4. STANDARD OPERATING PROCEDURES

1. 4. STANDARD OPERATING PROCEDURES RYERSON UNIVERSITY

2. Biological Safety Training – Certificate Holder and User Training BIOLOGICAL SAFETY 4. Standard Operating Procedures • Infection Control • Containment of Aerosols • Working in CL 1 areas • Working in CL 2 areas • Biological Safety Cabinets • Human Blood and Body Fluids • Needle Stick Injury Prevention • Signs and Labels • Personal Protective Equipment • Purchasing/Transfer • Inventory Control • Decontamination/Waste Disposal • Large Scale Work RYERSON UNIVERSITY

3. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresInfection Control • Good microbiological practice: • is a basic code of practice to handle biological agents • Involves specific sterile techniques of product protection, contamination control • applied to all types of work involving microorganisms irrespective of containment level to reduce the risk of exposure and infection Rayonnement - Danger - Radiation RYERSON UNIVERSITY

4. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresInfection Control • Good microbiological practices prevent contamination of: • laboratory workers • the environment • experimental samples • Good work practices can significantly reduce the risk of: • aerosol production • contamination of experimental equipment surfaces • contains the biological agent • reduces the risk of infection Rayonnement - Danger - Radiation RYERSON UNIVERSITY

5. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresInfection Control – Hand Washing When to wash? • Before starting any manipulations • Before leaving the lab • When hands are obviously soiled • Before and after completing any task in a biosafety cabinet • Every time gloves are removed • Before contact with one’s face or mouth • At the end of the day Rayonnement - Danger - Radiation RYERSON UNIVERSITY

6. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresInfection Control – Hand Washing • Frequent hand washing has proven to be the single most effective means of avoiding infection if done properly and frequently • liquid dispensers should be used rather than bars RYERSON UNIVERSITY

7. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresInfection Control – Hand Washing • Wet hands with warm water • Dispense soap into a cupped hand • Spread around hands and between fingers • Wash hands for at least 10 sec. • Rinse thoroughly under warm water. • Dry hands thoroughly with paper towels. RYERSON UNIVERSITY

8. Continue on to:Containment of Aerosols Return to SOP Main Menu RYERSON UNIVERSITY

9. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresContainment of Aerosols • Aerosols are gaseous suspensions of fine solid or liquid particles ranging in sizes from 0.01 to 100 µm and can remain suspended in air for extended periods of time. • Pathogens such as viruses and bacteria are so small that they can travel within one aerosol droplet and be dispersed by building ventilation. • Aerosols can settle on many surfaces where personnel may unwittingly be exposed to a potentially infectious material through the risk of direct contact. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

10. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresContainment of Aerosols • When appropriate, other primary barriers such as splash shields, face protection or gowns should also be used. • When conducting procedures that create considerable aerosols or when using agents classified at Containment Level 2, work should be conducted in a Biological Safety Cabinet Rayonnement - Danger - Radiation RYERSON UNIVERSITY

11. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresContainment of Aerosols • The generation and dispersal of aerosols must be minimized and controlled. • Numerous procedures and devices which can result in the generation of aerosols: • pouring liquids, • using centrifuges, shakers, blenders, • opening pressurized vessels, • inserting a hot loop into a culture, • pipetting, etc. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

12. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresContainment of Aerosols • Sterilization of inoculation loops in an open flame may create aerosols which may contain viable microorganisms. • Use a shielded electric incinerator. • Shorter handles minimize vibrations. • Disposable plastic loops are good alternatives. RYERSON UNIVERSITY

13. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresContainment of Aerosols Mouth pipetting is prohibited. All biohazardous materials should be pipetted in BSC’s. Never force fluids out, use ‘to deliver’ pipettes. To avoid splashes, allow discharge to run down dispense the receiving container wall. Never mix material by suction and expulsion. Reusable pipettes should be placed horizontally in a disinfectant filled pan. Autoclave before reuse. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

14. Continue on to:Working in Containment Level 1 & 2 Areas Return to SOP Main Menu RYERSON UNIVERSITY

15. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • The following requirements are basic for any laboratory using biological agents. These requirements follow Health Canada’s Laboratory Biosafety Guidelines 3rd ed 2004: • Good microbiological laboratory practices intended to avoid the release of infectious agents are to be used. • A documented procedural (safety) manual must be available for all staff and its requirements followed. The manual must be reviewed and updated regularly Rayonnement - Danger - Radiation RYERSON UNIVERSITY

16. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • PROHIBITED: • eating, drinking, smoking • storing food or utensils • applying cosmetics • inserting or removing contact lenses • oral pipetting • loose long hair - must be tied back or restrained. • doors to laboratories must not be left open (does not apply to an open area within a laboratory) Rayonnement - Danger - Radiation RYERSON UNIVERSITY

17. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • WORK AREA • laboratory must be kept neat, and clean • storage of materials not pertinent to the work and cannot be easily decontaminated must be minimized • paperwork and report writing should be kept separate from biohazardous work areas. • access to laboratory and support areas is limited to authorized personnel • extreme caution must be used when handling needles and syringes to avoid autoinoculation and the generation of aerosols during use and disposal. Needles must not be bent or sheared. • disposable needles and syringes must not be replaced in their cap but placed into a puncture-resistant container Rayonnement - Danger - Radiation RYERSON UNIVERSITY

18. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • WORK AREA • technical procedures must be performed in a manner that minimizes the creation of aerosols • work surfaces must be cleaned and decontaminated with the appropriate disinfectant at the end of the day and after any spill of potentially hazardous material. • loose or cracked work surfaces must be repaired or replaced. • contaminated materials and equipment leaving the laboratory for servicing or disposal must be appropriately decontaminated and labelled or tagged as contaminated Rayonnement - Danger - Radiation RYERSON UNIVERSITY

19. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • PERSONAL PROTECTIVE EQUIPMENT • laboratory coats must be worn and fastened by all personnel working in the laboratory. • suitable footwear with closed toes and heels and preferably with non-slip soles must be worn in laboratory • protective laboratory clothing must not be worn in non-laboratory areas; • lab coats must not be stored in contact with street clothing • suspected contaminated clothing must be decontaminated before laundering • eye protection must be worn when necessary to protect the eyes • hands must be washed after gloves are removed, before leaving the laboratory, and after handling materials known or suspected to be contaminated, even when gloves have been worn Rayonnement - Danger - Radiation RYERSON UNIVERSITY

20. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • TRAINING: • Lab personnel must receive training on the potential hazards and the necessary precautions to prevent exposure to infectious agents and release of contained material • personnel must show evidence that they understood the training provided • training must be documented and signed by both the employee and supervisor • retraining programs should also be implemented. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

21. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • DISINFECTION & WASTE DISPOSAL • Disinfectants effective against the agents in use must be available at all times within the areas where the biohazardous material is handled or stored • effective concentrations and contact times must be used • all contaminate materials must be decontaminated before disposal or reuse • efficacy monitoring of autoclaves used for decontamination with biological indicators must be done regularly (i.e. consider weekly, depending on the frequency of use of the autoclave) • records of these results and cycle logs (temperature, pressure) must also be kept on file Rayonnement - Danger - Radiation RYERSON UNIVERSITY

22. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 1 areas • ACCIDENTS • All spills, accidents (needlesticks, punctures, cuts, etc.) and overt or potential exposures must be reported in writing to the laboratory supervisor as soon as circumstances permit. • must file two reports: • Ryerson University’s Internal Accident Investigation Report filed with the Centre for Environmental Health and Safety Management (CEHSM) within 24 hours of incident • Workers’ Compensation Form (WSIB Form 7) form must be sent to Human Resources with 24 hours of incident. • Appropriate medical evaluation, surveillance, and treatment must be sought and provided as required. Actions taken to prevent future occurrences should be documented. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

23. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresWorking in CL 2 areas • In addition to the safety precautions outlined for Containment Level 1 laboratory additional operational practices are outline below: • biological safety cabinets must be used for procedures that may produce infectious aerosols and that involve high concentrations or large volumes of biohazardous material. • appropriate door sign must be posted outside each laboratory Rayonnement - Danger - Radiation RYERSON UNIVERSITY

24. Continue on to:Biological Safety Cabinets Return to SOP Main Menu RYERSON UNIVERSITY

25. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Biological Safety Cabinets (BSC) provide an effective means of physical containment for biological agents, especially when aerosols are generated. • The main role is to provide protection to personnel, and the environment and product. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

26. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Protection is achieved through the control of air movement within and prior to leaving the cabinet, and through the use of HEPA (high-efficiency particulate air) filtration • HEPA filters are designed to remove particles with a minimum size of 0.3 microns with an efficiency of 99.97%. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

27. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresLaminar Flow Cabinets • Laminar flow cabinets (LFC) are similar in appearance, but are not Biological Safety Cabinets: • only protect the product • intake room air which is passed through a pre-filter and a HEPA filter to remove contaminants, dust and other particles • purified air then enters the work surface in a laminar flow (non-turbulent) which is directed out of the cabinet or down into intakes • these cabinets provide product protection only and must not beused when working with any form of biohazard • sometimes referred to as Clean Benches. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

28. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Cabinet Certification • BSCs must be certified annually or after cabinet has been moved • laminar flow hoods should be certified every second year • undertaken to ensure the HEPA filter has not be damaged, leaking or plugged. • cabinet should be decontaminated prior to any certification activity. • HEPA filters & cabinets must be decontaminated prior to disposal Rayonnement - Danger - Radiation RYERSON UNIVERSITY

29. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • The effectiveness of a BSC is dependent upon: • the integrity of the cabinet – (the risk of exposure increasesif the integrity is jeopardized) • location of cabinet in a room • proper microbiological technique and work practices that do not disturb established airflow velocity and cause reverse currents that can re-introduce contaminants into the work area • continued maintenance and certification. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

30. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets Before using the cabinet: • Ensure BSC is certified • Disinfect work surfaces with disinfectant • Place essential items inside cabinet • Allow the blower to run for 5-10 min before work RYERSON UNIVERSITY

31. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets During use of a Biological Safety Cabinet: • ensure material and aerosol-generating equipment is placed near the back of the hood • do not block any vents • use techniques that reduce splatter and aerosols • general work flow should be from clean to contaminated areas • minimize movement so as not to impede air flow RYERSON UNIVERSITY

32. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets After completion of work: • Leave blower on at least 5 minutes to purge cabinet • Remove and decontaminate equipment and materials • Disinfect cabinet surfaces • Turn off blower and fluorescent lamp, turn on UV lamp RYERSON UNIVERSITY

33. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Flames in Biological Safety Cabinets • The use of flame to sterilize equipment within a BSC is controversial. An open flame in a BSC creates several major problems: • Flame creates turbulence, which disrupts the pattern of air supplied to the work surface, therefore reducing maximum efficiency. • Heat build-up inside the BSC that may damage the HEPA filters • Creates a fire hazard. • It is recommended that flame should not be used in BSC's. • Alternatives to flames include using disposable sterile inoculating loops and needles, or pre autoclaved equipment in sterile packaging. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

34. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Flames in Biological Safety Cabinets • If a flame is required, a touch-plate micro-burner equipped with a pilot light to provide a flame on demand may be used. • This device will minimize internal cabinet air disturbances and heat build-up. • During use, the heat source should be placed to the rear of the workspace where resulting air turbulence will have minimal effect. • An emergency shut off valve should be placed just outside the BSC gas supply line and during the use of any burner, all combustible materials and solvents must be removed. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

35. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets • Ultraviolet Lamps: • Intended to destroy microorganisms in air or on exposed surfaces • Have limited penetrating power and only effective when properly cleaned, maintained • Dust is attracted to the lamps which reduces the transmission of the germicidal effect • Have a limited life span – even if the blue-violet glows, the lamps are not effective if the terminal ends are blackened even slightly • UV lamps themselves are potential hazards since UV light can be harmful to the eyes and skin and should therefore be turned off when work is being conducted in the cabinet. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

36. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresBiological Safety Cabinets Maintenance of a Cabinet: • Twice daily - Work surfaces wiped down • Weekly - UV lamp should be wiped clean • Monthly - All vertical surfaces wiped down • Annually - certification RYERSON UNIVERSITY

37. Continue on to:Human Blood and Body Fluids Return to SOP Main Menu RYERSON UNIVERSITY

38. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresHuman Blood and Body Fluids • blood borne pathogens, which are microorganisms that are present in blood and bodily fluids and are capable of causing disease in exposed individuals • exposure to human blood and bodily fluids (e.g., semen, cerebrospinal, amniotic,), tissue cultures, or organ cultures increases the risk • pathogens of greatest concern are hepatitis B virus, hepatitis C virus and the Human Immunodefiency Virus (HIV) Rayonnement - Danger - Radiation RYERSON UNIVERSITY

39. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresHuman Blood and Body Fluids RISK OF EXPOSURE DEPENDENT ON: • pathogen involved • type of body fluid • route of exposure • duration of exposure • volume of blood involved in exposure • concentration of virus at time of exposure • PPE worn RYERSON UNIVERSITY

40. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresHuman Blood and Body Fluids • UNIVERSAL PRECAUTIONS: • The minimum standard of practice to prevent exposure to blood borne pathogens and includes: • education • personal protective equipment • hand washing • safe work practices • Universal precautions assumes the material to be infectious and required to use control measures to prevent skin and mucous membrane exposure. • These precautions must always be used whenhandling blood or body fluids. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

41. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresUniversal Precautions • Gloves should be worn when handling potentially contaminated surfaces. • Avoid touching items that are NOT contaminated when gloves are being worn. • PPE should be worn during procedures that are likely to generate droplets of blood or bodily fluids. • Contaminated lab coats and gloves should be removed immediately after procedure is completed. • 5. Hand washing is the most important preventative tool - hands should be washed immediately after gloves are removed and before leaving a work area. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

42. Continue on to:Needle Stick Injury Prevention Return to SOP Main Menu RYERSON UNIVERSITY

43. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresNeedle Stick Injury Prevention • Injuries from sharps (needles, syringes, etc.) may result from: • lack of training on proper work practices • crowded work conditions • incorrect recapping of non retracting needles • poor disposal practices • [risk of injury exists not only to the user, but also support staff such as caretaking or hazardous waste disposal personnel] Rayonnement - Danger - Radiation RYERSON UNIVERSITY

44. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresNeedle Stick Injury Prevention Should a needle stick injury occur it is important to report it immediately and seek a medical assessment. Such injuries must not be ignored - potential laboratory associated infections could develop without appropriate treatment. Rayonnement - Danger - Radiation RYERSON UNIVERSITY

45. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresNeedle Stick Injury Prevention • To avoid needle stick injury use: • needle-less techniques where possible • retractable sharps • fill syringes carefully • do not bend, or recap needles • approved designated sharps containers should be used for disposal that will not allow penetration or direct access to sharps Rayonnement - Danger - Radiation RYERSON UNIVERSITY

46. Continue on to:Signs and Labels Return to SOP Main Menu RYERSON UNIVERSITY

47. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresSigns & Labels Biohazardous or infectious materials fall under; Class D, division 3 of WHMIS (Poisonous and Infectious Material - Biohazardous Infectious Material) Class 6.2 of Transport Canada Transport of Dangerous Goods Act (Infectious Substances) RYERSON UNIVERSITY

48. Biological Safety Training – Certificate Holder and User Training4. Standard Operating ProceduresSigns & Labels ENTRANCES Biohazard signs must be posted on doors to rooms where biohazardous materials are used (Level 2 or greater) Rayonnement - Danger - Radiation RYERSON UNIVERSITY

49. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresSigns & Labels Biohazard labels must also be placed on containers, equipment and storage units (e.g., fridges, freezers) used for biological agents. RYERSON UNIVERSITY

50. Biological Safety Training – Certificate Holder and User Training 4. Standard Operating ProceduresSigns & Labels • INSIDE LAB • (posted prominently) • Internal Ryerson Biosafety Certificate • Current list of authorized users RYERSON UNIVERSITY