Western Carolina University –
Biological Safety Manual
This document has been provided to inform the laboratory personnel at WCU of the hazards
associated with the use of biological materials for both themselves and their environment. The
guide that follows provides methods for evaluating the risk involved with biological materials
and for proper handling practices that will effectively minimize the risk of an injury or illness.
Biohazardous materials are those which present a potential risk to the health of humans or
animals, including but not limited to: bacteria, viruses, parasites, rickettsia, fungi, rDNA toxins,
and human blood/(unfixed) human tissues.
Office of Safety and Risk Management
0|WCU Biological Safety Manual– Office of Safety and Risk
Management
EMERGENCY TELEPHONE NUMBERS
(A larger copy is available at the end of this document to post by your laboratory telephone)
Phone
227-7443
Hours
8:00am - 5:00pm
Monday-Friday
University Police Department
• Work Related Injuries
(After Normal Business
Hours)
Police Services - 227-7301
Emergency Line - 227-8911
24 hours
Fire or Smoke
911 or
University Police 227-8911
24 hours
Medical Emergencies
911 or
University Police 227-8911
24 hours
1-800-84 TOXIN
(1-800-848-6946)
24 hours
Safety and Risk Management
Office
• Work Related Injuries
(Normal Business Hours)
• Gas Leaks or Odors
• Chemical Spills
• General Inquiries
NC Poison Control Center
Safety and Risk Management Office Scope of Service
The Safety and Risk Management Office is composed of professionals trained in the field of occupational
and environmental health and safety to provide support for University activities and to assure a safe and
healthful environment for employees, students, and visitors. The Safety Office’s responsibilities include:
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Biological Safety - The Safety Office provides general surveillance over activities involving
biohazardous agents, monitors and reviews the performance and maintenance of containment
systems, provides consulting services on aspects of biological safety, biosafety cabinet and
laboratory chemical hoods
Chemical Safety – The Safety Office works to anticipate, recognize, evaluate, and control
personnel exposures to chemical hazards. Consultative services to laboratory personnel on
proper handling and storage of hazardous chemicals, engineering controls, safety equipment,
and personal protective clothing are available.
Environmental Affairs and Hazardous Waste Management – The Safety Office has
responsibility for oversight of environmental permitting and compliance activities, such as
underground/above ground storage tank management, storm water management,
environmental assessments and hazardous waste disposal programs.
Fire and Emergency Response – The Safety Office is responsible for enforcing the North Carolina
Building and Fire Codes, investigating fire incidents, developing evacuation procedures and
maintaining fire alarm and extinguishing systems and coordinating the Emergency Response
Team.
Indoor Air Quality – Although specific regulations have not been developed for indoor air
quality (IAQ) in the work place the Safety and Risk Management Office considers
recommendations from the American Conference of Governmental Industrial Hygienists
(ACGIH), American Industrial Hygiene Association (AIHA), and the American Society of Heating,
Refrigerating, and Air Conditioning Engineers (ASHRAE) and is committed to providing a work
environment that is free of recognized hazards and to investigate complaints that may be
related to poor IAQ.
Occupational and Environmental Hygiene – The Safety Office inspects University work
environments to anticipate, recognize, evaluate, and control personnel exposures to chemical
and physical hazards, including (but not limited to) asbestos, lead based paint, and manages
personnel monitoring programs.
Radiation Safety – The Safety Office provides services that include authorization for use of
radioactive materials and irradiators, personnel monitoring, x-ray safety surveys, sealed-source
leak tests, and laboratory safety inspections.
Workplace Safety – The Safety Office offers expertise in maintenance, construction projects,
ergonomics, respiratory protection, safety training, and workers compensation.
Condensed laboratory Safety Information for Research
Personnel
Safe use of biohazardous materials requires knowledge of risks to the researcher, campus community,
and environment. Researchers learn to handle biohazardous materials safely during their scientific
training and experience, as well as through information and training provided by their supervisors and
the University’s Safety and Risk Management Office. This section summarizes some key requirements,
and the subsequent chapters of this Biological Safety Manual expand on these requirements.
Environmental, health, and safety policies and procedures have been established to minimize risk and
comply with state and federal laws. These policies and procedures are captured within this document as
well as others, such as the University Chemical Hygiene Plan, the OSHPAC, and the Laser Safety Manual.
All policies and procedures are available through the Safety and Risk Management website. Although
many of these policies and procedures are directed at laboratories, any research involving hazardous
materials must comply. Principal Investigators (PIs) must ensure that their research complies with these
policies and procedures and that their personnel receive appropriate safety information and training.
Laboratories Must Have a Lab Safety Plan
State and federal laws require that each laboratory utilizing chemicals have a Chemical Hygiene Plan
(CHP). At Western Carolina University, this consists of the University Chemical Hygiene Plan as well as a
Laboratory Specific Chemical Hygiene Plan. The University Chemical Hygiene Plan covers general
policies and procedures for laboratories, while each principal investigator prepares a Laboratory Specific
Chemical Hygiene Plan to address the hazards and precautions specific to his or her laboratory. The Lab
Specific CHP includes personnel, procedures, engineering controls, safe work practices, and emergency
response, and is covered in Chapter 3 of the University Chemical Hygiene Plan.
Safety and Risk Management Office Inspections
As required by state and federal law, the Safety and Risk Management Office inspects and surveys all
campus laboratories biannually, and sometimes more frequently. These surveys are comprehensive and
address record keeping, fire safety, egress, engineering controls, personal protective equipment, work
practices, and where appropriate, chemical, biological, and radiation safety. The Safety Office sends
inspection findings to the department head and lab PI’s. Lab safety inspections are available to all
laboratory personnel by request. Previous inspection reports are a good measure of addressing safety
issues and eliminating laboratory risks. Contact the Safety Office with questions about inspection
reports or environmental, health, and safety policies and procedures.
Summary of Documents Available to Laboratory Personnel
The following documents must be available to and/or completed by laboratory personnel. Review these
with all new staff before working in the laboratory and annually thereafter, and document these
reviews.
1. Chemical Hygiene Plan
2. Laboratory Specific Chemical Hygiene Plan
3. Applicable Standard Operating Procedures
a. General Use SOP
(Particularly for high risk
procedures/unique risks)
b. Carcinogens
c. Compressed Gas
d. Corrosives
e. Cryogenic Liquids
f. Flammable and
Combustible Materials
g. Highly Acutely Toxic
Materials
h. Irritants
i. Reactive Materials
j. Reproductive Toxins
k. Sensitizers
l. Tax-Free Ethanol
m. Anesthetic Gases
4. Safety Data Sheets (SDS) for chemicals used routinely. Researchers should consult the SDS
when using a particular compound for the first time. The University permits electronic access or storage,
but there must be no immediate barriers to employee access when an SDS is needed.
If applicable, the Principal Investigator must also keep the following documents accessible in the laboratory:
1. Biological Safety Manual – describes safe handling procedures for pathogens, includes procedures and forms
for registering r-DNA experiments with the Institutional Biosafety Committee (IBC). Also includes the
Exposure Control Plan for bloodborne pathogens.
• BSL-2 SOP Template
2. Laser Safety Manual – provides an orientation on lasers (non-ionizing radiation) and describes the laser
safety policies and procedures (particularly for class III(b) and IV lasers)
• Laser Registration Forms
• Laser SOP
3. Occupational Safety and Health Program for Personnel with Animal Contact (OSHPAC)
• ABSL-2 SOP Template
All forms, as well as additional information and safety training modules are available by accessing the Safety and Risk
Management website. The Safety and Risk Management office continually updates the website to best serve Western
Carolina University.
Biological Safety Manual Table of Contents
Section 1: Responsibilities ..................................................................................................................1
Section 2: Routes of Exposure............................................................................................................2
Section 3: Standard Laboratory Practice and Technique ......................................................................3
3.1 Personal Protective Equipment (PPE) ........................................................................................................................... 3
3.2 Handwashing................................................................................................................................................................. 3
3.3 Hand to Face Contact .................................................................................................................................................... 3
3.4 Housekeeping................................................................................................................................................................ 3
3.5 Pipetting ........................................................................................................................................................................ 4
3.6 Sharps............................................................................................................................................................................ 4
3.7 Decontamination .......................................................................................................................................................... 4
Section 4: Biosafety Levels .................................................................................................................5
4.1 Biohazard Labeling ........................................................................................................................................................ 6
4.2 Biological Safety Cabinets (BSCs) .................................................................................................................................. 7
4.3 Standard Practices when utilizes BSCs .......................................................................................................................... 7
4.4 Certification of BSCs ...................................................................................................................................................... 7
Section 5: Biohazard Spill Clean Up .....................................................................................................8
5.1 Blood or Body Fluids ..................................................................................................................................................... 8
5.2 BSL 2 Microorganism..................................................................................................................................................... 8
Section 6.0: Recombinant DNA (rDNA) ...............................................................................................8
6.2 rDNA Descriptions ......................................................................................................................................................... 9
6.3 Responsibilities ............................................................................................................................................................. 9
6.4 The rDNA Registration Process ................................................................................................................................... 12
6.5 General Laboratory Procedures .................................................................................................................................. 12
6.6 Incident Response and Reporting ............................................................................................................................... 12
6.7 Training ....................................................................................................................................................................... 12
Section 7: Waste Management .........................................................................................................13
7.1 Roles and Responsibilities ........................................................................................................................................... 13
7.2 Categories of Biological Waste and Acceptable Treatments ...................................................................................... 14
7.3 Labeling Requirements ............................................................................................................................................... 15
7.4 Requirements for Holding Area .................................................................................................................................. 15
7.5 Manifest Requirements .............................................................................................................................................. 15
7.6 Program Review .......................................................................................................................................................... 16
Section 8 Laboratory Equipment.......................................................................................................16
8.1 Furniture Selection...................................................................................................................................................... 16
8.2 Biological Safety Cabinets (BSCs): Refer to Section 4.2 .............................................................................................. 20
8.3 Centrifuges: ................................................................................................................................................................. 20
8.4 Blenders and Homogenizers: ...................................................................................................................................... 20
Section 9 Bloodborne Pathogens ......................................................................................................20
9.1 Scope ........................................................................................................................................................................... 20
9.2 Rationale ..................................................................................................................................................................... 20
9.3 Exposure Risk Determination...................................................................................................................................... 21
9.4 Schedule and Method of Implementation .................................................................................................................. 21
9.5 Compliance Monitoring .............................................................................................................................................. 23
9.6 Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up ...................................................................... 24
9.7 Labels and Signs .......................................................................................................................................................... 25
9.8 Bloodborne Pathogens Training Program ................................................................................................................... 25
9.9 Employee access to the ECP........................................................................................................................................ 26
9.10 Assistance.................................................................................................................................................................. 26
9.11 Review and Update of ECP ........................................................................................................................................ 26
Section 1: Responsibilities
Department Heads:
• Ensure compliance with Biological Safety Manual and IBC requirements for biological safety within their respective
departments.
• Provide direction on departmental approach to development and implementation of laboratory specific Chemical
Hygiene Plans.
• Ensure that proper storage areas are provided.
Principal Investigators/Supervisors:
• Identifying biohazardous conditions or operations in the lab, determining safe procedures and controls, and
implementing and enforcing standard safety procedures.
• Establishing standard safety operating procedures.
• Providing laboratory personnel under his/her supervision with access to the Biological Safety Manual, the laboratory
specific CHP, and all applicable SOPs and SDS’s.
• Training laboratory personnel and students he/she supervises to work safely with biological materials and
operations, and maintain records of training provided locally.
• Maintaining in functional working order appropriate personal protective equipment (e.g., gloves, goggles).
• Prompt reporting of laboratory accidents and injuries to the Office of Safety and Risk Management.
• Making available required medical surveillance or medical consultation/examination for laboratory personnel.
• Informing facilities personnel, other non-laboratory and any outside contractors of potential lab-related hazards
when they are required to work in the laboratory environment. Identified potential hazards should be minimized to
provide a safe environment for repairs and renovations.
• Identifying hazardous conditions or operations in the lab, determining safe procedures and controls, and
implementing and enforcing standard safety procedures.
• Develop and document the Laboratory Specific CHP.
• Ensure training and coordinating audits are completed.
• Additional responsibilities regarding IBC involvement listed in section 6.0.
Laboratory Employees and Students:
• Following the all laboratory safety documents.
• Following oral and written laboratory safety rules, regulations, and standard operating procedures required for the
tasks assigned.
• Keeping the work areas safe and uncluttered.
• Reviewing and understanding the hazards of materials and processes in their laboratory research prior to conducting
work.
• Utilizing appropriate measures to control identified hazards, including consistent and proper use of engineering
controls, personal protective equipment, and administrative controls.
• Understanding the purpose, capabilities, and limitations of personal protective equipment issued to them.
• Promptly reporting accidents and unsafe conditions to the PI/Laboratory Supervisor.
• Completing all required health, safety and environmental training.
• Participating in the medical surveillance program, when required.
• Informing the PI/ Laboratory Supervisor of any work modifications ordered by a physician as a result of medical
surveillance, an occupational injury or exposure.
Added Duties of Laboratory Personnel Working Autonomously.
In addition to the above responsibilities, laboratory personnel working autonomously or performing
independent research are also responsible for:
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Providing the PI/Laboratory Supervisor with a written scope of work for their proposed research.
Notifying and consulting with the PI/Laboratory Supervisor, in advance, if they intend to deviate
from their written scope or scale of work.
• Providing appropriate oversight, training and safety information to laboratory personnel they
supervise or direct.
Note: Generally, it is prudent to avoid working in a laboratory building alone. Under normal working
conditions arrangements should be made between individuals working in separate laboratories outside of
working hours to crosscheck periodically. Alternatively, police may be asked to check on the laboratory
worker. Experiments known to be hazardous should not be undertaken by a worker who is alone in a
laboratory.
Office of Safety and Risk Management:
• Assisting PI/Laboratory Supervisors in the selection of appropriate safety control requirements, which include
laboratory practices, personal protective equipment, engineering controls, and training.
• Maintaining in functional working order appropriate work place engineering controls (e.g., fume hoods) and safety
equipment (e.g. emergency showers/eyewashes, fire extinguishers), with emphasis on controls for particularly
hazardous substances.
• Assisting with hazards assessments, upon request.
• Maintaining area and personal exposure-monitoring records.
• Reviewing and providing advice on Laboratory SOPs, upon request.
• Providing technical consultation and investigation, as appropriate, for laboratory accidents and injuries.
• Helping to determine medical surveillance requirements for laboratory personnel.
• Coordinating with University Health Services when laboratory personnel request to review their medical records.
Office of Safety and Risk Management does not have access to medical records, for privacy reasons.
• Reviewing plans for installation of engineering controls and new laboratory construction/renovation, as requested.
• Reviewing and evaluating the effectiveness of the Biological Safety Manual at least annually and updating it as
appropriate.
• Additional responsibilities regarding IBC involvement listed in section 6.0.
University Health Services:
• Provide medical consultation and surveillance as needed.
• Provide medical care for employees suffering injury or illness from hazardous agents in the lab.
Institutional Biosafety Committee
• Refer to Section 6.0 Recombinant DNA (rDNA)
Section 2: Routes of Exposure
There are four main routes of exposure employees need to be aware of and attempt to avoid when working with
biohazardous agents in the laboratory.
• Ingestion: Accidental ingestions typically results from improper personal hygiene in the laboratory. Hands must be
washed after removing gloves, immediately upon visible contamination, and before leaving the laboratory. Food,
drink, tobacco products (including electronic cigarettes), and cosmetic application are prohibited in all areas of the
laboratory.
• Percutaneous Injuries (Injection): results from needlesticks, cuts or abrasions from contaminated items. Particularly
serious route of entry because of possibility for immediate entry of the agent into the bloodstream. All sharps must
be handled and disposed of as noted in Section 7 Waste Management.
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Inhalation: Various laboratory procedures can cause the aerosolization of infectious agents. Appropriate work
practices must be implemented to minimize the aerosolization of materials, especially those known to be
transmitted via aerosols (Tuberculosis, Adenovirus, Brucellosis)
Mucous membrane absorption: exposure of mucous membranes to infectious agents can lead to occupationally
inquired infections. Mucocutaneous exposures typically result from splashes to the face or inadvertent inoculation
from contaminated hands. Face protection should always be worn if there is potential of splash or spray.
Section 3: Standard Laboratory Practice and Technique
3.1 Personal Protective Equipment (PPE)
When a biological hazard has been identified, the supervisor/principal investigator (PI) must assign appropriate PPE to
be worn. Supervisors are responsible for training those exposed in their laboratories proper selection and use.
Appropriate PPE must be donned before handling potentially hazardous biological materials and replaced immediately if
excessively contaminated or damaged occurs. PPE must be removed before exiting the laboratory.
• Gloves: Gloves must always be worn when handling biohazardous materials. Disposable gloves (nitrile
or latex) typically provide an adequate barrier to most biohazardous materials.
• Lab Coats/Gowns: Long sleeved lab coats or gowns (preferably cuffed) must be worn to protect skin and
personal clothing from contamination. If the potential for splash or spray exists, the garment must be
resistant to liquid penetration. Reusable clothing needs to be laundered on sit or by a laundering
service. Personnel should not take laboratory clothing home.
• Face Protection: Including but not limited to goggles, side-shielded safety glasses, and face shields.
Must be used when splash or spray of potentially hazardous biological materials is anticipated and the
work is being performed outside of a biological safety cabinet.
• Respirators: When engineering controls (such as BSCs) are not available to provide sufficient protection
against aerosolized agents, or when mandated by regulations or MSDS guidelines, respirators shall be
worn. WCU requires that employees be medically cleared, fit-tested, and trained on proper care and
usage in order to wear a respirator. For questions, contact the Safety Office at x7443.
• Disposable Booties: When significant splash and spray are anticipated, shoe covers/booties should be
utilized. Covers/booties must be removed and disposed of before leaving the laboratory.
3.2 Handwashing
Hands must be washed (thoroughly for 20 seconds with mild soap) as soon as possible after coming in contact with
potentially infectious materials. Hands should also be washed after glove removal, and before exiting the laboratory.
3.3 Hand to Face Contact
To minimize potential exposure eating, drinking, smoking (including electronic cigarettes), applying cosmetics, and
handling contact lenses is prohibited in laboratory areas. Food and drink may not be stored in refrigerators in which
laboratory materials are also stored, unless they are for lab use only, and are labeled as such.
3.4 Housekeeping
Work benches will be maintained as organized and clutter-free as practical. Benches must be wiped down with a 10%
bleach solution or other approved disinfectant at least once a day and immediately after a spill of potentially infection
materials.
3|WCU Biological Safety Manual– Office of Safety and Risk Management
3.5 Pipetting
In order to prevent the accidental inhalation, contact, or ingestion of pipetted infectious agents please follow the
following safety precautions when pipetting in the laboratory:
1. Never pipette by mouth, always use mechanical pipetting aids.
2. Release contents so that they may run down the wall of the container, do not release them from a height (to
reduce risk of splatter)
3. Place absorbent paper on benchtops to absorb any dripped infectious materials from pipette tips and reduce the
risk of aerosol generation.
4. Place disposable pipettes into pipette disposal boxes that have been lined with an autoclave bag and autoclave
for 30 minutes at 250°F (refer to Section 7 Waste Management for full disposal guidelines).
3.6 Sharps
Needles, scalpels, lancets, glass slides and cover slips, and glass pipettes all pose potential sharps hazards in the
laboratories and therefore plasticware should be used whenever possible (plastic graduated cylinders, funnels,
aspirators et) and appropriate precautions should be taken to avoid injuries. These items must be disposed of
immediately after use in an appropriate puncture-resistant container. Recapping needles should only be done when
absolutely necessary and must be done via a mechanical device or the one handed scoop method. Clipping and bending
of needles is prohibited. Safety devices such as safety needles and Mylar coated capillary tubes should be used when
available.
3.7 Decontamination
The following describes the three main types of physical and chemical means of decontaminating hazardous materials in
order to ensure their safety for additional handling.
• Radiation: Ultraviolet radiation (UV) may be used in biological safety cabinets (BSC) in order to
decontaminate surface contamination. UV does not have a very high penetrating power and therefore
is not effective against dirty/dusty areas. UV poses a burn hazard to eyes and skin and cannot be use
when the work area is occupied. UV should also be used in conjunction with another disinfection
process and not relied up on a sole means of decontamination.
• Heat: Wet heat (steam) is the most reliable method of sterilization. Autoclaves are to be utilized to
sterilize glassware and media and decontaminate BSL 1 and 2 level waste (aside from human
blood/tissues which will be sent to a 3rd party for incineration). Autoclaves should be monitored for
efficacy by use of biological indicators. The generator of the waste is responsible for performing and
documenting this testing.
• Liquid Disinfectant: Liquid disinfectants are used for surface decontamination. Any EPA registered
disinfectant can be used. Tuberculocidal disinfectant or 10% bleach solution should always be used for
decontamination when human materials are handled. Bleach solutions must be mixed at least weekly
and stored in containers that are labeled with contents and an expiration date.
If a process besides one described above is intended to be utilized in a WCU laboratory, the PI needs to contact the
Safety Office for prior approval.
4|WCU Biological Safety Manual– Office of Safety and Risk Management
Section 4: Biosafety Levels
Biological agents are assigned to biosafety levels (BSL) according to the risk they pose to human health and the
environment. Please refer to the information below when determining the most appropriate BSL. If a particular agent is
not listed below, or further assistance is needed in interpreting BSL requirements, contact the Safety Office at x7443. A
sign incorporating the universal biohazard symbol must be posted at the entrance to the laboratory when infectious
agents are present. BSL 3 and BSL 4 pathogens and research are forbidden at WCU. The table below summarizes BSL
laboratory practices and set up and is summarized from information found at
http://www.cdc.gov/od/ohs/biosfty/bmbl5/bmbl5toc.htm
BSL
Agents
Practices
Safety Equipment
(Primary Barriers)
Facilities (Secondary
Barriers)
1
Not known to
regularly cause
diseases in
immunocompetent
adults.
Standard biosafety practices
listed in Section 1. Integrated
pest management program.
None required
PPE as needed
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May cause disease
but are difficult to
contract via
aerosol.
BSC or other physical
contamination
devices, PPE (lab
coats, gloves, face
protection as
needed)
3
May cause serious
or potentially lethal
disease via
inhalation, but for
which treatment
exists.
BSL-1 plus:
• Limited access to areas
• sharps precautions
• defined waste
contamination
• medical surveillance
policies
• Laboratory specific
biosafety SOP.
BSL-2 practices plus:
• Controlled access to
areas
• Decontamination of
all waste
• Decontamination of
laboratory clothing
before laundering
4
May cause serious
or potentially lethal
disease via
inhalation, and for
which treatments
and vaccines do
not exist.
BSL-3 plus:
• Clothing change
before entering
• Shower on exit
• All material
decontaminated
before leaving.
Cabinet laboratorymanipulation of
agents must be
performed in a Class
III BSC or
Suit laboratorypersonnel must wear
a positive pressure
supplied air
protective suit.
BSC or other physical
contamination
devices, PPE (lab
coats, gloves, face
protection as
needed)
Open chemical resistant
bench top
• Non-porous furniture
• No rugs/carpets
• Doors for access control
• Windows that open to
the exterior must be
fitted with screens.
• Sink for Handwashing.
BSL-1 plus:
• Autoclave available
• Eyewash readily
available.
• Doors should be selfclosing and lockable.
BSL-2 plus:
• Self-closing, double
door access.
• Exhausted air not
recirculated
• Negative air pressure in
lab
• Entry through airlock
• Hand washing sink at
laboratory exit.
BSL-3 plus:
• Separate building or
isolated zone
• Dedicated supply and
exhaust, vacuum, and
decontamination
systems.
• Additional
requirements detailed
in CDC text.
5|WCU Biological Safety Manual– Office of Safety and Risk Management
4.1 Biohazard Labeling
BSL-1 is appropriate for work involving well-characterized agents not known to regularly cause disease in
immunocompetent adult humans, and present minimal potential hazard to laboratory personnel and the
environment. All bacterial, viral, fungal, rickettsial, parasitic, and chlamydial agents that have been assessed for
risk and do not belong to a higher risk group may be safely handled at BSL-1. It is important to be aware that
numerous agents not ordinarily associated with disease are opportunistic pathogens that may cause infection in
the elderly, the young, and immunocompromised individuals and still need to be treated as though they are
pathogenic. Examples of agents handled at BSL-1 include: Bacillus subtilis, non-pathogenic E. coli, yeast, canine
hepatitis, etc. For Biosafety Level 1 (BSL 1) the sign may include the name of the agent(s) in use, and the name
and contact information of the PI.
BSL-2 is appropriate for work involving agents that pose moderate threat to humans in that they may cause mild
disease or are difficult to contract via aerosol. BSL-2 differs from BSL-1 in that the laboratory personnel have
specific training in handling pathogenic agents, access to the laboratory is restricted, and any procedure that
could create infectious aerosols is conducted within a biosafety cabinet (BSC) or other physical containment
equipment. For Biosafety Level 2 (BSL 2) the sign must include the name of the agent(s) in use, an indication that
the area is a BSL 2 lab, and the PI’s name (or other responsible personnel), telephone number, and required
procedures for entering and exiting the laboratory. Written standard operating procedures (SOP) for agents
used at BSL2 are required and supplement this general lab safety manual for your lab-specific training. SOP
Templates are available from the Safety Office.
BSL- 2 Viral Agents:
BSL-2 Viral Agents
BSL-2 Bacterial/Rickettsial Agents
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Adenovirus
Creutzfeld‐Jacob agent
Cytomegalovirus
Eastern equine encephalitis
Epstein‐Barr virus
Hepatitis A, B, C, D, E
Herpes simplex viruses
HTLV types I and II
Human Blood & Blood Products
Kuru
Monkeypox virus
SIV
Spongiform encephalopathies
Vaccinia virus
HIV
VSV (lab adapted strains)
Campylobacter fetus, coli, jejuni
Chlamydia psittaci, trachomatis
Clostridium botulinum, tetani
Corynebacterium diphtheriae
Legionella spp
Neisseria gonorrhoeae
Neisseria meningitidis
Pseudomonas aeruginosa, pseudomallei
6|WCU Biological Safety Manual– Office of Safety and Risk Management
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BSL-2 Fungal Agents
BSL-2 Parasitic Agents
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Proteus mirabilis, vulgaris
Salmonella spp
Shigella boydii, dysenteriae, flexneri,
sonnei
Treponema pallidum
Vibrio cholera (including El Tor)
Vibrio parahemolyticus
Vibrio vulnificus
Yersinia pestis
Blastomyces dermatitidis
Cryptococcus neoformans
Microsporum spp
Exophiala dermatitidis (wangiella)
Fonsecaea pedrosoi
Sporothrix schenkii
Trichophyton spp
Entomeoeba histolytia
Crytosporidium spp
Giardia spp
Naegleria fowleri
Plasmodium spp
Strongyloides spp
Tania solium
Toxoplasma spp
Trypanosoma spp
4.2 Biological Safety Cabinets (BSCs)
BSCs are the most commonly used primary containment devices in microbiological laboratories. There
are three classes of BSCs (Class I, II, and III). Each class provides different levels of protection. Because
WCU utilizes BSL-1 and BSL-2 agents, it is our policy to default to use of Class II BSCs to ensure consistent
protection. The main difference between Class I and II cabinets is the HEPA filtration of the air flow
down across the work surface of a Class II cabinet.
4.3 Standard Practices when utilizes BSCs
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Keep front and rear perforated grills free of clutter.
Avoid installing BSCs near windows or doorways
Avoid sudden movements in and out of the cabinet. Also, always enter straight forward,
without sweeping motions.
Do not use gas burners or volatile chemical inside the BSC.
Don’t store items on top of the cabinet.
Disinfect the interior of the cabinet before and after all use.
Change HEPA filters as necessary.
4.4 Certification of BSCs
BSCs are to be certified by a Safety Office approved vendor. All cabinets in which human materials and
infectious (or potentially infectious) material are being manipulated should be certified annually. BSCs
in which non-infectious material are manipulated should be certified every two years. All newly
7|WCU Biological Safety Manual– Office of Safety and Risk Management
purchased or recently moved cabinets must be certified before they can be used. Costs associated with
certification are the responsibility of the department that the BSC belongs to.
Section 5: Biohazard Spill Clean Up
During spill cleanup, be especially cautious of sharps. Always remove sharps with mechanical means
(pieces of cardboard, tongs, etc.) and do not pick up with your hands.
5.1 Blood or Body Fluids
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Don all appropriate PPE. Disposable gloves are required, shoe covers and face masks may be
necessary.
Absorb fluids with disposable towels. Place materials in a red biohazard bag.
Clean area of all visible fluids with soap and water.
Decontaminate area with a 10% bleach solution or Tuberculocidal disinfectant.
5.2 BSL 2 Microorganism
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Alert people in immediate are of spill and request that they leave.
Don all appropriate PPE. Disposable gloves are required, shoe covers and face masks may be
necessary.
Cover spill with disposable absorbent (towels or inert loose material).
Carefully pour a 10% bleach solution around the edges of the spill and then into the center of
the spill. Do not splash. Leave for 20 minutes.
Using disposable paper towels, wipe up the spill, working from the outside towards the center.
Dispose of materials in a red biohazard bag.
Clean spill area with fresh towels soaked in an approved disinfectant or 10% bleach solution and
allow to air dry. Also place these materials in a red biohazard bag.
Section 6.0: Recombinant DNA (rDNA)
Researchers at Western Carolina University who construct and/or handle materials containing
recombinant DNA molecules must comply with the requirements of the National Institutes of Health
(NIH) Guidelines for Research Involving Recombinant DNA Molecules (available for review here). The
following information and procedures are developed to assist Western Carolina University researchers
with the documentation of this compliance. Generally, experiments requiring the use of recombinant
biological agents should be handled under the same BSL requirements as the wild type agent. For
example, handling of adenoviral vectors should be performed under BSL 2 conditions. NIH Guidelines for
Research Involving rDNA molecules are applicable to all rDNA research conducted or sponsored by an
institution that receives any support for rDNA research from the NIH. rDNA research at WCU must be
registered with the WCU Institutional Biosafety Committee (IBC) whether or not the Principal
Investigator received funding from NIH for the project.
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6.2 rDNA Descriptions
The NIH rDNA Guidelines defines rDNA as
1) Molecules that are constructed outside living cells by joining natural or synthetic DNA segments
to DNA molecules that can replicate in a living cell
And
2) Molecules that result from the replication of those described in (1) above.
At WCU, rDNA work may include:
1. Plasmids and viral vectors
2. Any synthetic DNA or RNA
3. Any RNA produced from rDNA, including messenger RNA (mRNA), small interfering RNA (siRNA),
micro RNA (miRNA), etc.
4. Genetically-modified organisms (animals, plants, bacteria, viruses, fungi, etc.). This includes
creation, cross-breeding, or manipulation of transgenic animals and plants.
5. Any such material obtained from another researcher or source
6.3 Responsibilities
The Institutional Biosafety Committee (IBC)
The NIH rDNA Guidelines requires that an IBC be established at any institution receiving NIH funding for
rDNA research to oversee all rDNA research at that institution, and insure that such work is compliant
with the Guidelines. The mission of the WCU IBC is to:
1. Ensure that all recombinant DNA research conducted at the institution or sponsored by the
institution is conducted in compliance with the National Institutes of Health Recombinant DNA
Guidelines.
2. Ensure that protocols of research involving Select Agents (defined by the Centers for Disease
Control and Prevention), including but not limited to recombinant DNA, are reviewed and found
to comply with all national, state, and local requirements
The Office of Safety and Risk Management staff will support the IBC in carrying out its mission. The IBC is
authorized to inspect research facilities, approve research practices and procedures, and to take actions,
such as enforcement of cessation of laboratory or clinical research activities, in the event of an unsafe
workplace situation. The IBC responsibilities are broken down as follows:
Chairperson, Institutional Biosafety Committee
• Ensure that the Institutional Biosafety Committee is properly constituted and fulfills its
requirements under the appropriate regulations, rules, etc.
• Ensure that all members of the IBC are adequately trained in appropriate containment practices,
secondary containment procedures, and accidental spill containment procedures to fulfill their
responsibilities as member of the IBC
• Call and preside over meetings of the IBC
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•
•
•
Review and insure compliance of all authorized researchers utilizing biohazardous materials.
Coordinate the review process of researchers seeking use of biohazardous material through
research programs at the University
Review all instances of noncompliance and recommend corrections to the University.
Notify the Principle Investigator of the results of the IBC’s review
Institutional Biosafety Committee
• Advice the Chancellor, Provost, Associate Provosts, Deans, and Department Chairs on matters
related to biohazards and biosafety with their respective areas of responsibility
• Develop, recommend, and implement policies and procedures for biological risk assessment and
biological risk reduction throughout the University
• Develop emergency plans for the containment and resolution of accidental spills and other
related emergencies with an emphasis on risk reduction, personnel protection, and
environmental protection
• Oversee all research and teaching activities involving biohazardous agents including review and
approval prior to initiation, annual reviews and updates, reviews of laboratory safety equipment
and procedures, and certification of compliance with all applicable rules and regulations
governing the use of biohazardous materials and approve those research projects that are found
to conform with NIH Guidelines, OSHA and the CDC including (a) an independent assessment of
containment levels required by the NIH Guidelines for the proposed research; and (b)
assessment if applicable, of the facilities, procedures, practices, and training and expertise of
personnel involved in the proposed use of infectious biological agents.
• Ensure that all Principal Investigators are sufficiently trained in appropriate containment
practices, secondary containment practices, and their responsibilities as Principal Investigators.
• Advise and provide technical expertise, whenever possible, to the Safety Officer on matters
involving biosafety
• Conduct investigation of serious violations or problems and to make recommendations to
Chancellor for the resolution of continued non-compliance or serious infractions.
• Conduct periodic inspections of laboratories to ensure compliance with established procedures.
Office of Safety and Risk Management
• Investigate laboratory accidents and report problems, violations and injuries or illnesses
associated with biohazardous research activities, to the IBC
• Provide advice and assistance to the IBC and PI concerning containment procedures and
practices, laboratory security, recommended laboratory containment equipment, rules,
regulations, and other matters as may be necessary
• Provide oversight and assurance that laboratory safety containment is functioning properly,
including field testing and certification, where appropriate, of all biosafety cabinets
• Serve as a member of the IBC
• Provide industrial hygiene and safety support for all laboratory operations
• Ensure transportation and disposal of all infectious waste in compliance with all applicable
federal, state, and local ordinances
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•
Assist, as necessary, in the emergency response, cleanup, and decontamination of biological
spills and accidents
Provide Occupational Health training
Office of Research Administration (Compliance Officer)
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•
Provide the necessary liaison between PIs, the IBC, granting agencies, and regulatory agencies
Serve as the administrator for the IBC
Provide all necessary documentation, forms, regulatory guidelines and regulations for PIs
Principal Investigators (PI)
• Ensure compliance with appropriate National Institute of Health guidelines and all conditions
stated in the protocol approved by the IBC
• Submit protocol applications for all activities or modifications of activities involving
biohazardous materials and obtain approval by the IBC prior to initiation of the activities or
modifications
• Ensure that all laboratory staff, including students, are trained in the accepted procedures in
laboratory practices, containment methods, disinfectant and disposal practices, and required
actions in the event of an accidental spill
• Develop a Laboratory Safety Plan, including an emergency action plan for accidents and spills, in
accordance with the Laboratory Specific Chemical Hygiene Plan (refer to Western Carolina
Universities Chemical Hygiene Plan for more information)
• Ensure compliance with all shipping requirements for biological agents and toxins
• Ensure proper handling and disposal of all infectious wastes
• Request immunizations for laboratory personnel when working with biological agents for which
there is an effective vaccine available
• Maintain all biosafety equipment in appropriate operating condition. Decontaminate laboratory
equipment prior to maintenance or disposal
• Maintain records of microorganisms and toxins used in the laboratory and biosafety cabinets
• Ensures that laboratory workers who work with animals involved in the work participate in the
IACUC Review process detailed in the OSHPAC.
Laboratory Safety – All other employees and students
• Conduct no activities under the research protocol until the protocol is approved by the IBC and
appropriate training is completed
• Follow all procedures and containment methods established for activities conducted
• Properly utilize all laboratory protective equipment including proper clothing, personal
protective equipment, and containment devices
• Report all accidents and spills to the PI or the Institutional Biosafety Officer as soon as possible
• Report unsafe conditions to the PI, IBC, or Safety Office immediately
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6.4 The rDNA Registration Process
If your experiment is in an exempt category, IBC approval is not required. If your experiment does not
fall within the following exempt categories, you are obligated to have current IBC approval.
Your rDNA is never going to be in an organism or virus.
Your rDNA is solely from a single non-chromosomal or viral source.
Your rDNA is solely from a prokaryotic host and propagated in the same host or
transferred to another host by naturally occurring means.
Your rDNA is from a eukaryotic host and is propagated in the same host.
Your rDNA is from species that naturally exchange DNA.
Your rDNA does not present a significant risk to health or to the environment, as
determined by the NIH (rDNA from BL-2 agents is not exempt)
Exempt (III-F-1)
Exempt (III-F-2)
Exempt (III-F-3)
Exempt (III-F-4)
Exempt (III-F-5)
Exempt (III-F-6)
All research that is not exempt from compliance with the NIH Guidelines for Research Involving rDNA
Molecules must be registered with the IBC. Non-exempt manipulation of recombinant DNA molecules
includes, but is not limited to cross-breeding to create a new strain of animal or plant. Submit the
appropriate documents to the IBC. Templates are below.
• rDNA form
• SOP for BSL2/ABSL2 labs, and
• Plasmid/Vector Table.
6.5 General Laboratory Procedures
Review the general laboratory procedures for biosafety and rDNA work. These procedures include
physical containment, standard practices and training. The procedures can be found in Appendix G of
NIH Guidelines. The appendix provides rDNA-specific descriptions.
6.6 Incident Response and Reporting
The NIH requires institutions to report incidents involving rDNA materials including loss, theft, or
release. This includes both NIH exempt and non-exempt rDNA materials. Report any loss, theft, or
release involving rDNA materials to the IBC. Report any human exposure to rDNA to the Safety Office at
x7443. Complete the Report of Occupational Injury or Illness form.
6.7 Training
The following training is available for employees working with rDNA, and is available online at the Safety
Office website.
1. General Laboratory Safety
2. Lab-specific orientation and training is provided by the P.I.
3. Biosafety training is for those who handle infectious material or other potentially
infectious material (OPIM) that poses a splash, splatter, or percutaneous exposure
hazard.
4. Bloodborne Pathogens training is required for those who handle materials of human
origin (i.e. primary and well-established cell lines).
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5. Animal risk training (IACUC)
Section 7: Waste Management
Appropriate waste handling practices at Western Carolina University are based on compliance with
OSHA regulations in order to protect those employees who handle the waste and the North Carolina
Medical Waste Regulations in order to ensure appropriate disposal. Biohazardous Waste or Biowaste is
defined as any waste which is generated from biological sources or is used in the diagnosis, treatment or
immunization of human beings or animals. Biowaste can consist of solids, liquids, sharps, and other
laboratory wastes that are potentially infectious. The purpose of this document is to organize and track
the biowaste generated at WCU in a manner that promotes the safety of employees and the community
by reducing the risk and/or spread of infection through the safe handling and disposal of biowaste as
required by local, state and federal regulations.
It is intended that WCU faculty and staff who generate Biowaste are responsible for the appropriate
disposal. In an effort to assist WCU faculty and staff the Safety Office has established this program to
manage biowaste.
7.1 Roles and Responsibilities
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•
All Faculty and Staff: Complete initial and refresher (every five (5) years) biosafety training.
Wear safety glasses with side shields and gloves when handling biowaste. Follow labeling and
packaging instructions for the different classifications of biowaste. Dispose of biowaste in
designated containers.
Supervisors/Principle Investigators: Attend initial and annual refresher training. Ensure initial
training for employees handling biowaste is completed before assigning waste handling duties.
Ensure refresher training is completed every five (5) years after initial training for biowaste
handlers. Ensure biowaste is properly handled.
Biowaste Handlers: Attend initial and refresher training. Receive Hepatitis B vaccines and/or
demonstrate immunity. Wear safety glasses with side shields and disposable latex or nitrile
gloves when handling biowaste. Package biowaste in designated containers for biowaste. Label
all containers with pre-generated labels from Stericycle in designated area on box.
Office of Safety and Risk Management: Develop and implement a University Program. Develop
and implement an initial and refresher training course. Receive Hepatitis B vaccines and/or
demonstrate immunity. Wear safety glasses with side shields and disposable latex or nitrile
gloves when handling biowaste. Package biowaste in designated containers for Biowaste.
Ensure labels are visible in accumulation area. Maintain accumulation and storage facilities,
accumulation container labeling and collection records. Schedule and complete periodic
shipments of biowaste. Retain copies of all signed manifest (3 years of records maintained onsite.)
Housekeeping: Attend initial and annual refresher training. Receive Hepatitis B vaccines and/or
demonstrate immunity. Wear safety glasses with side shields and disposable latex or nitrile
gloves when handling biowaste. Collect biowaste daily or as called from labs. Weigh and record
each class of biowaste received. Package biowaste in designated containers for biowaste. Label
all containers with pre-generated labels from Stericycle in designated area on box and transport
to biowaste accumulation area. Ensure labels are visible in accumulation area. Inspect biowaste
accumulation area weekly. Disinfect biowaste storage area weekly. Maintain accumulation and
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•
storage facilities, accumulation container labeling and collection records. Send copies of the
manifest to the Safety Office.
Office of the Dean of Health and Human Sciences: Will maintain inventory clipboard of
biowaste in HHS 347. Clipboard will contain the generators name, date, and amount (number of
bags). Prior to biannual pickups, the Office of the dean of HHS will confirm that the number of
bags matches the information on the clipboard. This information will then be used for billing.
7.2 Categories of Biological Waste and Acceptable Treatments
Biowaste cannot contain any hazardous chemical or radioactive waste components. The biological
component must first be decontaminated and then treated as chemical or radioactive waste.
Microbiological Waste (Cultures, stocks, & biologicals):
• Agents infectious to humans (those that require BioSafety level 1 or 2 containment,
including cultures and stocks from medical, pathological, or research laboratories,
and their associated biologicals and rDNA)
• Waste from the production of biologicals (e.g., biologicals defined as serums,
vaccines, antigens, antitoxins, cell lines, and cultures)
• materials used for cleanup of spills.
• Discarded live or attenuated vaccines, biological toxins.
• Systems used to grow and maintain infectious agents in vitro, including, but not
limited to nutrient agars, gels, and broths.
• Culture dishes and devices used to transfer, inoculate or mix cultures, including, but
not limited to: plastic or glass plates, paper, gloves, growth media, gels, filters,
stoppers, plugs, flasks, inoculation loops and wires, contaminated pipette tips,
tubes, stirring devices, jars, etc.
Solid microbiological waste should be placed in autoclaved before disposal. Place in a
clear autoclave bag. Liquid biological waste (not containing hazardous chemicals) can
be autoclaved or chemically disinfected (ie bleached) and then disposed of down the
drain.
Pathological Waste: Included in this category are: human pathological waste (organs,
limbs, body fluids) and animal carcasses that must be incinerated (not autoclaved).
Blood and OPIM: Containers of blood and OPIM less than 20 mls must be autoclaved
and then sent for disposal. Items with greater than 20 ml of blood should be placed in
biohazard bags and put in the biowaste accumulation area until such time that they are
sent for incineration.
Sharps: Needles, scalpels, lancets, glass slides and cover slips, razors, and broken
glassware that is contaminated with biological materials. Needles and syringe units
must be discarded as a unit without clipping, bending, breaking, shearing, or recapping.
Sharps boxes that clip off the needle are prohibited. Sharps containers must be
discarded when they are ¾ full or at fill-line. Sharps boxes should be rigid, leak proof,
puncture-resistant containers that can be secured to prevent loss of contents. Each
container must be prominently labeled with a universal biohazard sign or the word
"Biohazard". Sharp containers must be placed in a red biowaste bag and then placed in
the biowaste accumulation area until they are sent for incineration.
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Non-contaminated glass: Non-contaminated glass should be discarded in a broken glass
collection box. Use an appropriately labeled container that indicates box contains glass.
DO NOT use boxes with “biohazard” symbols printed on them. Do not overfill boxes;
attempt to keep under 30 lbs.. When full, tie bag, tape lid closed, and place in the hall
for housekeepers to remove.
Urine and Feces: Included in this category are: Urine and feces from animals and/or
humans. Urine and feces must always be disposed of down a drain connected to a
sanitary sewer (ie toilet). It must NEVER be poured into or flushed down a sink used for
hand washing or disposed of in a trash can. Urine and feces contaminated animal
bedding should be placed in a clear bag and tied off before placing into a dumpster.
7.3 Labeling Requirements
Each package of biowaste must be labeled with a water-resistant universal biohazard symbol and be
marked “Medical Waste” when appropriate. Each package of biowaste must be marked on the outer
surface with the following information
• The generator's name, (Department specific), address, and telephone number.
• Safety Officer name, address, and phone number
• Treatment facility name, address and telephone number.
• Date of shipment.
7.4 Requirements for Holding Area
When all biowaste is collected it must be stored in an area that:
• Prevents leakage of the contents of the package.
• Maintains the integrity of the packaging at all times.
• Is cool.
• Limits access to unauthorized personnel.
• Provide floor drains that discharge directly to an approved sanitary sewage system.
• Provides ventilation and discharges to the environment so as not to create nuisance odors.
• Must not be stored longer than fourteen calendar days from the date received from the
departments unless the biowaste is refrigerated at an ambient temperature between 35 and 45
degrees Fahrenheit then it should not be stored longer than 30 days.
• Kept clean.
• Vermin and insects shall be controlled.
• Is disposed of promptly so as not to create a visual or odor problem.
• Is inspected weekly.
• Refrigeration or freezing of animal carcasses and parts, if they are not disposed of immediately,
to delay putrefaction.
• Biohazardous waste in the College of Health and Human Sciences will be transported in
secondary containment to HHS 347 for collection in wheeled containers.
7.5 Manifest Requirements
Records of biowaste shall be maintained for each shipment and shall include the information listed
below.
• Weight of package.
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• Date shipped off-site.
• Name of transporter.
• Name of storage or treatment facility.
A signed copy of the manifest will be provided to the WCU Safety Office at the time of waste collection.
The manifest will be in the custody of the driver hauling the Biowaste to its treatment destination at all
times. The signed manifest will be mailed to the Safety Office. The Safety Office will maintain signed
copies of all tracking documents and other associated records for minimum of 3 years.
7.6 Program Review
Annual waste management program review will consist of the following.
• Compliance and content of this program
• Amount and types of biowaste being generated at WCU
• Cost to manage a particular biowaste stream
Section 8 Laboratory Equipment
8.1 Furniture Selection
The following guidelines should be used when selecting new furniture for laboratories. If there is a
question on furniture selection, contact the Safety Office. No furniture used in laboratories that has
been exposed to corrosive, toxic, or flammable chemicals or biological hazards may be repurposed for
use in an office setting. Furniture that is no longer needed must be disposed of or relocated to another
laboratory that its design and construction is suitable for.
A. Casework Materials:
• Metal or hardwood (such as oak or other approved equivalent) may be used in general research
and teaching laboratories where humidity and temperature will be normal (standard for
occupied rooms), and where biohazardous, flammable, corrosive, or toxic substances will not be
absorbed into the surface.
• Plastic laminate may be used in miscellaneous storage and workrooms requiring base or wall
storage facilities, and where the infusion of appropriate colors may be architecturally desirable.
• Only non-combustible and non-reactive chemical resistant laminates and resins may be used
where biohazardous, flammable, corrosive, or toxic chemicals are to be used or stored.
• Millwork shall not be considered for new construction. Variances may be considered on
renovation projects on a case by case basis.
B. Counter Tops:
• Chemical Reaction and Abuse Resistance – for chemical resistance work surfaces, either of the
following shall be used:
o Type 1: Composition Stone with a chemical resistant resin finish
o Type 2: Natural Quarry Stone with a chemical resistant resin finish
o Type 3: Solid Resin- for chemical resistant surfaces and in the bottom of general
purpose fume hoods.
• General Purpose – Areas where neither chemical nor physical abuse is expected and where no
liquids or biological hazards are to be used (such as writing surfaces, instrument support
surfaces, or storage areas) shall use either of the following:
o Type 4: Wood Core- A wood fiber or wood particle board core with chemical
resistant finish on all exposed surfaces.
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Type 5: Plastic Laminate – Plastic laminate surface with a wood particle core; may
be self-edged or post-formed.
• Radiation and Other Special Uses – areas where radioactive materials or other special uses are
approved shall use the following:
o Type 6 – Stainless Style – Type 316 polished stainless steel counter top surfaces may
be approved on a case-by-case basis.
• Physical Abuse Resistance – areas where abrasive physical abuse is expected; Physics, Earth
Sciences, Geology shall use:
o Type 3 – Solid Resin with a chemical resistant surface, or
o Type 7 – Composition Stone with a low gloss vinyl sealer.
• Fume Hood Work Surfaces – shall be selected as follows:
o General Purpose Hoods – Type 3: Solid Resin (chemical resistant)
o Radiation Hoods – Type 6: Type 316 Stainless Steel
o Perchloric Acid Hoods – Type 6: Type 316 Stainless Steel
o Special Purpose Hoods – Type 3, Solid Resin (chemical resistant)
C. Chairs:
Laboratory seating should be upholstered with vinyl or be constructed of solid materials such as plastic
or wood that has been sealed to render it non-porous. Finishes shall be as resistant as possible to the
corrosive chemical activity of chemicals used in the laboratory, as well as disinfectants. Natural or
synthetic fabric upholstery is not acceptable for use in a laboratory.
• Chairs for working at laboratory benches, computer workstations, or biological safety cabinets
should have the following adjustments:
o Pneumatic height adjustment
o Adjustable lumbar support
o Adjustable foot ring
o Adjustable seat pan depth (preferred)
• If the chair has arms, the arms should have the following adjustments:
• Adjustable height arms (small “T” style)
• Adjustable arm width (preferred)
o
8.1.2 Furniture and Equipment Surplus or Disposal
All laboratory equipment and potentially contaminated furniture used in a laboratory must be cleared
by the Safety and Risk Management Office prior to disposal through Facilities Management or surplus.
The first step in the process is determining whether or not you need to have your equipment cleared by
the Safety Office. For example, if the equipment was used in an office and had no potential for
exposure to chemical, biological, or radioactive materials, clearance through the Safety Office is not
necessary. All other equipment must be certified that it is free of contamination prior to disposal as
follows.
•
Any equipment that contains a radioactive source or that potentially came in contact with
radioactive materials must be tested and cleared by a Safety Officer from the Safety and
Risk Management Office prior to handling for disposal.
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Equipment that has been used in experiments involving biological materials must be
decontaminated with a 10% bleach solution or approved EPA disinfected by laboratory
personnel prior to handling for disposal. All exposed surfaces of the equipment or
potentially contaminated furniture must be wiped down with the bleach solution. In
addition, if your laboratory is disposing of a Biological Safety Cabinet (BSC) that has been
used with infectious agents, you will need to contact your BSC service vendor for
decontamination. The Safety Office can provide guidance as needed.
In general, most other laboratory equipment can be decontaminated with soap and water
solution or mild detergent. If your equipment appears too contaminated to perform
decontamination safety, contact the Safety Office for guidance.
Any equipment that contains oil must be properly drained of its contents prior to disposal.
Collected oil will be collected for disposal. Contact the Safety Office for guidance if
necessary.
If the unit to be cleared is a refrigerator or freezer, the unit must be unplugged, defrosted,
and wiped dry. DO NOT defrost freezers with Radioactive Material stickers without first
obtaining Radiation Safety clearance. When defrosting, place absorbent materials (pads,
paper towels) around the unit and monitor periodically to prevent water from collecting
onto the floor. Additionally, all samples should be removed prior to unplugging refrigerators
or freezers to reduce the generation of offensive odors.
The next step in the process is to have the equipment or furniture “cleared” by the Safety Office.
Contact the Safety Office at 7443 and request an equipment clearance. A Safety Officer will visit your
laboratory to verify the equipment has been decontaminated as described above and affix a “Clearance
Form” to the equipment, as well as provide one to the PI and the surplus department for their records.
This process will indicate that it is safe to handle and dispose of or surplus the equipment.
Once items have been cleared by the Safety Office, follow normal surplus or disposal procedures, found
here. A flow chart depicting this process can be found on the following page.
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WCU Surplus Lab Equipment Process Flow Chart
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8.2 Biological Safety Cabinets (BSCs): Refer to Section 4.2
8.3 Centrifuges:
Centrifuges (including microhematrocrit centrifuges) are frequently used in the laboratory and must be
used properly and maintained to ensure safe operation. The following are recommended practices:
• Maintain centrifuge in adherence to the owner’s manual.
• Visually inspect the equipment for unusual cracks, irregularities, and wear prior to each use.
• Always verify proper loading of specimens to maintain balance.
• During operation, listen for unusual noises/vibrations until programmed speed is reached.
• Prevent the release of aerosol by using “safety devices” such as sealed buckets, sealed heads,
and safety trunnion cups. Always open safety cups in a BSC after centrifuging to avoid release of
aerosols.
• Routinely decontaminate interior surfaces with an approved disinfectant. Disinfect immediately
upon notice of visible contamination.
• Spills should be addressed immediately by following Chapter 2: Section 4 of the Laboratory
Safety Manual.
8.4 Blenders and Homogenizers:
These items are frequently used in laboratories, and both can potentially produce aerosols. Safety seals
homogenizers and blenders are available and should be used when working with agents that could be
transmitted via aerosols. They may be used on an open benchtop; however, they must be opened in a
BSC. All non-sealed devices must be used exclusively in a BSC.
Section 9 Bloodborne Pathogens
The following Exposure Control Plan (ECP) has been developed to eliminate or minimize employee
exposure to bloodborne pathogens. This plan addresses all of the provisions of the Occupational Safety
and Health Administration's (OSHA) Occupational Exposure to Bloodborne Pathogens Standard (29CFR
1910.1030), and is implemented by the Office of Safety and Risk Management.
9.1 Scope
Blood and body fluid precautions must be used by all employees who come in contact with any human
blood, body fluid, or other potentially infectious materials.
9.2 Rationale
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•
According to OSHA, Universal Precautions are defined as the infection control practices in which
all human blood and certain human body fluids are treated as though they are known to be
infectious for bloodborne pathogens. The Universal Precaution approach is based on the
premise that many people do not know that they are infected and that medical history and
examination cannot reliably identify all people infected with bloodborne pathogens.
OSHA mandates that Universal Precautions shall be observed to prevent contact with blood or
other potentially infectious materials.
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•
WCU employees should consider all human blood and body fluids as potentially infectious and
must employ appropriate protective measures to prevent possible exposures. All body fluids are
included, not just those that appear bloody. Blood is not always visible in body fluids or is not
recognized until an exposure has occurred.
Western Carolina University also includes the following under “other potentially infectious
materials”: Any unfixed human tissues or organs, HIV-, HBV-, or HCV-containing cell lines, any
animals or animal tissues infected with these pathogens, all primary human cell lines, and any
established human cell lines. All human cell lines (including established lines) are also included in
the definition of “other potentially infectious materials.”
9.3 Exposure Risk Determination
Exposure risk is determined by reviewing employee positions for reasonably anticipated risk of
occupational exposure to human blood, body fluids, or other potentially infectious materials (OPIMs) as
defined by the Bloodborne Pathogens Standard and OSHA interpretations as follows:
1. Occupational Exposure Risk is “reasonably anticipated skin, eye, mucous membrane, non-intact
skin, or parenteral contact with blood and other potentially infectious materials that may result
from the performance of an employee’s duties.”
2. Other Potentially Infectious Materials are any unfixed tissue or organ (other than intact skin)
from a human (living or dead); including primary and established human cell lines and HIVcontaining cell or tissue cultures, organ culture medium or other solutions, and blood, organs, or
other tissues from experimental animals infected with HIV, HBV, or HCV.
All employee positions will be assessed via their supervisors/PIs, using the Hazard Assessment
Worksheet (available from Safety Office). The Safety Office will assist in hazard assessments as
requested, and shall maintain a complete database of the exposure risk determinations.
9.4 Schedule and Method of Implementation
Where possible, engineering and work practice controls shall be used to eliminate or minimize
employee exposures.
1) Standard Safe Work Practices
i) Eating, drinking, smoking (including electronic cigarettes), applying cosmetics, and handling
contact lenses are prohibited in work areas where there is potential for occupational
exposure to blood or OPIM,.
ii) Food and drink shall not be stored in work areas where blood or OPIM are present.
iii) Procedures involving blood or OPIM are to be performed in a manner to minimize splashing,
spraying, spattering, and droplet generation.
iv) Mouth pipetting is prohibited. Always use mechanical means to pipette.
2) Puncture Precautions
i) All employees must take precautions to prevent injuries when using sharp instruments or
devices during procedures; when cleaning used instruments; during disposal of used needles
and sharps; and when handling sharp instruments after procedures.
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ii) All employees must be trained on the availability and use of approved safety devices where
appropriate for their work responsibilities.
iii) Needles must not be recapped, purposely bent or broken, removed from disposable
syringes, or otherwise manipulated by hand. Exceptions (such as when needles must be
recapped for sterility, i.e., re-use of needle on the same patient) for specific procedures
must be approved by the Safety Office. Any approved recapping procedures must be done
either by using a recapping device or a one-handed scoop method for recapping.
iv) Broken, contaminated glassware must not be handled directly with hands, but must be
cleaned up by mechanical devices such as a dustpan, cardboard, or tongs.
v) After use, disposable syringes and needles, scalpel blades, scissors, slides, any activated or
inactivated safety devices, and other sharp items must immediately, or as soon as feasible,
be placed in puncture-resistant containers for disposal by the sharps user.
vi) The puncture-resistant containers must be located as close as practical to areas where
disposable needles or sharps are used. The needle disposal containers are to be replaced
before they become full.
3) Hand/Skin Washing
i) Hands and other skin surfaces must be washed as soon as possible if they become
contaminated with blood or body fluids.
ii) Hands must be washed immediately after removing gloves, and before leaving the
laboratory/work area.
4) Laundry
i) Soiled linen or reusable protective clothing must be handled as little as possible.
ii) All used laundry should be considered potentially infectious and should be placed in the
standard laundry bags which have been chemically treated to minimize fluid leakage.
iii) If linen is soaked with blood or body fluids and is likely to leak through a single bag, "doublebags" are to be used.
iv) Laundry is to be processed via an outside contractor. Do not take laundry home with you.
5) Environmental Controls
i) Laboratories where blood or OPIM are being manipulated must be designed and ran to
meet BSL-2 guidelines.
ii) Work areas must be maintained in a clean and sanitary condition. Work surfaces must be
decontaminated with an appropriate disinfectant after completion of procedures or as soon
as feasible when contaminated with blood or body fluids, and after the work shift.
iii) Blood or body fluid spills must be decontaminated as soon as feasible. Spills should be
soaked up with absorbent material (i.e., paper towels), and disinfected with an EPAapproved tuberculocidal disinfectant or a freshly-prepared diluted bleach solution (1:10
bleach: water).
iv) Disposable, contaminated items (dressings, disposable gloves, gauze, etc.) should be placed
in a sturdy, leak-proof plastic bag and tightly closed for transport. Double bagging may be
necessary if hard edges might perforate a single bag.
v) Bulk blood or body fluids (greater than 20 ccs) or materials contaminated with blood or
OPIM (large volumes) are regulated medical waste and must be placed in "biohazard" boxes
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lined with plastic bags for proper disposal. Other biowaste waste is handled according to
Section 7 Waste Management.
vi) Contaminated, reusable equipment must be either decontaminated on-site or covered (i.e.,
placed in a plastic bag ) and labeled with a biohazard warning sign to prevent exposures
during transport.
vii) Biohazard warning signs must be affixed to containers of regulated medical waste,
refrigerators and freezers containing blood or OPIM; and other containers or bags used to
store or transport contaminated materials, needles and sharps.
6) Barrier Precautions (Personal Protective Equipment)
i) Employees must use appropriate barrier precautions to prevent skin and mucous membrane
exposure when contact with any blood or other body fluids is anticipated. Each department
must assess the exposure potential from procedures performed by their employees and
identify all procedures which necessitate routine use of personal protective equipment
because of a probability of exposure. In addition, each employee should critically review
their work responsibilities to make informed decisions regarding the appropriate use of
personal protective equipment.
ii) Gloves must be worn for touching blood or body fluids, mucous membranes, or non-intact
skin of all patients, for handling items or surfaces soiled with blood and body fluids, and for
performing venipuncture and other vascular access procedures.
iii) Masks and protective eyewear or face shields must be worn to prevent exposure of mucous
membranes of the mouth, nose, and eyes during procedures that are likely to generate
splashes or splatters of blood or other body fluids.
iv) Appropriate protective gowns or aprons must be worn during procedures that are likely to
generate splashes of blood or other body fluids. For procedures during which you anticipate
your clothing will be soaked, fluid resistant aprons or gowns must be worn.
v) Shoe covers or boots must be worn in instances where gross contamination with
blood/body fluids is reasonably anticipated (i.e. sewage spill)
9.5 Compliance Monitoring
The Safety Office will conduct site audits and investigate reasons for non-compliance with the policy as
identified through complaints or reported exposures. Following investigation, the Safety Office will
make suggestions to modify procedures based on an investigation of the problem, and will provide
additional education as needed. Department heads, managers, and supervisors/PIs are responsible for
ensuring compliance and monitoring adherence to this safety policy. Specifically, they must ensure that
all personnel working under their supervision:
1. Understand and comply with practices/procedures identified in the ECP and other relevant
safety procedures.
2. Have access to appropriate and necessary personal protective equipment.
3. Receive training, as required by this ECP.
Failure to comply with this policy will be managed as a work rule violation through the University policy
on disciplinary actions.
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9.6 Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up
Hepatitis B Vaccination: Hepatitis B vaccine and post-exposure follow-up records will be maintained by
University Health Services. Employee compliance with hepatitis B vaccine provisions are available from
the Safety Office or University Health Services and are maintained in the Safety Office.
a. Supervisors must ensure that new employees meeting the following criteria for
occupational exposure risk receive the required training and meet with the Safety Office
and University Health Services for a health review and hepatitis B evaluation within 10
working days of initial assignment:
b. Employees with occupational exposures to blood or body fluids must be offered and
should be encouraged to participate in the free hepatitis B vaccination program.
Employees are to contact University Health Services to obtain the vaccine. Employees
must read the Hepatitis B Information Sheet and then sign EITHER the Hepatitis B
Vaccination Consent Form OR the Hepatitis B Declination Form. All forms are available
here.
Post Exposure Evaluation and Follow-up: Significant exposure includes contamination by blood or
other body fluids or high titers of cell-associated or free virus via
1) percutaneous, e.g., needlestick;
2) permucosal, e.g., splash in eye or mouth; or
3) cutaneous exposure, e.g., non-intact skin, or involving large amounts of blood or
prolonged contact with blood, especially when exposed skin is chapped, abraded, or
afflicted with dermatitis.
All blood or body fluid exposures must be washed vigorously and then reported immediately to the
supervisor and University Health Services. Supervisors must fill out incident report forms and return
them to the Safety Office (forms are located here).
The exposure will be reviewed. Hepatitis B virus (HBV), hepatitis C (HCV), and human immunodeficiency
virus (HIV) infection status of the source patient will be specifically investigated but the presence of
other bloodborne diseases will be evaluated and appropriate protocols instituted, as needed. Examples
of these diseases include malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections,
relapsing fever, Creutzfeld-Jakob disease, HTLV-1, and viral hemorrhagic fever.
Information regarding all human blood or body fluid exposures is entered into the University Health
Services blood/body fluid exposure surveillance database. Information includes the type, brand, and
purpose of device involved in the incident (if known), the location where the incident occurred, the
occupation of the injured employee, an explanation of how the injury occurred, and the source
material’s infectious status. This data forms the basis for the Western Carolina University Sharps Injury
Log. University Health Services will report the incident to the Safety Office. The Safety Office will review
the exposure. Other blood or body fluid exposure protocols will be instituted, as indicated.
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9.7 Labels and Signs
Biohazard warning signs must be affixed to containers of regulated medical wastes, refrigerators,
freezers, and incubators containing blood, body fluids, or other PIM; and other containers or bags used
to store or transport contaminated equipment, materials, needles and sharps.
9.8 Bloodborne Pathogens Training Program
Employee training is provided by the Safety Office as an on-line training module and “in-person” upon
request, for example orientation training for research employees, incoming housekeeping staff, and
allied health / medical students.
Target Population: All employees with routine, anticipated exposure to blood, body fluids, and other
potentially infectious materials (PIM).
Training Objectives:
• Understand the modes of transmission of bloodborne pathogens, and the philosophy
behind "Universal Precautions";
• Have a general understanding of the epidemiology and symptoms of bloodborne diseases;
• Be familiar with the Western Carolina University Exposure Control Plan and the means by
which the employee can obtain a copy of the written plan:
• Know the appropriate methods for recognizing tasks and other activities that may involve
exposure to blood and OPIM;
• Be familiar with the use and limitations of methods that will prevent or reduce exposure
including appropriate engineering controls, work practices, and personal protective
equipment;
• Know the types, and proper use of personal protective equipment;
• Know the basis for selection of personal protective equipment;
• Be informed about hepatitis B vaccine, including information on its efficacy, safety, method
of administration, the benefits of being vaccinated, and that the vaccine and vaccination will
be offered free of charge;
• Be informed of the appropriate actions to take and persons to contact in an emergency
involving blood or other PIM;
• Know the procedure to follow if an exposure incident occurs, including the method of
reporting the incident and the medical follow-up that will be made available;
• Be informed on the post-exposure evaluation and follow-up that the employer is required to
provide for the employee following an exposure incident;
• Know the signs and labels and/or color-coding required by the standard;
• Be familiar with waste management, laundry, and housekeeping practices specific for
Western Carolina University;
• Understand his/her role and the University's role in the standard.
Training Requirements
• On-line training includes a quiz that must be passed for compliance.
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•
•
•
Area-specific training is provided upon request.
Departments who wish to provide area-specific or departmental training may do so upon
approval of training material by the Safety Office
Training is required for all employees with reasonable exposure risk within 10 working days
of initial assignment to work area involving exposure prone tasks and at least annually
thereafter, or when changes in tasks/procedures result in a change of the exposure
potential.
Training Records
• Institutional training records will be maintained by the Safety Office.
o Supervisors, training coordinators and other persons responsible for providing
training should submit copies of updated training records to the Safety Office at
least quarterly.
o Records will be maintained for 3 years from the date of training.
o Training records will contain the following:
 Dates of training sessions.
 Contents or a summary of the training session.
 Name and qualifications of the trainer.
 Name and 92# of all persons attending the session.
• Documentation of employee participation in appropriate training will be maintained by the
employee’s administrative office.
9.9 Employee access to the ECP
•
•
•
A copy of the ECP is available on the safety web-site
Copies of the ECP are available in many work areas. Ask your supervisor about the location of
the ECP in your work area.
A copy of the ECP will be provided to any employee upon request to the Safety Office
9.10 Assistance
Additional information regarding Universal Precautions and the Bloodborne Pathogens may be found at
the biological safety website here. The Office of Safety and Risk Management should also be contacted
at x7443 for assistance in implementing procedures or to provide training for employees in Universal
Precautions and the Bloodborne Pathogens Exposure Control Plan.
9.11 Review and Update of ECP
A. The ECP will be reviewed by the Safety Officer at least annually
B. The ECP will be updated whenever tasks or procedures affecting occupational exposure are
modified.
C. Affected employees will be trained regarding these modifications following approval either
through the annual update training or through department-specific training.
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EMERGENCY TELEPHONE NUMBERS
Phone
227-7443
Hours
8:00am 5:00pm
MondayFriday
University Police Department
• Work Related Injuries
(After Normal Business
Hours)
Fire or Smoke
Police Services 227-7301
Emergency Line 227-8911
911 or
University Police
227-8911
24 hours
Medical Emergencies
911 or
University Police
227-8911
24 hours
NC Poison Control Center
1-800-84 TOXIN
(1-800-848-6946)
24 hours
Phone
Hours
Safety and Risk Management
Office
• Work Related Injuries
(Normal Business Hours)
• Gas Leaks or Odors
• Chemical Spills
• General Inquiries
24 hours
Lab Supervisor Contact
Name
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