University of Cambridge
NIHR BRC Phenotyping Hub, Department of Medicine
Risk Assessment Form
This form is to be filled in if hazard ratings/quantities/dilutions make University procedures and/or
“Good Laboratory Practice” insufficient control.
Group leader: Anna Petrunkina Harrison
Personnel involved: Simon McCallum, Chris Bowman, Natalia Savinykh, Esther Perez, Jelena
Djuric, Alex Hatton, Valeria Radjabova and all users of flow cytometry equipment in the
sorting room
Activity being assessed:
HANDLING AND ANALYSING SAMPLES from
UNSCREENED HUMAN tissue and blood
Hazards identified:
Unscreened human blood may contain Blood Borne Viruses including HIV, Hep BV, Hep CV
amongst others and should be handled as such. Other tissues may be similarly contaminated
with these agents or harbour other agents associated with them
Hazards from contamination include:
1. Percutaneous inoculation from sharps, including needles, scalpels, broken glass etc.
including contamination of exposed skin or pre-existing cuts and abrasions etc.
2. Inhalation of aerosols from shaking, agitation, mixing and failure of containment etc.
3. Ingestion from inadvertent sample to mouth transmission.
4. Contamination of Conjunctivae by inadvertent contact with eyes.
resulting in infection.
Therefore, unscreened human samples should be handled at Containment Level 2 in accordance with
the revised ACDP guidance from the HSE.
If there is a significant risk that, or it is actually suspected that, the blood/tissue is infected with
any Blood Borne Viruses (BBVs), including the above, or any other pathogenic agent, then a
separate Risk Assessment must be carried out in order to reduce the risk (e.g. fixation with
PFA) and an appropriate Containment Level used. Such samples can be processed in the sorter
room only after enquiries with Biological Safety Officer and after approval by Departmental
Biosafety Committee.
Guidance Documents: See
University booklet “Safe Biological Practice (SBP) – for Prevention and Control of Exposure to
Biological Agents in the Laboratory”
University Clinical School Guidance on Blood Taking, Blood Handling and Work at Containment
Level 2.
Advisory Committee on Dangerous Pathogens (ACDP) Guidance “Protection against blood-borne
infections in the workplace- HIV and Hepatitis (HSE/HMSO : ISBN 0 11 321953 9)
Revised Advisory Committee on Dangerous Pathogens Guidance (www.doh.gov.uk/ACDP):-
Control measures to reduce the level of risk:
Unscreened human samples processed for flow cytometry analysis should be handled at
Containment Level 2.
In addition to the measures and facilities normally specified for work at Containment Level 2
(see relevant guidance), the additional measures listed below should also apply when, as here,
Containment Level 2 is specified.
These extra precautions should be in constant use to guard against percutaneous inoculation, contamination of
the skin, conjunctivae, mucous membranes and the working surfaces.
• All work must be conducted in a designated containment level 2 work area (Phenotyping Hub sorting lab space) with
sufficient space to work safely. The whole sorting room with exception of specially designated office area on the left-hand
and right hand side is Containment Level 2 space – these are not to be used for or exposed to samples.
• Access to CL2 areas is restricted to authorised staff ONLY, in order to ensure that the person(s) conducting the work is
(are) free from the risk of disturbance or accidental contact with others.. Only trained cytometry operators are authorised
to work in the sorting room unsupervised. All users are advised that the sorter room is a CL2 workspace, and on the
necessity to adhere to procedures relevant for handling their own samples and to perform risk assessment for their own
experiments. This advice is now incorporated in the training for flow cytometry area.
• The use of sharps and glassware must be avoided in the Sorting lab. Where such use is essential, particular care must be
taken in their handling and disposal after contact with unfixed materials, and any exception can be only subsequent to the
application and review of the RA for the protocols.
• Lesions on exposed skin should be covered with waterproof dressings.
• Protective clothing must include an appropriate laboratory gown, disposable gloves and other personal protective
equipment appropriate to the task, including eye protection when appropriate. The need for wearing eye protection will be
specified in the particular project Risk Assessment prepared by the investigators in consultation with flow cytometry unit,
and after approval by the Biosafety Committee.
• The workstations must be kept clear of unnecessary equipment and not used for storage.
• When operating a sorter, samples must be handled with care, especially when taking them off the injection port and
when a blockage has occured. There is a risk of aerosol generation form the sorting equipment. . Sorters are now placed
into MSC thereby containing these aerosols. The MSC is serviced once a year by contractor. It is a contractor
responsibility to calibrate the MSC or otherwise monitor that the settings are appropriate to ensure adequate level of
biocontainment. Fumigation of the cabinet is done by a contractor according to an approved SOP and in accordance with
the local Rules. All prospective users must fill out and sign a FACS Biosafety assessment sheet for batches of similar sort
within a project. The biosafety sheet is signed off by Flow Cytometry and Imaging Officer Simon McCallum, or, in his
absence by trained core staff. Only qualified sorter operators (Hub core staff) can make decision on whether to process the
samples for sorting and only they can operate sorters. Any obviously CL 1 or 2 material can be sorted without delay. All
other applications must be sent for assessment/discussion to the Biological Safety Officer Mark Wills. Dr. Mark Wills will
assess whether the risk assessment for experiments is adequate, in particular, whether the risk has been sufficiently
reduced by additional procedures and factors (e.g. additional training, special handling procedures which are adequate for
each particular project etc) and refer to the Safety Committee in cases of enhanced risk. In situation where the residual
risk is still considered to be above CL2 levels, and an approval of Safety Committee cannot be obtained, samples cannot
be processed. The bench surface and any equipment must be disinfected immediately after completion of work.
Disinfection policy:
1) After completion of flow cytometry work, the sorter injection port must be cleaned as described in the guidance
notes by the manufacturer . The waste tank needs to be supplemented with Trigene in the quantity prescribed for
each particular instrument (final concentration of 10%). NOTE: Virkon must be never used for cleaning sorting
equipment injection port or any other parts due to risk of corrosion!
2) In case of spillages, surface area has to be sprayed with Trigene and wiped.
• For all operating staff of the Hub conducting work on the sorter, Hep BV vaccine, together
with follow-up procedures, is a requirement.
• Contaminated waste will be disposed of in accordance with local guidance and rules for the safe
disposal of Containment Level 2 waste; including chemical sterilisation of liquids with autoclaving
and incinerating for solids as appropriate.
Level of risk remaining:
Residual risk of percutaneous inoculation; which must be minimised by the avoidance of sharps.
Residual risk of splashes in eyes; which must be minimised by use of suitable eye protection.
Emergency procedures:
NB: See Guidance Documents as above.
First Aid: Wash any contaminated skin, conjunctivae or mucous membrane immediately.
In the event of a wound, it should be allowed to bleed by irrigation under running water.
Seek medical Advice and contact University Occupational Health Service immediately.
Spillage: All spillages and surface contamination must be immediately cleaned up and removed
including decontamination with a suitable validated disinfectant (10% solution of Trigene).
Blockages of the AriaIII: When the cell sorters are blocked, there may be a generation of infective
aerosol. The waste drawer and stream should be shut off and the sort chamber opened after checking
that the hood still functions. The system should then be left for 5min for any aerosol to evacuate,
before spraying the chamber and all other relevant parts/surfaces with 70% Ethanol and attempting
repair. Only core staff will deal with the blockage.
Major spillages and leaks (resulting in significant surface being covered with fluid, more than 100 ml)
should be reported to core manager Simon McCallum who will assess the incident, keep the record of
it and report it to biosafety officer if appropriate.
Name and status of assessor:
Anna Petrunkina, Director of the Cell Phenotyping Hub
Date of assessment:
1/09/15
Signature of assessor:
Revision due date:
1/09/16