Director, Communicable Disease Division and Emergency Laboratory Response Wisconsin State Laboratory of Hygiene

2. __________________________________________________________WSLH 2 Laboratory Biosafety Historical perspective Principles of biosafety Elements of containment including the Biological Safety Cabinet (BSC) Biosafety levels Biosafety risk assessment Biosafety beyond the laboratory walls Biosecurity

3. __________________________________________________________WSLH 3 Laboratory Biosafety Key Resources (I) Biosafety in Microbiological and Biomedical Laboratories (BMBL),5 th Ed.Biosafety in Microbiological and Biomedical Laboratories (BMBL),5 th Ed. U.S. Department of Health and Human Services http://www.cdc.gov/od/ohs/biosfty/bmbl5/bmbl5toc.htm http://www.slh.wisc.edu/wps/wcm/connect/extranet/comdis/ Laboratory Biosafety Manual, 3 rd Ed. World Health Organization, 2004 http://www.who.int.csr/resources/publications/biosafety/ WHO_CDS_CSR_LYO_2004_11/en/

4. __________________________________________________________WSLH 4 Laboratory Biosafety Key Resources (II) Primary Containment for Biohazards: Selection, Installation and Use of Biological Safety Cabinets, 2nd Edition U.S. Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention and National Institutes of Health September 2000 http://www.cdc.gov/od/ohs/biosfty/bsc/bsc.htm Control of Communicable Disease Manual, 18 th Edition David L. Heyman, MD, Editor APHA

5. __________________________________________________________WSLH 5 Laboratory Biosafety Key Resources(III) Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS),Version 2.3; July 20 2004 http://www.cdc.gov/ncidod sars/guidance Biological Safety: Principles and Practices, 4 th Ed ASM Press, 2006 Laboratory Security and Emergency Response Guidance for Labs Working with Select Agents MMWR, December 6, 2002; Vol.51/ No. RR-19 http://www.cdc.gov/mmwr/PDF/RR/RR5119.pdf

6. __________________________________________________________WSLH 6 Laboratory Biosafety Historical perspective (I) Landmark studies by Pike and Sulkin Questionnaire assessment Between 1930 – 1978, 4,079 LAIs with 168 deaths Most common causative agents of overt infection include: 1. Brucella spp. 6. M.tuberculosis 2. C. burnetti 7. B. dermatidis 3. HBV 8. VEE 4. S. typhi 9. C.psittaci 5. F. tularensis 10. C.immitis No specific accident or exposure event in > 80%

7. __________________________________________________________WSLH 7 Laboratory Biosafety Historical perspective (II) Followup worldwide literature search, 1979-2004 1, 141 overt infections, 24 deaths Most common causative agents of overt infection include: 1. M. tuberculosis 6. HBV 2. Arboviruses 7. Shigella spp. 3. C. burnetti 8. Salmonella spp 4. Hantavirus 9. HCV 5. Brucella spp. 10. N. meningitidis Many asymptomatic infections Many newer agents, e.g. SARS-CoV, Cryptosporidium, etc. No specific exposure event in most cases

8. __________________________________________________________WSLH 8 Laboratory Biosafety Historical perspective (III) What types of laboratories involved ? % of LAIs according to laboratory type 1930-1975 1979-2004 Clinical 17% 46% Research 59% 50% Production 3% 3% Teaching 3% 1% Unknown 18% < 1% Reasons for increase in LAIs in clinical labs? Better surveillance and reporting Absence of biosafety containment equipment Failure to use adequate containment procedures early in diagnostic process

9. __________________________________________________________WSLH 9 Laboratory Biosafety Historical perspective (IV) What were the predominant means of exposure? As mentioned before no specific exposure event identified in most cases Those identified included: Inhalation of aerosols generated by work practices or procedures or spills Percutaneous inoculation Contamination of mucous membranes Ingestion

10. __________________________________________________________WSLH 10 Laboratory Biosafety Principles of Biosafety The objective of biosafety is the containment of potentially harmful biological agents The purpose of containment is to reduce/eliminate exposure of lab workers, other persons and outside environment to biohazardous agents Key elements of containment include: Laboratory practice and technique Safety equipment (primary barriers and PPE) Facility design and construction (secondary barriers) Risk Assessment of the work to be done with a specific agent or under specific circumstances determines the appropriate combination of these elements to employ

11. __________________________________________________________WSLH 11 Laboratory Biosafety Elements of Containment Laboratory Practice and Technique Arguably the most important element of containment Awareness of potential hazards and training and experience are critical Applies to pre-analytical, analytical and post-anaytical processes What about non-traditional testing sites and personnel? Behavioral factors Need for clear focus on work – all ages Creative innovation and risk taking Suggested age relation Lose the bad habits: sniffing, hot looping, etc. Working in absence of other containment elements

12. __________________________________________________________WSLH 12 Laboratory Biosafety Elements of Containment Safety Equipment (Primary barriers and PPE) Available for each possible route of exposure Aerosol: BSCs, covered centrifuge carriers, loop incinerators or disposable loops, PPE (respirators, PAPRs) Percutaneous: sharps disposal; retractable needles Mucous membrane contact: goggles or safety glasses, face shields, gloves Ingestion: automatic pipetting devices

13. __________________________________________________________WSLH 13 Laboratory Biosafety Elements of Containment The Biological Safety Cabinet (I) Arguably the single most important piece of safety equipment in the laboratory! Information Resources Importance of the Biological Safety Cabinet The principal device used to provide containment of infectious splashes or aerosols generated by many microbiological procedures Provides protection to the operator, the laboratory environment and work materials Which type is for you?

14. __________________________________________________________WSLH 14

15. __________________________________________________________WSLH 15 Laboratory Biosafety Elements of Containment The Biological Safety Cabinet (II) Follow proper BSC work practices and procedures BMBL5, Appendix A They dont work at all if you dont use them! Need for a lab-specific algorithm for BSC use A POLICY ISSUE Tie into risk assessment

16. __________________________________________________________WSLH 16 Laboratory Biosafety Element of Containment Facility Design and Construction (Secondary Barriers) Contributes to laboratorian safety, however, primary role is to protect persons outside of the lab and persons in the community from agents that might be accidentally released. Recommended secondary barriers depend on the risk of transmission of specific agents BSL-1/BSL-2 vs. BSL-3

17. __________________________________________________________WSLH 17 Laboratory Biosafety Biosafety Levels 4 biosafety levels Consist of combinations of lab practices and techniques, safety equipment and lab facilities Purpose: To categorize risk associated with infectious agent and define the appropriate safety practices, equipment and facilities for handling the agent safely Appropriate BSL determined by: Microbiological agent Risk Group Mode of transmission Procedural protocols Experience of staff Likelihood of aerosol generation Work involves use of amplified agent Other?

18. __________________________________________________________WSLH 18 W.H.O. Agent Risk Group Classification

19. __________________________________________________________WSLH 19 BSLAgentsMicrobiology Practices Safety Equipment (Primary Barriers) Facilities (Secondary Barriers) 1 Not known to consistently cause disease in healthy adults Standard Microbiological Practices None requiredOpen bench top sink required 2 Associated with human disease, hazard equals percutaneous injury, ingestion, mucous membrane exposure BSL-1 plus: Limited access, biohazard warning signs, sharps precautions, biosafety manual defining waste decontamination & medical surveillance policies Class I or II BSCs or other physical containment for manipulations of agents that cause splashes or aerosols of infectious materials, PPE: lab coats, gloves, face protection as needed BSL-1 plus: Autoclave 3 Indigenous or exotic agents with potential aerosol transmission; may have serious or lethal consequences BSL-2 plus: Controlled access; Decontamination of all waste & lab clothing before laundering; Baseline serum Class I or II BCSs or other physical containment for all manipulations; PPE: protective clothing; gloves; respiratory protection as needed BSL-2 plus: Physical separation from corridors; Self-closing, double-door access; Exhausted air not recirculated; Negative airflow into laboratory 4 Dangerous/exotic agents with high risk of life-threatening disease, aerosol-transmitted infections; or related agents with unknown risk of transmission BSL-3 practices plus: Clothing change before entering, shower on exit, all material decontaminated on exit All procedures in Class III BSCs or Class I or II BSCs in combination with full-body, air-supplied, positive pressure personnel suit BSL-3 plus: Separate building or isolated zone, dedicated supply, exhaust, vacuum, & decon systems; other requirements. Recommended Biosafety Levels for Infectious Agents Biosafety in Microbiological and Biomedical Laboratories,5th Ed

20. __________________________________________________________WSLH 20 Laboratory Biosafety Risk Assessment

21. __________________________________________________________WSLH 21 Handling Unusual Test Requests in the Clinical Lab What is meant by unusual test request? Novel agents, high public health impact SARS, Monkeypox, Avian influenza, smallpox Agents of particular public health importance Mumps, measles, rubella, hantavirus, etc. Novel agents, impact uncertain hMNV, Coronaviruses (non-SARS), Bocavirus, HPV Rare or exotic agents B virus, HFVs, chikungunya, dengue, etc.

22. __________________________________________________________WSLH 22 Handling Unusual Test Requests Handling Unusual Test Requests Considering the request Assessments needed Type of request Diagnostic capability Does it exist in lab? Should it be used? Can it/should it be developed? Biosafety considerations Expertise and Experience Regulatory restrictions on testing

23. __________________________________________________________WSLH 23 Laboratory Biosafety Risk Assessment(I) Whose responsibility? Technically, the lab director Practically, the bench microbiologist Primary factors to consider: Agent hazards Laboratory procedures planned Potential for aerosol generation Consider facility, equipment needed; appropriate PPE Capability of the staff Training, technical proficiency, good habits Known vs. unknown agent risk For known or suspected agent, consult BMBL agent summary statements, other references For unknown agent…

24. __________________________________________________________WSLH 24 Laboratory Biosafety Risk Assessment(II) Risk Assessment for Unknown Agents Reason for the need The Age of Emerging Diseases SARS, avian influenza, influenza A (H2N2) Key element of the assessment In addition to above, patient information is critical Evaluate completeness of patient information to assess risk of specimen testing When should it be undertaken? During emergency response (BT or EID) vs. routinely? Need new biosafety model in the laboratory! Standard (Universal) precautions for blood and fluids Enhanced precautions for respiratory (and other?) specimens needed???

25. __________________________________________________________WSLH 25 Laboratory Biosafety Risk Assessment(III) Other Considerations in the Clinical Laboratory Strict BSL-2 practices and procedures should be the minimum standard Biosafety cabinets (BSCs) are a must! But the reality is… Needs to be an organizational priority At minimum, develop algorithm for their use based on risk What about a possible BSL3 agent but no BSL3 lab? Mix &match PPE and good practice with equipment and facility based on risk assessment BSL 2+ Be aware of the potential for exposure to a BSL4 agent Look for just in time guidance, e.g. SARS

26. __________________________________________________________WSLH 26 Laboratory Biosafety Biosafety Beyond the Laboratory Walls Specimen collection sites Specimen transport: route and packaging Specimen labeling and requisition – A heads up Close communication with ICP and clinicians Dont forget your rapid test sites!

27. __________________________________________________________WSLH 27 Locations of Sentinel Laboratories and Rapid Test Sites in Wisconsin-2005 Sentinel Laboratories Douglas Bayfield Ashland SawyerWashburn Burnett Polk BarronRusk Price Iron Vilas Oneida Lincoln Taylor Chippewa St. Croix Pierce Dunn Pepin Eau Claire Buffalo Trempealeau Jackson Monroe Clark Marathon WoodPortage JuneauAdams Sauk LaCrosse Vernon Crawford Richland Grant LaFayette Green Rock Dane Iowa ColumbiaDodge JeffersonWaukesha Walworth Kenosha Racine Ozaukee Sheboygan Fond du Lac Green Lake Marquette WausharaWinnebago Calumet Manitowoc Kewaunee Brown Outagamie Waupaca Shawano Menominee OcontoLanglade Forest Marinette Florence Door Milwaukee Washington Rapid Test Sites

28. __________________________________________________________WSLH 28 Laboratory Biosafety Addressing Rapid Test Site Biosafety Needs Obvious need for basic biosafety training Role for WSLH and clinical labs to participate in training Strategies to enhance biosafety & reduce potential exposure Collect & communicate patient travel history and risk factors to testing staff In most cases, no BSC. Therefore: Techniques to minimize aerosol production Consider use of personal protective equipment (PPE) during test performance Consider use of physical barriers for test performance (e.g., bench shields) Sequester/isolate testing area

29. __________________________________________________________WSLH 29 Biosecurity What is biosecurity? Select Agent Regulations Elements of a facility security plan

30. __________________________________________________________WSLH 30 Biosecurity What is biosecurity? Protection of high-consequence microbial agents and toxins, or critical relevant information, against theft or diversion by those who intend to pursue intentional misuse A concern in light of recent terrorism events Relationship to biosafety Its all about risk assessment and containment! Need for general biosecurity planning??? No current federal requirement for such a plan Excellent review in Section VI of BMBL 5 th Ed. Enhanced emphasis under Select Agent regulations Specific requirement for a facility security plan

31. __________________________________________________________WSLH 31 Biosecurity Select Agent Regulations What is the Select Agent Regulation and who is affected? Establishes a listing of agents thought to pose a threat to public safety Requires entities that possess any of these agents to follow the guidelines within this regulation Requires a Facility Security Plan http://www.cdc.gov/od/sap

32. __________________________________________________________WSLH 32 Biosecurity Select Agent Regulation Clinical labs likely to be exempt unless they possess S.A.s What are diagnostic/clinical labs required to do if they encounter* a select agent? Notification Contact WSLH Contact CDC by phone Select agent handling protocol Within 7 days of identification: Transfer to registered entity Destroy---autoclave, incinerate Documentation APHIS/CDC form 4; maintain copy for 3 years APHIS/CDC form 2 if transferred*

33. __________________________________________________________WSLH 33 Biosecurity Elements of a Facility Security Plan Required under Select Agent Regulations Pragmatic applications apart from select agents Conduct risk assessment as precursor to security plan Element of plan include: Physical security Data and IT security Personnel security assessment policy Controlled access to areas containing select agents Select Agent accountability including receipt and transfer Emergency response plan Incident reporting system

34. __________________________________________________________WSLH 34 Laboratory Biosafety Any Questions?