Chapter 26.07 Biosafety – Required Work Processes

Work Process A. Starting and Conducting Work Safely
Work Process B. Work and Risk Assessment
Work Process C. Biosafety Principles and Levels
Work Process D. Specific Biosafety Controls
Work Process E. Assessment and Improvement
Work Process F. Institutional Biosafety Committee

Work Process A. Starting and Conducting Work Safely

This section and Table 1 provide a simplified list to assist supervisors, work leads, and principal investigators in getting work with biological materials planned, assessed, authorized, and conducted. Specific sections of this manual should be consulted for additional information and requirements:

Table 1. Guidance for Starting and Conducting Work

Guidance	Berkeley Lab Policy Section
Work Operation Planning, Risk Assessment, Authorization, and Control Complete and maintain a WPC Work Activity or exposure Control Plan (ECP) and any other required authorization. The WPC Activity documents the work, risks, and controls. Implement the controls listed in the authorization.	Work Process D.1
Create a WPC Work Activity for research with biological materials.	Work Process D.1.a.ii
Submit the Activity to the Environment/Health/ Safety (EHS) Biosafety Office (biosafety@lbl.gov) for review by the Institutional Biosafety Committee (IBC) and/or Biosafety Officer.	Work Process D.1.a.ii
Resolve any review comments.
Work with the Biosafety Office to get the WPC Activity approved and authorized in the Activity Manager application.	Table 10
Ensure workers are familiar with the authorization document, understand the required controls, and are trained.	Work Process D.2
Ensure the containment controls noted in the Activity are implemented. Also implement applicable controls noted in this ES&H Manual Biosafety Program. Standard Laboratory Biosafety Level (BL) 1 and BL2 criteria are summarized in Appendix C.	Work Process C and Work Process D
Update personnel, biosafety training, and work locations as needed in the Activity Manager application.
Update the authorization document and submit it for review to the Biosafety Office prior to the target renewal date. Ensure authorization document is re-authorized as needed.	Table 10
Complete and submit an Exposure Control Plan for nonresearch work that involves exposure to bloodborne pathogen materials.	Work Process D.1.a.v
Complete and submit a Biosafety plan for nonresearch work that involves exposure to aerosol transmissible pathogens.	Work Process D.1.a.vii
Complete and get approval on any required protocols for research involving vertebrate animals or human subjects (including human-derived data or human-derived tissues) via the Animal Welfare and Research Committee (AWRC) or Human Subjects Committee (HSC), respectively.	ES&H Manual: Research with Human and Animal Subjects Program
Worker Authorization and Control Identify the work, hazards, and controls for each worker or subcontractor and ensure the controls are implemented. Ensure each worker completes:
A WPC Activityor Subcontractor Job Hazards Analysis (SJHA)	Work Process D.2.a
Required controls on their WPC Activity or SJHA, including required training courses	Work Process D.2.b
Applicable job and operation-specific instruction related to biosafety	Work Process D.2.c
Any required medical surveillance noted on their WPC Activity or SJHA	Work Process D.3
Assessment and Improvement Assess and continuously improve the biosafety of the work.	Work Process E
Conduct periodic biosafety assessments of the operation as specified in the Division Self-Assessment Program, including assessment of the safety of tasks being performed, safety of the work area and equipment, training, and compliance with the Biosafety Work Authorization and standards.	Work Process E.1
Participate in periodic Biosafety or other ES&H Program Self-Assessments of the operation, when scheduled.	Work Process E.2
Continuously improve the biosafety of the work, including tracking and correcting deficiencies when required in the Corrective Action Tracking System (CATS).	Work Process E.2
Whom to Call Refer to the Whom to Call list in Section 26.5.1.	Section 26.5.1

Work with biological materials, like all work at Berkeley Lab, must be conducted using the guiding principles and five core functions of Integrated Safety Management (ISM) (e.g., define scope of work, analyze hazards, develop and implement controls, perform work within controls, feedback and continuous improvement) as discussed in ES&H Manual General ES&H Requirements, Responsibilities, and Work Practicesprogram. These core functions are integrated into the work authorization and control functions summarized above in Table 1.

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Work Process B. Work and Risk Assessment

The work scope must be defined and hazards and risks must be assessed before work begins. These work-planning processes are the first two core ISM functions and required by biosafety standards. Biological work and risks at Berkeley Lab are defined using established institutional assessment and authorization processes, a structured approach as required by DOE, and the standard biosafety risk assessment process defined by the CDC and NIH. It is a primary responsibility of workers, work leads, and supervisors to ensure these processes are implemented before work begins.  

• Berkeley Lab Assessment and Authorization Processes. Berkeley Lab uses the following institutional assessment and authorization processes and documents to define work, identify biological hazards and potential exposures, assess biological risks, and establish biosafety controls:
  • Work Planning and Control (WPC) document is prepared for each worker (see the ES&H Manual Work Planning and Control program)
  • A Subcontractor Job Hazards Analysis (sJHA) and Work Authorization is prepared for each subcontractor, vendor, or affiliate (see the ES&H Manual sJHA Process – Subcontractor Job Hazards Analysis program).
  • WPC Activities are prepared for work with biological materials in specific operations or projects. In the case of research involving biological materials, the Institutional Biosafety Committee(IBC) reviews and approves the definition of work, risk assessment, and controls as part of the authorization process. See Work Process B.2 below for details.
• Biosafety Risk Assessment Process
  • The institutional assessment and authorization processes and documents noted in Work Process B.1 above incorporate the standard biosafety risk-assessment process defined and required by the CDC, NIH, and DOE in the Biosafety in Microbiological and Biomedical Laboratories (BMBL), the NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules(NIH Guidelines), and the Worker Safety and Health Program (WSHP).
  • The standard biosafety risk-assessment process starts with considering three primary factors: (1) the inherent work hazard posed by the biological material or agent, (2) the susceptible hosts (i.e., receptors) that may be affected by the material or agent, and (3) the exposure pathways between the threat hazard and the susceptible host.
  • In addition, BMBL outlines the following five-step approach for laboratory supervisors and work leads to assess biological risk and to select controls for laboratory workIdentify material or agent hazards, and perform an initial risk assessment.
    • Identify laboratory procedure hazards.
    • Make a final determination of the appropriate biosafety containment level, and select additional controls indicated by the risk assessment.
    • Evaluate a worker’s proficiency in safe work practices, and ensure the integrity of safety equipment.
    • Review the risk assessment with the biosafety professional, subject matter expert, and the IBC.
  • The remaining sections of Work Process B present in greater detail the key factors underlined above that must be considered when conducting risk assessments and selecting controls. Primary factors include material or agent hazards (perceived or real) and procedure hazards. Secondary factors include staff proficiencies and other personal factors. See Section II of BMBL for more information on biological risk assessment.
• Material or Agent Hazards and Requirements
  • Biological Materials and Agents. The material or agent hazard(s) and associated requirements must be considered at the start of the risk assessment. Terms used to describe biological materials must also be defined and understood before a risk assessment takes place. This is because these terms often have specific meanings, associated requirements, and associated lists:
    • The term biological materials is used in this program and the risk-assessment process to describe a broad range of organisms, cells, viruses, and other materials of biological origin that pose differing levels of risks to plants, animals, or humans.
    • The term biological agent or agent is used to describe a specific biological organism or material that is often directly responsible for producing an effect (e.g., disease). Examples of biological agents include a microorganism (e.g., bacterium, fungus, or parasite), virus, prion, or biological toxin. For example, humans are composed of tissues that contain blood; the blood contains fluids and cells; and the blood may contain the viral pathogen hepatitis B. Although the human body, tissues, blood, cells, fluids, and pathogens are all biological materials, only the hepatitis B virus is a biological agent.

• Material Viability. In addition, the risk assessment should consider the state or treatment of the biological material that may change or eliminate the hazardous characteristics of the material, and this information should be included in the Biosafety Work Authorization when the information significantly describes the safety aspects of the work. For example, biohazardous characteristics of a biological material may not be present if the material is in a nonviable, fixed, inactive, or decontaminated state. These terms are listed below along with simplified definitions and examples:
• • Nonviable means the material or agent is not capable of living or developing under favorable conditions. Examples include sections of plant or animal tissue that are often not capable of propagating, and extracts of biological samples such as DNA or RNA that cannot replicate without cells. These materials may not pose risks as long as there is no potential for the presence of pathogens.
  • Fixedmeans the material has been treated so that it has been stabilized and preserved in place. For example, properly fixing cells with paraformaldehyde or glutaraldehyde typically kills the cells and most potential pathogens.
  • Inactive means the material is not capable of acting or reacting normally. For example, infectious proteins (i.e., prions) may be inactivated by chemical destruction.
  • Decontaminated means the material has been treated (e.g., sterilized or disinfected) so that biological contaminants or components have been reduced or inactivated to an acceptable level to reduce or eliminate the possibility of transmission of pathogens to undesired hosts. For example, fresh human bones may be decontaminated internally by radiation.

Plate A shows microbial growth    Plate B shows no visible colonies

The above pictures show sterility certification of a genomic DNA preparation from a sewage-derived culture. Sample viability is determined by plating, incubating, and comparing the culture before gDNA extraction on plate A (positive control) with the gDNA prepared sample on Plate B. Following incubation: (a) Plate A shows a lawn of microbial growth, and (b) plate B shows no visible colonies and confirms sterility of the prepared sample. Source: Harry Beller, LBNL, JBEI (April 2011). Assessment of viability is often a component of the risk assessment and work process and determines biosafety containment level.

• Risk Group Classification:
  • The principal hazardous characteristics of the agents that are present or that may be present in the biological material must be considered while completing the initial risk assessment. This consideration includes an assessment of the agent’s capability to infect and cause disease in a susceptible human or other host, the severity of disease, and the availability of preventive measures and effective treatments. To facilitate this assessment process, the World Health Organization (WHO) and NIH established an agent risk group (RG) classification for laboratories. This RG classification system, which was also adopted by the CDC, describes four general RGs based on the hazardous characteristics of agents, and the transmission route of natural disease in humans.
  • Berkeley Lab uses the four RG levels and definitions provided in Appendix B of the U.S.-based NIH Guidelines (see Table 2 below). As shown in Table 2, a higher RG level indicates a higher risk for disease in humans. Assignments of RGs to specific agents may be found in various sources, including:
    • Appendix B, under 26.10: Provide a list of human pathogens and their RG designations as excerpted from Appendix B of the NIH Guidelines (Classification of Human Etiologic Agents on the Basis of Hazard)
    • The American Biological Safety Association (ABSA) Risk Group Database
      

Table 2. Risk Group Classification

Risk Group (RG) Level	Risk Group Definition
1	Agents that are not associated with disease in healthy adult humans
2	Agents that are associated with human disease that is rarely serious, and for which preventive or therapeutic interventions are often available
3	Agents that are associated with serious or lethal human disease for which preventive or therapeutic interventions may be available (high individual risk but low community risk)
4	Agents that are likely to cause serious or lethal human disease for which preventive or therapeutic interventions are not usually available (high individual risk and high community risk)

Source: Adapted from the NIH Guidelines, Appendix B, Table 1.

• • Berkeley Lab policy requires that each biological material or agent used for research be categorized by RG in the WPC work activity, and the RG must be based on the agent’s or material’s potential for causing disease in humans. This categorization should be based on the following principles:
    • Agents must be assigned the RG designated by NIH, unless a risk assessment in the WPC work activity indicates an alternate RG is warranted for the specific agent to be used.
    • Agents not classified as RG2, 3, or 4 by NIH are not automatically or implicitly classified as RG1. Examples include uncharacterized isolates from environmental samples and opportunistic pathogens. A risk assessment must be conducted for unclassified agents based on their known properties and relationship to well-characterized agents listed in NIH RGs.
      • Uncharacterized environmental isolates should not be automatically considered as RG1 due to their unknown risks. Full genome sequencing with phylogenetic relationship analysis should be used to characterize unknown isolates and to determine the RGs.
      • Opportunistic pathogens are microorganisms that can cause disease when a host’s immune system is compromised, for example, by certain medical conditions, procedures, drugs, or pregnancy.

• Some information sources for biological agents only state the recommended biosafety level (BL) to be used for the agent. An agent’s recommended BL is typically the same as its RG (i.e., RG2 agents are handled at BL2). If an agent has not been assigned an RG by NIH, the risk-assessment process must be used to determine its BL. See Work Process C.4.a for information on BLs.
• Bloodborne pathogen materials should be designated RG2. This is because BMBL specifies BL2 containment practices for bloodborne pathogen materials and compliance with the Cal/OSHA Bloodborne Pathogens Standard (see Work Process B.3.f.i of this program).
  

Pathogenic Agents and Toxins

• The risk assessment includes identification and assessment of the pathogenic agents or toxins that are involved with the work, or may be present in the biological material. A pathogen is an infectious microbe (e.g., bacterium, protozoon, fungus, virus, etc.) or other agent (e.g., prion) that causes disease in a healthy host organism such as a human, animal, or plant. A toxin is a poisonous substance produced by a living organism.\
• Depending on potential hosts and impacts (e.g., humans or livestock), pathogens and toxins may be regulated by a variety of agencies. Table 3 below and the remainder of this section identify categories of pathogens and toxins used in biosafety standards and by regulatory agencies to identify agents, toxins, and associated requirements. Appendix B of this manual also provides lists of many pathogens and toxins.
  

Table 3. Pathogenic Agent and Toxin Categories

Agent or Toxin Category	Agent or Toxin Subcategory	General Example or Source
Human Pathogens	Human Etiologic Agents (NIH Guidelines)	Risk Group 2, 3, or 4 agents such as the bacterial, fungal, parasitic, viral, and rickettsial agents listed in Appendix B of the NIH Guidelines
	Human Pathogens (BMBL)	Bacterial, fungal, parasitic, rickettsial, viral, and arbovirus agents that are included in BMBL agent-summary statements and require BL2 or greater containment
	Biological Etiologic Agents (DOE WSHP)	Human pathogens such as those listed in Appendix B of the NIH Guidelines
	Bloodborne Pathogens, (Cal/OSHA § 5193)	Pathogens are present in human blood and can cause disease in humans such as the human immunodeficiency virus (HIV), hepatitis B and C viruses (HBV and HCV).
	Select Agents (CDC)	Pathogens categorized by the CDC as select agents because of their severe threat to humans (e.g., biological weapons)
	Aerosol Transmissible Pathogens (ATPs) (Cal/OSHA § 5199 Aerosol Transmissible Diseases)	A pathogen for which droplet or airborne precautions are required, as listed in Appendix A of the Standard.
	Aerosol transmissible pathogen – laboratory (ATP-L) (Cal/OSHA § 5199 Aerosol Transmissible Diseases)	A pathogen that meets one of the following criteria: (1) the pathogen appears on the list in Appendix D the Standard, (2) the Biosafety in Microbiological and Biomedical Laboratories (BMBL) recommends biosafety level 3 or above for the pathogen, (3) the biological safety officer recommends biosafety level 3 or above for the pathogen, or (4) the pathogen is a novel or unknown pathogen.
Plant and Animal Pathogens		Materials, organisms, or agents regulated by USDA-APHIS that may harm domestic or native animals or plants, or natural resources
Toxins		Bacterial, fungal, algal, and animal toxins
Select Agents and Toxins		Human, animal, and plant pathogens and toxins categorized by the CDC and Animal and Plant Health Inspection Service (APHIS) as select agents and toxins because of their potential severe threat to humans (e.g., biological weapons)
Prions		Misfolded proteins and materials potentially containing other misfolded proteins that cause diseases known as transmissible spongiform encephalopathies (TSEs)

• Pathogen and Toxin Information and Guidance

• • Documentation of the hazardous characteristics and controls for well-known pathogens and toxins is usually readily available and should be considered in the risk assessment. This section lists agencies and organizations that provide such information, along with links to the information sources.
  • Because it may be difficult to find information on lesser-known pathogens or toxins, variants of pathogens, or opportunistic pathogens, their use may require additional risk assessments. For example, special technical information might be needed for avirulent or attenuated agents that have been physiologically modified or genetically altered and therefore several-orders-of-magnitude less likely to produce disease in a healthy host organism.In addition, “opportunistic pathogens” may not be listed as pathogens because they may only infect immunocompromised hosts.
    • BMBL Agent Summary Statements.Section III of the BMBL provides summary statements for many agents associated with laboratory-acquired infections or increased public health concern. Risk assessments must consider any information from these agent summary statements that apply to specific Berkeley Lab work activities. Categories included in the agent summary statements are listed below:

• • • • Bacterial agents
      • Fungal agents
      • Parasitic agents
      • Rickettsial agents
      • Viral agents
      • Arboviruses and related zoonotic viruses
      • Alphabetic listing of 597 arboviruses and hemorrhagic fever viruses
      • Toxin agents
      • Prion diseases

1. • Pathogen Safety Data Sheets for Infectious Substances. The Public Health Agency of Canada produces and provides pathogen safety data sheetsfor infectious substances as a safety resource for Canadian laboratory workers who may be exposed to these agents in research, public health, teaching, and other laboratories.
   • CDC Health Information.The CDC A-Z Index provides information on topics with relevance to a broad cross section of CDC audiences. The items are representative of popular topics and frequent inquiries, or have critical importance to the CDC’s public health mission. Topics such as diseases and vaccinations are covered.
2. Human Pathogens. Human pathogens are infectious microbes (e.g., bacteria, protozoa, fungi, viruses, etc.) or other agents (e.g., prions) that cause disease in healthy humans. Pathogens are also often referred to as etiologic agents or infectious agents. “Etiologic” is an adjective that means disease-causing. The terms “infectious agent” and “infectious material” are also used in biosafety standards and in this manual. “Infectious agent” means human pathogen. “Infectious material” means a biological material that potentially contains human pathogens or infectious agents. Listed and linked below are biosafety standards that cover human pathogens.
   • Human Etiologic Agents (NIH Guidelines). The NIH Guidelines provide a list of human pathogens and their RG2, RG3, and RG4 designations in Appendix B (Classification of Human Etiologic Agents on the Basis of Hazard) of the NIH Guidelines (also see Appendix B of this manual). Work with human pathogens at Berkeley Lab will be conducted in accordance with the agent-specific RG designations in Appendix B of the NIH Guidelines and this Biosafety Program.
   • BMBL Human Pathogens.BMBL agent summary statements contain BL-specific containment guidance for specific human pathogens (see Work Process B.3.i, Pathogen and Toxin Information and Guidance, of this program). Work with human pathogens at Berkeley Lab will be conducted in accordance with the IBC. The IBC will determine the proper containment level for pathogenic work, and use the recommended BL guidance presented in BMBL agent summary statements when available and applicable to the work activity. See Work Process C.4.a of this manual for additional information on BLs.
   • DOE WSHP Biological Etiologic Agents. The DOE WSHP regulation (10 CFR 851, Appendix A, Section 7) has specific requirements for “biological etiologic agents.” Berkeley Lab’s program to comply with 10 CFR 851 defines a biological etiologic agent as an agent of biological origin (e.g., bacterium, fungus, parasite, virus, etc.) that causes disease in humans (i.e., is pathogenic to humans). See Appendix B of this manual for the NIH list of human etiologic agents. Work with biological etiologic agents must be documented, reviewed, and authorized as discussed in Work Process D.1.a.ii, WPC Activities, of this program. During and following the review and authorization process, the IBC and EHS Division ensure the implementation of oversight and reporting responsibilities for biological etiologic agents. See Appendix A for specific Berkeley Lab requirements related to biological etiologic agents under 10 CFR 851.
   • Bloodborne Pathogens. See Work Process B.3.f, Bloodborne Pathogens and Human Material, and Appendix C for requirements related to human pathogens that are considered bloodborne pathogens (BBPs) under the Cal/OSHA Bloodborne Pathogens Standard.
   • CDC Select Agents. The Health and Human Services (HHS) CDC regulation on select agents and toxins lists agents that are both select agents and human pathogens. See Work Process B.3.d, Pathogenic Agents and Toxins, for more information.
   • Aerosol Transmissible Pathogens. The Cal/OSHA Aerosol Transmissible Diseases Standard provides a list of Aerosol Transmissible Pathogens/Diseases including pathogens requiring airborne infection isolation and pathogens requiring droplet precautions in Appendix A. See Work Process B.3.i Aerosol Transmissible Pathogens for requirements pertained to non-laboratory work.
   • Aerosol Transmissible Pathogens (Laboratory).The Cal/OSHA Aerosol Transmissible Diseases Standard provides a list of agents that,when reasonably anticipated to be present, require compliance with Section 5199 for laboratory operations in Appendix D. See Work Process B.3.j Aerosol Transmissible Pathogens – Laboratory for requirements for laboratories working with these pathogens.

• Plant and Animal Pathogens. See Work Process B.3.e, USDA-Regulated Materials, Organisms, and Agents, of this program for information on plant and animal pathogens; and Work Process B.3.d.v, Select Agents and Toxins, for more information on plant and animal pathogens that are also select agents.
• Toxins.A biological toxin, biotoxin, or toxin is a poisonous substance produced by a living organism. The poisonous nature of toxins means that they may cause death or severe incapacitation at relatively low exposure levels. Toxins include, for example, bacterial toxins, fungal toxins, algal toxins, and animal toxins. Examples include microcystins produced by freshwater cyanobacteria, or venoms produced by snakes or spiders. The word “toxin” without other descriptors such as “bio” is used in this manual and is a proper technical term to specifically describe toxins of biological origin. Toxic substances that are not of biological origin are properly termed “poisons.”

• • Typical laboratory work with very small quantities of most toxins can be performed with minimal risk to the worker. Toxins do not replicate, are not infectious, and are difficult to transmit mechanically or manually from person to person. Other characteristics that further limit the spread of toxins include the fact that many commonly employed toxins are relatively unstable in the environment (especially in the case of protein toxins) and have very low volatility.
  • Toxins must be handled using the general and “particularly hazardous substance” sections of the Berkeley Lab Chemical Hygiene and Safety Plan (CHSP). In addition, safety and security controls (presented below) based on a risk assessment must be used for each specific laboratory operation. The main laboratory risks are accidental exposure by direct contamination of the mouth, eyes, or other mucous membranes; inadvertent aerosol generation; and needlestick or other accidents that may compromise the normal barrier of the skin.
  • Requirements and guidelines for storage and work with toxins in the laboratory are covered and summarized below. See Work Process B.3.d.v.3, Select Agents and Toxins,for additional information on toxins listed in the National Select Agent Registry.
    • BMBL Guidelines for Work with Toxins. According to Appendix I of BMBL, toxins of biological origin must be reviewed and should be incorporated into work with toxins based on a risk assessment approved by the IBC. Key criteria in the guidelines and Berkeley Lab policies.
      • A risk assessment should be conducted to develop safe operating procedures and a specific chemical plan. It is Berkeley Lab policy that this toxin assessment and plan should be documented in the Biosafety Work Authorization and should cover applicable topics and guidelines presented in Appendix I of BMBL. General topics should include: description of work; safety and security risks, hazards, or concerns; and safety and security controls.
      • Each worker must be trained in the theory and practice of toxins, with emphasis on practical hazards associated with laboratory operations. This training includes how to handle transfers of toxins or liquids containing toxin, where to place waste solutions and contaminated materials or equipment, and how to decontaminate work areas after routine operations as well as after accidental spills.An inventory-control system should be in place to account for toxin use and disposition. At Berkeley Lab, original primary containers of toxins must have Berkeley Lab chemical barcodes and be entered into the Berkeley Lab Chemical Management System.
      • Access to work areas should be controlled.
      • Routine operations with dilute toxin solutions should be conducted under BL2 containment with the aid of personal protective equipment, laboratory hoods, biosafety cabinets, or comparable engineering controls.
      • Work with dry toxins should be minimized or eliminated.
    • BMBL Toxin Agent Summary Statements. Section VIII-G of BMBL contains information and guidance on specific toxins. When specific toxins listed in this section of the BMBL are used, this guidance must be reviewed and should be incorporated into the work in accordance with the IBC-approved risk assessment.

• • •  

Select Agents and Toxins

• Select agents and toxins are specific pathogenic agents and toxins regulated by the HHS-CDC and the USDA-APHIS due to their potential threat (e.g., as biological weapons) to human, animal, and plant health. Specific genetic elements, recombinant nucleic acids, and recombinant organisms that may pose a similar threat are also regulated. Appendix B, Section B.2, of this manual provides the list of select agents and toxins and additional toxin information.
• Possession, use, storage, or transfer of select agents and toxins must be conducted in compliance with the HHS-CDC and USDA-APHIS regulations related to human, plant, and animal select agents and toxins. Specific controls for select agents must be detailed in a Biosafety, Security, and Incident Response Plan for Select Agents. In addition, select agent registrations, transfers, and destructions will be reported to the DOE Berkeley Site Office when and as described in Appendix A. Contact the EHS Biosafety Officer for guidance and assistance. Controls for select agents have also been integrated into the overall Biosafety Program.
• See the National Select Agent Registry (NSAR) Program Web site for additional information on select agents provided by HHS-CDC and USDA-APHIS. The NSAR Program oversees possession of select agents and toxins for the HHS-CDC Division of Select Agents and Toxins and the USDA-APHIS Agricultural Select Agent Program.

• Prions

Normal and diseased (misfolded) prions. Source: ScienceBlogs, Basic Concepts: Prions, by Shelley Batts (February 11, 2007).

• A prion is an infectious agent composed of protein. All such agents discovered to date propagate by transmitting a misfolded protein; the protein does not itself self-replicate and the process is dependent on the presence of the polypeptide in the host organism. The misfolded form of the prion protein has been implicated in prion diseases known as transmissible spongiform encephalopathies (TSEs). TSEs are neurodegenerative diseases that affect humans and a variety of domestic and wild animal species. Examples are Creutzfeldt-Jakob disease (CJD) in humans and bovine spongiform encephalopathy (BSE), also known as mad cow disease, in cattle. All known prion diseases affect the structure of the brain or other neural tissue, are currently untreatable, and are always fatal.
• Prion diseases are transmissible by inoculation or ingestion of infected tissue or homogenates. Prion infections usually occur in brain or other central nervous system tissues, and to a lesser extent in lymphoid tissues including spleen, lymph nodes, gut, bone marrow, and blood.
• Section VIII-H of BMBL provides an agent summary statement that includes guidelines for prion diseases. When applicable, this guidance must be used to incorporate controls based on a risk assessment into the Biosafety Work Authorization.

• USDA-Regulated Materials, Organisms, and Agents
  • The USDA-APHIS defends America’s animal and plant resources from agricultural pests and diseases by regulating materials, organisms, or agents that may harm domestic or native animals or plants, or natural resources. These materials, organisms, or agents may cause harm directly (e.g., predator or pathogen) or indirectly (e.g., vector). General examples include specific animals, plants, genetically engineered organisms, animal pathogens, plant pathogens, soil that may contain such pathogens, and agents that pose a severe threat.
  • The transfer, storage, use, and disposal of APHIS-regulated materials at Berkeley Lab must be conducted in accordance with APHIS regulations. Generally, APHIS requires a permit or other document to import, export, or store regulated materials from or to locations outside the continental United States or between U.S. states. APHIS permits are issued to individuals and are not transferrable to others. The APHIS permit and sometimes an accompanying “compliance agreement” dictate specific controls and limitations when working with regulated materials. Individuals responsible for the transfer, storage, use, or disposal of such materials will obtain permits when required, ensure that the materials and permits are covered in the Berkeley Lab Biosafety Work Authorization, and ensure that specific requirements in the permit and compliance agreement are implemented.
  • Materials, organisms, and agents that threaten animal and plant health are regulated by branches of the USDA-APHIS and examples are listed below in Table 4. Additional agency requirements and Web links for more information are detailed in Appendix I, Section I.2.2, of this manual. See Work Process B.3.d.v of this program for more information on select agents and toxins.

•  

Table 4. Materials Regulated by USDA-APHIS

APHIS Branch	Examples of USDA-APHIS-Regulated Materials, Organisms, and Agents
Plant Protection and Quarantine (PPQ)	Plant pests such as soil, plant pathogens, plants, plant products, weeds, insects, mollusks, and nematodes
Veterinary Services (VS)	Material, organisms, vectors, animal pathogens, animal products, cell cultures and their products, live animals, semen, embryos, and veterinary biologics (e.g., vaccines, antibodies, and diagnostic kits) that may harm animal health
Biotechnology Regulatory Services (BRS)	Certain genetically engineered organisms that may pose a plant pest risk, including organisms that are plants, insects, or microbes
Agricultural Select Agent Program	Animal and plant pathogens that are select agents

• Bloodborne Pathogens and Human Materials
  • The Cal/OSHA Bloodborne Pathogens Standard has comprehensive requirements for workers who are or may be exposed to BBPs or designated materials assumed to contain BBPs. Berkeley Lab uses the term “BBP materials” to describe the pathogens and materials covered by the Cal/OSHA standard. These BBP materials are summarized in Table 5 and discussed in the next paragraph. BMBL guidelines for working with human and mammalian cells and tissues are also discussed below.
    

BBP materials, including human blood, human tissue, and human cells. Source: Berkeley Lab.

Table 5. Materials Covered by the Cal/OSHA Bloodborne Pathogens Standard*

Bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) Human blood. Includes blood, blood components, and products made from human blood Other potentially infectious materials (OPIM): Unfixed human tissue or organ (other than intact skin) from a living or dead human Primary human tissue cultures. Explants of living human tissue placed in a medium for tissue culture Primary human cell strains.** Propagated in vitro from primary explants of human tissue or body fluids that have a finite lifetime (i.e., nontransformed) in tissue culture for 20 to 70 passages Established human cell lines.** Immortalized cells that have been transformed by spontaneous mutation or natural or laboratory infection with an immortalizating agent, and then propagated or passed many times (e.g., in vitro or in animals such as mice) Human body fluids. Fluids assumed to be potentially infectious, including semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Some human secretions that do not contain visible blood are not considered OPIM (e.g., urine, feces, vomit, tears, sweat, sputum, nasal secretions, and saliva). Any materials known or reasonably likely to contain or be infected with HIV, HBV, or HCV, including cell, tissue, or organ cultures from humans or experimental animals; blood, organs or other tissues from experimental animals; or culture medium or other solutions.

*Text taken from Cal/OSHA § 5193. Bloodborne Pathogens Standard and the OSHA Standard Interpretation on Applicability of 1910.1030 to Establish Human Cell Lines.

**Most primary human cell strains and established human cell lines at Berkeley Lab (e.g., American Type Culture Collection cell lines) are OPIM as required by the OSHA Standard Interpretation on such cells. If the researcher does not want to consider the cells OPIM, the cells must be “characterized.” Characterization must include documented screening of the cell lines or strains for viruses specified as BBPs in the OSHA standard, including human immunodeficiency viruses, hepatitis viruses, and herpes viruses (e.g., Epstein-Barr virus) if the cells are capable of propagating such viruses. Documentation that the cell line in culture is free of BBPs must be reviewed and approved by the Biosafety Officer and the Institutional Biosafety Committee.

• BBPs are infectious agents capable of causing human disease and are transmitted through human blood and tissues. Examples include HBV HCV, and HIV. According to the Cal/OSHA Bloodborne Pathogens Standard, materials that are regulated based on their potential to contain BBPs include human blood, human blood components, products made from human blood, and OPIM listed in Table 5. Berkeley Lab uses the term “BBP materials” to describe all of these materials covered by the standard. Dried blood and some human secretions (e.g., urine, feces, vomit, tears, sweat, sputum, nasal secretions, and saliva) that do not contain visible blood are not considered OPIM even though they may contain other types of infectious agents or present health concerns.

BBP work activity, blood collection. Source: HHS CDC Office of Health and Safety, Biosafety in the Laboratory presentation (Web accessed May 2010)

BBP work activity, culturing human cells. Source: Berkeley Lab EHS.

• Appendix H of BMBL states that a risk assessment should be conducted for human and primate cells based on the origin and source of cells or tissues, and such cells should be handled using BL2 practices and containment (see Work Process C.4.a for further discussion of BLs). While many requirements in the BMBL and Cal/OSHA Bloodborne Pathogens Standard are similar to one another, the Cal/OSHA standard additionally requires initial and annual BBP training, availability of hepatitis B vaccination at no cost to employees, and a written Exposure Control Plan (ECP). Researchers satisfy documentation requirements for a risk assessment, BL2 containment, and an ECP once they have an approved WPC Activity. BL2 containment must be used unless the Activity risk assessment indicates that alternative controls are sufficient. Activities are further discussed in Work Process D.1.a.iv, WPC Activities.
• Berkeley Lab work that involves BBP materials will be performed in compliance with the Cal/OSHA Bloodborne Pathogens Standard and BMBL. Berkeley Lab’s program for compliance with these standards is integrated into the larger Berkeley Lab Biosafety Program that is described in this manual.

• Recombinant Materials, Organisms, and Agents
  • Recombinant Terms, Processes, and Risks
    • Genetic material plays a fundamental role in determining the structure and nature of cell substances. It exists in the nucleus, mitochondria, and cytoplasm of a cell or organism, and is capable of self-propagation and genetic variation. The genetic material of a cell can be a gene, a part of a gene, a group of genes, a deoxyribonucleic acid (DNA) molecule, a fragment of DNA, a group of DNA molecules, or the entire genome of an organism. A nucleic acid is a macromolecule composed of chains of monomeric nucleotides. In biochemistry, nucleic acids carry genetic information or form structures within cells. The most common nucleic acids are DNAand ribonucleic acid (RNA). Nucleic acids are universal in living things, as they are found in all cells and viruses. The term “genetic recombination” is used to describe the process by which the strand of genetic material (usually DNA, but can also be RNA) is broken and then joined to a different DNA molecule to create recombinant genetic material. The NIH Guidelines defines recombinant and synthetic nucleic acid molecules as molecules constructed outside living cells by joining natural or synthetic nucleic acid segments to nucleic acid molecules that can replicate in a living cell or molecules that result from the replication of such molecules.
    • Vectors are commonly used in genetic engineering to create recombinant materials, organisms, agents, or cells. In molecular biology, a vector is a DNA molecule used as a vehicle to transfer foreign genetic material into another cell. Such a vector usually does not cause disease itself, but may change the properties and risks associated with the host cell. The four major types of vectors are plasmids, bacteriophages and other viruses, cosmids, and artificial chromosomes. Two common vectors are plasmids and viral vectors.
      • • Plasmidvectors are commonly used to multiply or express particular genes. Many plasmids are commercially available for such uses. Plasmids are DNA segments that are separate from chromosomal DNA and are capable of replicating independently of the chromosomal DNA. In many cases, a plasmid is circular and double-stranded. Plasmids usually occur naturally in bacteria, but are sometimes found in eukaryotic organisms. Plasmids are considered transferable genetic elements, capable of autonomous replication within a suitable host. Plasmid host-to-host transfer requires direct, mechanical transfer by “conjugation” or changes in host gene expression, allowing the intentional uptake of the genetic element by “transformation.” Plasmids provide a mechanism for horizontal gene transfer within a population of microbes and typically provide a selective advantage under a given environmental state. For example, plasmids may carry genes that provide resistance to naturally occurring antibiotics in a competitive environmental niche, or alternatively the proteins produced may act as toxins under similar circumstances. If these plasmids are inserted into a different host bacterium, the new host may acquire antibiotic resistance or produce toxic protein.

• • • • • Viral vectors are a viral tool commonly used to deliver genetic material into cells. This process can be performed inside a living organism (in vivo) or in cell culture (in vitro). Viruses have evolved specialized molecular mechanisms to efficiently transport their genomes inside the cells they infect. Delivery of genes by a virus is termed transduction, and the infected cells are described as transduced. Although viral vectors are occasionally created from pathogenic viruses, they are modified in such a way as to minimize the risk of handling them. This usually involves the deletion of a part of the viral genome critical for viral replication. Such a virus can efficiently infect cells, but once the infection has taken place, it requires a helper virus to produce new virions. Examples of recombinant viral vectors include:

• • • • • • Retroviral vectors from retroviruses such as the Moloney murine leukemia virus
          • Lentiviral vectors from lentiviruses (a subclass of retroviruses) such as HIV
          • Adenoviral vectors from adenoviruses
          • The adeno-associated virus (AAV)

• Transgenic organisms may also be used or created in genetic engineering. A transgenic organism is an organism whose genome has been altered by the transfer of a gene or genes from another species or breed. Examples of transgenic organisms include vertebrates such as mice, plants, and microbes.
• Recombinant Risks. Work with or the creation of recombinant organisms or specific recombinant genomic materials and nucleic acids may create new risks to humans, animals, plants, or the environment. These potential recombinant risks must be identified and evaluated during the risk-assessment process. Examples of genetic modifications that may increase risk Untitled event include modifications that increase an agent’s pathogenicity or susceptibility to effective treatments (e.g., antibiotics), or increase an organism’s ability to compete in the natural environment.

• Recombinant Requirements 

• • NIH Requirements.Requirements and specific practices for constructing and handling recombinant DNA molecules, and organisms and viruses containing recombinant DNA molecules, are specified in the NIH Guidelines. The NIH Guidelines have broad requirements for biosafety risk assessment and control similar to BMBL requirements. In addition, the NIH Guidelines have special institutional and line-management requirements such as an Institutional Biosafety Committee (IBC) review process and responsibilities specifically defined for principal investigators (PIs). Institutions such as Berkeley Lab that receive NIH funding are required to comply with the NIH Guidelines. As a condition for NIH funding, Berkeley Lab and lead investigators (e.g., PIs) must ensure that all nonexempt recombinant DNA research experiments conducted at or sponsored by the Berkeley Lab, regardless of the source of funding, comply with the NIH Guidelines. The work review and authorization processes and documents detailed in Work Process D.1.a.i, General Review and Authorization Process,  are key tools that assist researchers to comply with the NIH Guidelines.
  • APHIS Requirements. APHIS permits may also be required for the importation, interstate movement, or environmental release of certain genetically engineered organisms that may be plant pests (see Appendix I of this manual).
  • Recombinant research requires a risk assessment, establishment of containment levels and controls, and a Biosafety Work Authorization (for more information, see Work Processes A through E of this manual).

• • Animals

• Working with animals in research, caring for animals in animal care facilities, or coming in contact with animals or vectors in the field may cause zoonotic or other diseases. A zoonosis or zoonose is an infectious disease that can be transmitted (in some instances, by a vector) from nonhuman animals, both wild and domestic, to humans, or from humans to nonhuman animals (the latter is sometimes called reverse zoonosis). Human diseases caused by a noninfectious, etiological agent derived from animals or their vectors are not considered a zoonosis (e.g., allergic reactions to animal products such as dander or urine). Work involving animals may expose workers to etiologic agents in a variety of ways such as wound infections, inhalation of aerosols (e.g., dust from animal bedding), and animal bites or scratches. See Table 6 for examples of zoonotic diseases and other diseases related to animals.

Mice, bedding, and allergies. Source: Berkeley Lab EHS.	Aquarium fish and skin infections or gastroenteritis. Source: Wikipedia unrestricted distribution.	Dirt or compost containing feces and tetanus.	Ticks and Lyme disease. Source: Calif. Dept. of Public Health Web site, 2012.

• Worker safety, agricultural, and recombinant risks related to working with animals must be evaluated during the risk assessment, and proper containment measures must be employed. See the following sections and standards for additional information:
  • Work Processes B.3.e and B.3.g discuss agricultural and recombinant risks, respectively.
  • Work Process C.4.a provides an overview of laboratory and animal biosafety level containment categories and criteria.
  • Section VIII of BMBL provides agent summary statements for zoonotic agents. It also recommends containment levels for laboratory use of a zoonotic agent and containment levels for handling animals infected with an agent.

Table 6.Examples of Zoonotic and Other Diseases Related to Animals

Disease	Reservoir Vectors	Causative Agent	Exposure Routes
			Inhalation	Ingestion	Skin Contact
Allergies	Vertebrate animals	Animal allergens	Dander, urine, or saliva in dust or bedding	—	—
Anthrax	Animals	Bacillus anthracis	Contaminated dust with spores	Contaminated with spores	Contaminated materials with spores
Hantavirus pulmonary syndrome	Rodents/deer mice	Sin nombre virus	Contaminated dust from dried urine, saliva, droppings	—	—
Herpes B virus infection	Nonhuman primates, particularly endemic in rhesus and cynomolgus members of the Macaque genus	Herpesvirus simiae or B virus	Aerosolized macaque saliva	Mucosal splashes (e.g., monkey fluids contact the worker’s eyes or mouth)	Monkey bites, monkey scratches, or cage scratches; direct contamination of a preexisting wound with macaque saliva; needle-stick injuries following needle use in macaques
Lyme disease	Rodents/deer	Borrelia burgdorferi	—	—	Ixodid tick bite
Plague	Rodents/fleas	Yersinia pestis	—	—	Flea (Xenopsylla cheopis, Pulex irritans) bite
Q fever	Sheep, goats, cattle	Coxiella buretii	Barnyard dust contaminated by birth material and excreta	Milk ingestion, regurgitation, and perspiration	—
Rabies	Rabid animals	Rabies virus	—	—	Bites and saliva from an infected animal
Rocky Mountain spotted fever	Ticks	Rickettsia rickettsii	—	—	Tick bites or skin contact with contaminated materials
Tetanus	Animals	Clostridium tetani	—	—	Wounds contaminated with dirt or objects containing animal or human feces or saliva
Various diseases such as skin infections or gastro-enteritis	Fish aquarium water	Mycobacteriummarinum, M. fortuitum, Aeromonas hydrophila, other bacteria, and Cryptosporidium spp. protozoa	—	—	Skin contact with aquarium water, especially if skin has cuts or abrasions

• Aerosol Transmissible Pathogens (Non-Laboratory work)

• LBNL Health Services employees may have an occupational exposure to airborne infectious diseases (AirID) and refer AirID cases and suspected cases to other facilities. LBNL is considered a “referring employer” within the scope and application of the ATD Standard provided that Health Services:
  • Does not intend to provide medical services to airborne infectious disease (AirID) cases beyond first aid, initial treatment, or screening and referral.
  • Does not provide transport, housing, or airborne infection isolation to any person identified as an AirID case or suspected case, unless the transport provided is only nonmedical transport in the course of a referral.

• The following elements required by the Standard are included in Health Services GroupInfection Prevention and Control and Safety Plan and Infection Control and Screening for Aerosol Transmissible Disease (ATD): Policy and Procedure. Both documents are maintained by Health Services
  • Identification of an administrator responsible for the infection control procedures which include job categories in which employees have occupational exposure to ATDs and procedures for cleaning and disinfection of work areas, vehicles, and equipment that may become contaminated with ATPs and pose an infection risk to employees.
  • Source control procedures
  • Written procedures for the screening and referral of cases and suspected cases of AirIDs to appropriate facilities
  • Written procedures to communicate with employees, other employers, and the local health officer regarding the suspected or diagnosed infectious disease status of referred patients. These shall include procedures to receive information from the facility to which patients were referred and to provide necessary infection control information to employees who were exposed to the referred person.
  • Written procedures to reduce the risk of transmission of aerosol transmissible disease, to the extent feasible, during the period the person requiring referral is in the facility or is in contact with employees.
  • Training is provided by the clinic manager to all Health Services employees with occupational exposure to ATPs. Training shall be provided at the time of initial assignment to tasks where occupational exposure may take place and at least annually. Additional training shall be provided when there are changes in the workplace or when there are changes in procedures that could affect worker exposure to ATPs.

• Aerosol Transmissible Pathogens – Laboratory (ATP-L)

Berkeley Lab work that involves ATP-L materials will be performed in compliance with the Cal/OSHA Aerosol Transmissible Diseases Standard. Berkeley Lab’s program for compliance with this standard is integrated into the larger Berkeley Lab Biosafety Program that is described in this manual.

• All incoming materials containing ATPs-L are treated as containing the virulent or wild-type pathogens until there is laboratory verification that the pathogen has been deactivated or attenuated.
• BMBL guideline for risk assessment and controls shall also be followed. A risk assessment should be conducted in accordance with this work process for each agent and procedure involving the handling of ATPs-L. Safe practices for each evaluated agent/procedure shall be recorded in the WPC Activity. The ATP standard additionally requires initial and annual ATD training, availability of all vaccinations as recommended by applicable public health guidelines for the specific laboratory operations, and a written Biosafety Plan (BCP). Researchers satisfy documentation requirements for a risk assessment, appropriate control measures, and a BCP once they have an approved WPC Activity. BL2 containment should be used unless the Activity risk assessment indicates that alternative controls are sufficient. Activities are further discussed in Work Process D.1.a.ii, WPC Activities.
• An inspection of laboratory facilities, including an audit of biosafety procedures, shall be conducted at least annually.

• Laboratory Procedure Hazards

• • The BMBL five-step approach to assessing biological risk and selecting controls for laboratory work was initially presented in Work Process B.2.c of this program. Step 2 (identifying laboratory procedure hazards) of this approach is discussed in this section.
  • Historical data on laboratory acquired infections (LAIs) are an indicator of laboratory procedure hazards that have resulted in disease. As discussed in the BMBL, historical data show that past LAIs have occurred from:

• • • Parenteral inoculation by a contaminated sharp or syringe needle
    • Spills or splashes of contaminated materials directly onto the skin and mucous membranes
    • Ingestion through mouth pipetting
    • Animal bites and scratches
    • Inhalation of infectious aerosol

• See Section II of BMBL for more information regarding LAIs. Prevention of LAIs depends on the conscientious and proficient use of standard microbiological practices and special practices (see Work Process C.1) and the correct use of laboratory equipment. Table 7 below lists examples of hazards that may be found in laboratories using biological materials.

Table 7. Equipment Hazard Examples

Equipment Type	Hazards	Examples
Aerosol generating	The diameter of aerosols generated from certain types of equipment will vary from 0.1 to 100 microns. Bacterial cells and spores are 0.3 to 10 microns in diameter. Viruses are 0.02 to 0.3 micron in diameter. Biological particles generated from liquid or powder form particles that are 0.5 micron diameter.	Blender: 2-micron-diameter particles Sonicator: 4.8-micron-diameter particles Dropping bacterial flask: 3.5-micron-diameter particles Dropping lyophilized culture: 10-micron-diameter particles Pipette blow out: 4.9-micron-diameter particles Vortex culture: 4.8-micron-diameter particles Centrifuge: 4-micron-diameter particles
Cryogenic temperatures	Cryogenic temperatures of -80°C are used to remove moisture from materials and contain low-temperature refrigerants. If protective equipment is not used, exposure to low temperature may cause cryogenic burns and frostbite.	Freezers Lyophilizers (freeze dryers) Use of dry ice in shipping and receiving
High temperatures	The use of heat to decontaminate or sterilize materials is widely used in the biological research laboratory. Physical injury from burns may occur from sudden accidental releases of heat sources or from the handling of hot items.	Dry heat temperatures used for sterilization range from 80°C to 200°C. Wet heat is utilized by autoclaves to sterilize materials and can range between 80°C and 500°C. Saturated steam operates at 121°C.
High pressure	Compressed gas cylinders and pressurized equipment are commonly used in the laboratory. Injury may occur from ruptured high-pressure lines.	Autoclaves operate at high pressures of 1,000 kilo Pascal (145 psig).
Oxygen deficiencies	Low-temperature freezers may include a backup system involving the use of a cryogenic liquid. Backup systems may consist of 50–200 liters of liquid nitrogen or liquid carbon dioxide under pressure. Liquid helium is also used in nuclear magnetic resonance (NMR) laboratories.	Oxygen deficiency environment may result from: The displacement of oxygen by expanding gases (i.e., 700 parts of air to 1 part liquid nitrogen) The linear displacement of oxygen from carbon dioxide (gas) generated from the use of dry ice Compressed gas cylinders or tanks
Rotational energies	Sudden release of such rotational energies can cause serious physical injury from unbalanced equipment or flying shrapnel.	Tabletop and floor-mounted low, high, and ultracentrifuges rotate at speeds ranging from less than 5,000 to more than 100,000 rpm with rotor masses up to several kilograms.
Sharps	Any device having corners, edges, or projections capable of cutting or piercing the skin. Berkeley Lab’s definition of sharps includes regulated sharps (medical waste), unregulated biohazardous sharps, and unregulated uncontaminated sharps that pose a safety hazard to custodians and other personnel.	Needles with or without syringes Needles with vacutainers Needles with attached tubing Blades (razors, scalpels, X-Acto knives) Broken glass Glassware with sharp edges or points Pasteur pipettes and glass slides
Ultraviolet (UV)C radiation	UVC radiation is used for inactivating microorganisms. Its usefulness, however, is limited by a variety of factors (e.g., low penetrating power). The eyes and skin can be damaged by exposure to direct or strongly reflected UV radiation.	UV lights must be evaluated to determine whether the benefits outweigh the potential hazards. UV radiation is sometimes used in conjunction with: Unoccupied tissue culture rooms Biological safety cabinets UV light boxes

• Worker Competence and Health

• • General. The BMBL five-step approach to assessing biological risk and selecting controls for laboratory work was initially presented in Work Process B.2.c of this program. Step 4 of this approach (i.e., the evaluation of a worker’s proficiencies or competence) and the evaluation of a worker’s health are discussed in this section. Step 4 is an ongoing process in which the supervisor or work lead evaluates a worker’s training, instructions, qualifications, behavior, and health. Worker training and health requirements are also a component of the Biosafety Work Authorization.
  • Workers are the first line of defense for protecting themselves, others in the laboratory, and the public from exposure to biohazardous agents. Laboratory staff must therefore be properly trained, instructed, and qualified before conducting work. Supervisors and work leads should train and evaluate staff to the point where knowledge of the agent and procedure hazards, aseptic techniques, safety practices, use of safety equipment, caution, and attentiveness become second nature. Knowledge and experience prior to job assignment may also be necessary qualifications. See Work Process D.2, Training, Instruction, and Qualification, for more information on training, instruction, and qualification.
  • In addition, a worker’s health status may affect his or her susceptibility to an infection or ability to receive immunizations or prophylactic intervention. Workers who know they have an illness or medical condition that affects their immune system or their ability to receive vaccines or medications should seek an evaluation by Health Services in Building 26. See Work Process D.3, Occupational Health and Immunization, for additional information regarding worker health and immunization.

____________________

Work Process C. Biosafety Principles and Levels

To determine which controls are required to mitigate hazards and perform work safely, supervisors and work leads must understand and apply the processes and requirements for defining work, identifying hazards, and assessing risks, as discussed in Work Process B. Controls are safeguards employed to contain biological agents or materials and therefore prevent the exposure of workers, other people, or the environment to agents that may harm them.

In biosafety, the term “containment” describes the set of controls, including safe methods, equipment, and facilities needed to protect workers and the environment from biohazardous materials or agents. Controls used for containment in laboratories are described in Biosafety in Microbiological and Biomedical Laboratories (BMBL), Section III, as the Principles of Biosafety. These containment controls are listed below and summarized in the next sections:

• Laboratory practices and techniques
• Safety and personal protective equipment
• Facility design and construction

The Berkeley Lab Biosafety Work Authorization is used to define work, identify hazards, assess risks, and implement any of the containment controls listed above. See Work Process A and Work Process D.2 for additional information on work authorization documents.

• Laboratory Practices

The first and most important element of control for laboratory containment and research product protection is strict adherence to laboratory biosafety containment practices and good microbiological practice (GMP). Biosafety containment practices include standard microbiological practices and special practices specified by the CDC and NIH. GMP is based on widely accepted aseptic practices.

• Standard microbiological practices and special practices are administrative controls listed as BL containment criteria in BMBL and the NIH Guidelines to protect workers and the environment. (See Work Process C.4.a of this manual for additional information on BL containment categories and criteria.) These practices, along with requirements from other biosafety standards, are used for the safe performance of work documented in the Berkeley Lab Biosafety Work Authorization. Standard microbiological practices or special practices for laboratories apply to most Berkeley Lab work with biological materials. Standard practices for BL1 and BL2 laboratories address the following topics (see Appendix C and Work Process D for more information):

• • • Access control
    • Hand hygiene
    • Food and eating
    • Pipetting
    • Sharps control
    • Spill, splash, and aerosol control
    • Decontamination of work surfaces, equipment, materials, and spills
    • Signage and hazard communication
    • Pest management
    • Worker training and proficiency
    • Occupational health, immunization, and personal health
    • Incident reporting, evaluation, and worker treatment
    • Biosafety manuals or documents

• • Good microbiological practice (GMP) is also typically needed for containment and good research. GMP is based on aseptic techniques and other good microbiological practices necessary to prevent contamination of the laboratory with the agents being handled and contamination of the work with agents from the environment. See Appendix D for common GMP. Supervisors and work leads are responsible for selecting and instructing workers on the specific GMP needed to conduct the work, or additional safety practices needed for specific agents or procedures.

• Safety and Personal Protective Equipment

Worker exposure to infectious agents may be prevented by the use of standard and activity-specific safety and personal protective equipment (PPE) as primary barriers or controls. The need for additional activity-specific safety equipment or PPE must be determined during risk assessment, and any equipment needed for safety should be included in the Biosafety Work Authorization.

Standard safety equipment and PPE are equipment controls listed as biosafety level (BL) containment criteria in BMBL and the NIH Guidelines. They provide primary barriers that prevent worker exposure to infectious agents. See Work Process C.4.a for additional information on BL containment categories and criteria. These standard equipment requirements, along with requirements from other biosafety standards, are used and customized for the work to be conducted. They are also summarized in the Berkeley Lab Biosafety Work Authorization. Standard safety equipment and PPE are applicable to most work with biological materials at Berkeley Lab. The following types of standard equipment and PPE are further discussed in Appendix C and Work Process D:

• Biosafety cabinets
• Other physical containment devices such as centrifuge safety cups
• PPE
  

• Facility Design and Construction

Facility design and equipment provide secondary barriers that protect laboratory workers, persons outside the laboratory, the public, and the environment from potentially hazardous materials or agents that may be accidentally released from the laboratory.

Standard facilities provide secondary barriers.

Source: HHS CDC Office of Health and Safety.

Berkeley Lab designs, constructs, approves, and operates its buildings and laboratories in accordance with nationally recognized codes regulations, standards, acts, and manuals as detailed in the Facilities Division Construction Details and Design Guidelines and ES&H Manual’s Fire Prevention and Protection program. In addition, EHS personnel are assigned to conduct design reviews for new projects as described in the Capital Projects Procedures Manual (PUB-3193). Specifically assigned EHS personnel are responsible for reviewing facility design and installation for concerns and requirements related to biosafety. Line management must ensure that facilities are appropriate for the laboratory activities and meet the required BL for the agents or materials being handled.

In addition, Berkeley Lab designs and operates its facilities in which work with biological materials is conducted in accordance with applicable standard facilities criteria. “Standard facilities” are design features, materials, and equipment incorporated into the laboratory or facility in accordance with BL containment criteria stated in BMBL and the NIH Guidelines (see Work Process C.4, Biosafety Containment Levels and Criteria, for more information).

Standard BL1 and BL2 laboratory facility barriers are sufficient to control most work at Berkeley Lab. This is because risks related to most work are associated with direct contact with materials or agents in standard laboratories. Examples of standard facility barriers and equipment are listed below. See Appendix C for standard laboratory facilities criteria that summarize how these barriers must be employed. See Work Process D for additional information on each of these topics.

• Doors
• Sinks
• Cleanable surfaces and furnishings
• Window screens
• Ventilation and biosafety cabinets
• Vacuum line filters and traps
• Eyewashes
• Autoclaves

If the risk assessment indicates a risk of exposure to an infectious aerosol, then higher levels of safety equipment and PPE (primary barriers) or multiple secondary facilities barriers are necessary. Multiple secondary facilities barriers are not typically needed at Berkeley Lab.

Some standard facilities are summarized in the Biosafety Work Authorization. Any additional special facility barriers that are required should also be included in the authorization.

• Biosafety Containment Levels and Criteria

Berkeley Lab requires researchers who work with biological materials to implement containment controls in accordance with an established BL. BL is a standard combination of practices and techniques, safety equipment, and facilities to safely contain biohazardous materials or agents to be used in the work, as specified by BMBL or the NIH Guidelines.

Work at Berkeley Lab requires routine application of BLs developed for biological laboratories, and occasional application of BLs developed for other types of work such as large-scale recombinant operations. BLs for laboratories are presented in the next section. BLs for large-scale, plant, and animal uses are presented in Work Process C.4.b, Additional Containment Categories, of this program.

The appropriate BL must be selected once the risk assessment has been completed. The final BL determination should consider all aspects of the work, hazards, and controls. The PI or supervisor should propose the appropriate BL(s) when submitting the authorization for review. The final BL(s) are determined by the Institutional Biosafety Committee (IBC).

• Laboratory Containment Levels. Containment controls for laboratory biosafety are categorized into four BLs. Definitions of each laboratory BL are provided in Table 8. Work at Berkeley Lab is commonly conducted at BL1 or BL2; work at BL3 or BL4 is not currently conducted. Laboratory work at Berkeley Lab must be conducted in accordance with the standard and special work practices, safety equipment, and facility requirements noted in the laboratory BL1 and BL2 criteria listed in Appendix C.

Table 8. Laboratory Biosafety Containment Levels

Present at Berkeley Lab	Biosafety Level (BL)	Biosafety Level Definition
Yes	1	BL1 is suitable for work involving agents of unknown or minimal potential hazard to laboratory personnel and the environment,1 or work with defined and characterized strains of viable microorganisms not known to consistently cause disease in healthy adult humans.2
	2	BL2 is suitable for laboratory work involving agents of moderate potential hazard to personnel and the environment.1 Primary hazards to personnel working with these agents relate to accidental percutaneous or mucous membrane exposures, or ingestion of infectious materials.2
No	3	BL3 is applicable to facilities in which work is conducted with indigenous or exotic agents that may cause serious or potentially lethal disease as a result of exposure by the inhalation route.3
	4	BL4is required for work with dangerous and exotic agents that pose a high individual risk of life-threatening disease, aerosol transmission, or related agents having an unknown transmission risk.3

Footnotes:

1. NIH Guidelines
2. BMBL, fifth edition, Section III
3. BMBL, fifth edition, Section IV

When developing the Biological WPC Work Activity, the appropriate laboratory BL must be determined after conducting the risk assessment. Typical BLs used for various materials and agents are listed in Work Process C.4.a.i, Laboratory Biosafety Level 1, and Work Process C.4.a.ii, Laboratory Biosafety Level 2. The final BL(s) are determined by the IBC.

• Laboratory Biosafety Level 1

BL1 laboratories are not necessarily separated from the general traffic patterns in the building. Work is typically conducted on open benchtops using standard microbiological practices. Special containment equipment or facility design is not required, but may be used as determined by a risk assessment. Laboratory personnel must have specific training in the procedures conducted in the laboratory and must be supervised by a scientist trained in microbiology or a related science.

Laboratory BL1 work with open benchtops and standard microbiological practices.Source: Berkeley Lab EHS.

The BL will be determined as part of the risk assessment. BL1 containment is typically required for laboratory work involving:

• Biological agents that meet the definition of Risk Group (RG) 1 (i.e., agents not associated with disease in healthy adult humans)
• Biological materials not suspected of containing RG2 or higher agents in a quantity or form that may cause human disease (e.g., nonprimate animal cells)
• Biological agents or materials not considered by the supplier or LBNL as RG2 or higher
• Transgenic or wild-type laboratory animals that have size or growth requirements allowing the use of containment for laboratory animals (e.g., rodents) and are both:
  • Free of zoonotic diseases
  • Not infected with, implanted with, or containing RG2 or higher agents or materials

• Laboratory growth of nongreenhouse transgenic plants (see Work Process C.4.b.ii, Recombinant Plant Containment Levels )
• Biological agents, materials, or animals not typically categorized as RG2 or BL2 (or higher) as detailed Work Process C.4.b, Additional Containment Categories.

• Laboratory Biosafety Level 2

BL2 laboratories follow BL1 requirements and additional BL2 requirements such as:

• Laboratory personnel have specific training in handling any pathogenic agents and are supervised by scientists competent in handling infectious agents and associated procedures.
• Access to the laboratory is restricted when work is being conducted.
• All procedures in which infectious aerosols or splashes may be created are conducted in biological safety cabinets (BSCs)or other physical containment equipment.

BL2 work inside a BSC. Source: Berkeley Lab EHS.

The BL will be determined as part of the risk assessment. The risk-assessment process must take into account the agent hazards (Work Process B.3) and lab procedure hazards (Work Process B.4). Laboratory BL2 containment is typically required for laboratory work involving:

• Biological agents categorized as RG2 in the NIH Guidelines or by LBNL standard (e.g., opportunistic pathogens). Exception: BL1 containment for handling opportunistic pathogens may be approved by IBC if demonstrated as appropriate, using research studies and risk analysis.
• Uses of biological agents described as BL2 in BMBL agent summary statements or other BMBL
• Biological materials that may contain RG2 agents (e.g., sewage)
• Bloodborne pathogen (BBP) materials (e.g., human blood, human tissues, or human cells)
• Aerosol or splash-generating procedures with uncharacterized environmental isolates and environmental samples. (Containment requirement may be lowered after characterization of these microorganisms.)
• Nonhuman primate tissues or cells
• Viral vectors that are replication defective but still infectious to human cells
• Laboratory animals (e.g., rodents) infected with, implanted with, or containing RG2 agents or materials (e.g., infected with a human pathogen or containing a xenotransplant of human cells)
• Tissues or cells potentially containing an RG2 agent (e.g., cells transformed with a RG2 virus)

• Additional Containment Categories

Additional types of containment specified in the NIH Guidelines or BMBL may also be applicable to work with biological materials at Berkeley Lab. Table 9 below lists these additional containment categories and relevant NIH Guidelines or BMBL section. When selecting a containment level for a type of work listed in Table 9, the supervisor, work lead, and IBC should carefully review this tableto determine if the containment category and criteria apply to the planned Berkeley Lab work.

Laboratory- or operation-specific authorizations, biosafety manuals, or other documents may be used to document the containment requirements related to the work. If the containment categories or criteria presented in Table 9 are not applicable to the work, the laboratory BLs presented in Work Process C.4.a are applied.

• Recombinant Large-Scale Containment Levels 

Physical containment guidelines from Appendix K of the NIH Guidelines must be used for large-scale research or production activities involving viable organisms containing recombinant DNA molecules. “Large scale (BL–Large Scale)” is a term used in the NIH Guidelines and the Berkeley Lab biosafety policy to describe uses of and containment levels for organisms containing recombinant DNA molecules involving a quantity of culture greater than 10 liters. Note that this quantity category typically means the quantity of a material in a single batch of liquid culture; however, this batch quantity is not defined by NIH and should be used as a guideline to determine the applicability of large-scale containment criteria. Criteria for large-scale containment address the biological hazard associated with organisms containing recombinant DNA only. Large-scale containment criteria must be selected based on the findings of the risk assessment, and then documented in the Biosafety Work Authorization.

Large-scale processes and containment. Left: Photobioreactor process. Source: Berkeley Lab EHS.

Right: Fermentation process to produce biofuel. Source: Berkeley Lab Public Affairs.

• Recombinant Plant Containment Levels

Biosafety containment levels and criteria for recombinant research with plants must be selected based on the findings of the risk assessment, and then documented in the Biosafety Work Authorization. Laboratory or plant biosafety containment levels must be applied to the work as follows:

Arabidopsis sp. Source: Berkeley Lab EHS.

• Laboratory BLs and criteria discussed in Work Process C.4.a and Appendix G of the NIH Guidelines should be used when the research plants are of a size, number, or have growth requirements that allow good containment when using laboratory BLs.
• Plant BLs (BL-P) must be used when the research plants are of a size, number, or have growth requirements that preclude the use of laboratory BLs. For plant BLs and criteria, see Appendix P (Physical and Biological Containment for Recombinant or Synthetic Nucleic Acid Molecule Research Involving Plants) of the NIH Guidelines.
  

Table 9. Additional Containment Categories

Containment Category	Standard and Section	Focused Scope of Containment Criteria
Large-scale uses of organisms containing recombinant DNA molecules	NIH Guidelines, Appendix K	Physical containment guidelines for large-scale (greater than 10 liters of culture) research or production activities involving viable organisms containing recombinant DNA molecules
Recombinant DNA research involving plants	NIH Guidelines, Appendix P	Physical and biological containment conditions and practices suitable to greenhouse operations that conduct experiments involving plants, plant-associated microorganisms, and small animals (e.g., arthropods or nematodes)
Recombinant DNA research involving animals	NIH Guidelines, Appendix Q	Containment and confinement practices for research involving whole animals when the animals are of a size or have growth requirements that preclude the use of containment for laboratory animals (i.e., including but not limited to nonhuman primates, cattle, swine, sheep, goats, horses, and poultry) and: The animals’ genomes have been altered by the introduction of recombinant DNA or DNA derived therefrom into the germ line (transgenic animals), or Experiments involving viable recombinant DNA-modified microorganisms have been tested on whole animals.
Vertebrate animal BL criteria for indoor research facilities (e.g., vivaria)	BMBL, Section V	Use of experimentally infected animals housed in indoor research facilities (e.g., vivaria), and the maintenance of laboratory animals that may naturally harbor zoonotic infectious agents
Arthropod containment guidelines	BMBL, Appendix E	Risk assessment and containment for arthropods of public-health importance, including those that transmit pathogens. Arthropods that only bite, sting, or cause myiasis and infestation are not included. Myiasis is an infestation of tissue by fly larvae, or a disease resulting from such infestation.

The plant BLs listed in Appendix P of the NIH Guidelines specify physical and biological containment conditions and practices suitable for conducting greenhouse experiments involving recombinant DNA-containing plants, plant-associated microorganisms, and small animals. Acronyms for plant BLs are BL1-P through BL4-P. The following bullets further clarify terms and applicability of the plant biosafety levels:

Plant containment (BL1-P) in a greenhouse facility. Source: Berkeley Lab EHS.

• The term greenhouse refers to a structure with walls, a roof, and a floor designed and used principally for growing plants in a controlled and protected environment. The walls and roof are usually constructed of transparent or translucent material to allow the passage of sunlight for plant growth. The term greenhouse facility includes the actual greenhouse rooms or compartments for growing plants, including all immediately contiguous hallways and head-house areas, and is considered part of the confinement area.
• The plants covered in Appendix P of theNIH Guidelinesinclude but are not limited to mosses, liverworts, macroscopic algae, and vascular plants including terrestrial crops, forest, and ornamental species.
• Plant-associated microorganisms include viroids, virusoids, viruses, bacteria, fungi, protozoans, certain small algae, and microorganisms that have a benign or beneficial association with plants, such as certain Rhizobium species and microorganisms known to cause plant diseases. Microorganisms being modified to foster an association with plants are also included.
• Plant-associated small animals include those arthropods that have an obligate association with plants, are plant pests or plant pollinators, or that transmit plant disease agents. They also include other small animals such as nematodes that require the use of plants to test their biological properties. Microorganisms associated with such small animals (e.g., pathogens or symbionts) are also included.

A Practical Guide to Containmentdeveloped by Virginia Polytechnic and State University is a good example of how to apply plant BLs in research with greenhouse transgenic plants and microbes.

Vertebrate Animal Containment Levels

• Biosafety containment levels and criteria for the use or care of vertebrate animals must be selected or developed following the risk assessment and covered in the Biosafety Work Authorization. Laboratory or animal biosafety containment levels must be applied to the work as follows:

• Laboratory biosafety level criteria should be used for laboratory animals such as rodents whose size or growth requirements allow the use of laboratory containment levels specified by the NIH Guidelines. Laboratory BLs and criteria are discussed in Work Process C.4.a.
• Animal biosafety levels must be applied when (1) recombinant research involves larger animals (e.g., nonhuman primates), (2) animals are infected with human pathogens, or (3) animals may harbor zoonotic agents (see Table 9 for more information). Acronyms for animal biosafety levels are BL1-N through BL4-N. In some cases, animal use, animal care, and hazards at Berkeley Lab may not be directly applicable to these established animal biosafety levels and criteria. In these cases, specific criteria that may be applicable may be selected, customized, and incorporated into the Biosafety Work Authorization.
  

Small-animal containment at BL1 (left) and BL2 with a

BSC (right).Source: Berkeley Lab EHS.

Agent summary statements for zoonotic agents in Section VIII of BMBL also recommend containment levels for laboratory use of zoonotic agents, and for handling animals infected with the agent.

• Arthropod Containment Levels 

Biosafety containment levels and criteria for the use of arthropods must be selected or developed after the risk assessment. Laboratory or arthropod biosafety containment levels must be applied to the work as follows:

• Laboratory biosafety level criteria should be used for arthropods that do not present risks to humans, plants, or animals (e.g., most research uses of Drosophila spp.).
• Arthropod containment guidelines discussed in Appendix E of BMBL must be used for arthropods of public health importance, including those that transmit pathogens. Arthropods that only bite, sting, or cause myiasis and infestation are not included. Most uses of Drosophila spp. are also excluded from these arthropod containment guidelines. The Appendix E of BMBL references the Arthropod Containment Guidelines published by the American Society of Tropical Medicine and Hygiene.

____________________

Work Process D. Specific Biosafety Controls

This section further describes biosafety controls, including safe methods, equipment, and facilities that were generally introduced in Work Process C, Biosafety Principles and Levels.

1. Work Authorizations

Berkeley Lab Work Planning and Control (WPC) and Subcontractor Job Hazards Analysis (sJHA) document the definition of work, identification of hazards, risk assessments, and controls. Biological work Activities include:

• Exposure Control Plans (ECPs)
• Biosafety Plan (BSP)

PIs, work leads, workers, division safety coordinators, and EHS Division Biosafety Program personnel have access to their Work Activities through the Work Planning and Control system so that controls may be implemented and authorizations updated. Documentation, review, and authorization of new work should be initiated by creating an Activity in WPC. See Work Process A, Starting and Conducting Work Safely, for additional information on these work authorizations.

These work authorizations consolidate and document a wide variety of biosafety requirements and controls to meet various biosafety standards. For example, the BUA is also regarded as:

• The registration document that must be submitted to the Berkeley Lab Institutional Biosafety Committee (IBC) as required by the NIH Guidelines for recombinant work (BURs also document such recombinant work)
• The Laboratory-specific biosafety manual required by Biosafety in Microbiological and Biomedical Laboratories (BMBL) when Biosafety Level (BL) 2 work is performed with Risk Group (RG) 2 agents or materials
• The ECP required by the Cal/OSHA Bloodborne Pathogens (BBP) Standard when BBP agents or materials are used.

• Institutional Biosafety Committee Review and Research Biosafety Authorization

Work leads and principal investigators (PIs) must define their research projects or operations with biological materials, evaluate the biological hazards, implement biosafety containment controls, and ensure their work is documented and authorized as WPC Work Activities. These authorizations are maintained in and accessible through the Berkeley Lab WPC Activity Manager. See Table 10 for a summary of Institutional Biosafety Committee (IBC) review, documentation, and authorization requirements for research work with biological materials. The sections below provide additional explanation.

• General Review and Authorization Process

The work lead and PI must ensure that research with biological materials and any regulatory permits are documented, reviewed by the IBC, and authorized under a Biosafety Work Authorization when and as required. Submission of a WPC Activity form by the work lead or PI and approval by the IBC and line management results in a Biosafety Work Authorization (e.g., BUN, BUR, or BUA), as detailed in Table 10. EHS Division Biosafety Program personnel assist the work lead or PI in screening the work documentation, determining the applicable requirements and documentation, and coordinating the IBC review process.

Additionally, the work lead and PI must keep the work authorization documentation updated. This includes:

• Making routine changes in personnel, worker-specific training requirements, and locations in the online WPC Activity Manager system. These changes may be made by the PI or work lead, are typically considered minor changes, and generally do not require IBC review at the time of the change.
• Updating and submitting the entire work authorization document for review to the Berkeley Lab Biosafety Program in accordance with the renewal cycles shown in Table 10 or when there are significant changes in the work. Examples of significant or major changes include the addition of recombinant DNA work or pathogens, new types of biohazardous materials, major changes in location (e.g., operation relocation), or changes in responsible personnel. If the changes in work are not significant and the IBC reviewed the document less than three years prior, the Biosafety Program may approve and distribute the updated document without IBC review. These authorizations do not expire, but their target renewal dates and reauthorizations are tracked by the Biosafety Officer and IBC. Authorizations that are not updated and reauthorized within established time goals may be inactivated by the Biosafety Officer or IBC.

If a research project does not have funding that designates a PI, a project work lead will authorize or approve the authorization document. In addition, if the PI is not managing the work activities or safety, the PI may designate a project work lead to authorize or approve the work.

• Work Planning and Control (WPC) Activity

An approved WPC Activity is required for work that involves only RG1 biological material or recombinant material exempted by NIH Guidelines and does not involve other conditions that require review (see Table 10). The PI-authorized Activity must be submitted to the IBC prior to or simultaneously with experiment initiation, and must receive concurrence by the Biosafety Officer or IBC Chair. This notification process at the start of a project defines and assesses the work, establishes containment levels, and ensures that the requirements and hazards for the project are correctly identified and addressed.

An approved WPC Activity is required for work with RG1 recombinant biological materials that are covered by NIH Guidelines (i.e., recombinant DNA molecules or RG1 organisms and viruses containing recombinant DNA molecules). The PI-authorized Activity must be submitted to the IBC prior to or simultaneously with experiment initiation. The BUR must be reviewed and approved by the IBC.

An approved WPC Activity is required for research with biological materials that involve biohazardous materials (i.e., RG2 or higher materials, biological etiologic agents, select agents or toxins, or the use of BL2 containment for safety).

A WPC Activity is a type of the Berkeley Lab “Formal Authorization” as defined in the ES&H Health & Safety Manual’s Safe Work Authorizations Program. The Activity meets ECP requirements and is also considered the Cal/OSHA-required ECP for the use of BBP materials,the Cal/OSHA-required BCP for the use of aerosol transmissible pathogens-Laboratory, and the BMBL-required laboratory-specific biosafety manual when work is performed with RG2 agents or materials at BL2. The PI-approved Activity requires full IBC review and approval, and authorization by the PI’s supervisor prior to commencing work.

Table 10. Berkeley Lab Review, Documentation, and Authorization for

Work with Biological Materials in Research

To determine work-review requirements for any given project with biological materials, classify the work types in accordance with the first column, and then select the highest-level authorization type indicated in the second column. Generally, work that involves recombinant DNA, RG2 agents, BL2, or BBP material has more stringent requirements. Further conditions that determine the level of review include requirements for specific regulatory permits, regulatory registrations, or funding agency assurance.
	Biological Work Type	Berkeley Lab Authorization Type1	Required Biosafety Work Documentation (approximate renewal cycle)	Berkeley Lab Approval Process IBC = Institutional Biosafety Committee PI = principal investigator BSO = Biosafety Officer
Risk Group 1	Work with RG1 biological material, including work with NIH-exempt2 recombinant DNA molecules	Line management authorization	BUN (3 Years)	BUN process: BSO reviews document for high-level administrative needs and work categorization. PI and PI’s supervisor reviews and approves. BSO notifies PI, supervisor, and EHS Div. Liaison.
	RG1 work with recombinant DNA molecules and organisms or viruses containing recombinant DNA molecules2	Registration	BUR (2 years)	BUR process: IBC reviews and approves. IBC Chair provides final IBC approval  on behalf of the IBC. PI reviews and approves. BSO notifies PI, supervisor, and EHS Div. Liaison.
Risk Group 2	RG22 or higher work, BL22 used for safety, or work withBBP materials as defined in Work Process B.3.f3	Formal authorization	BUA (1 years)	BUA process: IBC reviews and approves non-exempt recombinant work and work with RG2 agents. IBC Chair provides final IBC approval on behalf of the IBC. BSO reviews work with RG2 or BBP materials or concerns and concurs. PI and PI’s supervisor reviews and approves. BSO notifies IBC Chair, PI, PI’s supervisor, Div. Safety Coordinator, and EHS Div. Liaison.
References – Authorization principles and types are specified in the ES&H Health & Safety Manual, Chapter 6 (Safe Work Authorizations), and the Integrated Environment, Safety & Health Management Plan: Integrated Safety Management (ISM) System (PUB-3140). – NIH Guidelines, the most recent version. – Cal/OSHA Bloodborne Pathogens Standard, CCR Title 8, Section 5193. – In general, the renewal date of the authorization should also not extend beyond the expiration date of any regulatory permit covered by the authorization.

• Exposure Control Plan

Work with or worker exposure to bloodborne pathogen materials defined in Work Process B.3.f, Bloodborne Pathogens and Human Materials  requires an Exposure Control Plan (ECP). The ECP must meet the requirements of the Cal/OSHA Bloodborne Pathogens Standard and must be authorized before work or designated job duties are initiated. If the work pertains to research, a BUA meets ECP requirements and is considered the Cal/OSHA-required ECP. If the work does not pertain to research, an ECP must be developed, authorized, and maintained by the supervisor or program manager and division line management.

• Human Subjects and Animal Use Approvals

Review and authorization of work that may have biosafety concerns related to use of humans, human-derived tissues, or animals must be conducted as described in the previous sections. General biosafety concerns include worker safety, public health, agricultural protection, and environmental protection (e.g., waste). Research involving human subjects or animals may also require review and approval by other processes and committees as summarized below.

Research involving human subjects, human-derived data, or human-derived tissues must be evaluated through ethical review using established principles and requirements. These requirements are based on U.S. Department of Health and Human Services (HHS) regulations and DOE orders. These standards require that an Institutional Review Board (IRB) review and approve any proposed research project involving human subjects before research begins. The IRB for Berkeley Lab is the Human Subjects Committee (HSC). See the HSC Web site and the ES&H Health & Safety Manual Research with Human and Animal Subjects Program for additional information.

In addition, research involving vertebrate animals must comply with established standards and requirements for the care, treatment, and use of animals. These requirements are based on USDA animal welfare regulations and the U.S. Public Health Service (PHS) Policy on Humane Care and Use of Laboratory Animals. Compliance with the PHS policy is overseen by the NIH Office of Laboratory Animal Welfare (OLAW). These standards require that the Berkeley Lab Animal Welfare and Research Committee (AWRC) review and approve proposed research that involves vertebrate animals and is performed at or funded through the Berkeley Lab before research begins. See the AWRC Web site and EHS Program, Research with Human and Animal Subjects for additional information.

While the HSC, AWRC, and IBC conduct separate review processes, they all request that researchers document in each application form that the appropriate committee has reviewed their research. See the HSC Web site, AWRC Web site and Chapter 22 of ESH Manual for additional information and requirements.

•  Biosafety Plan (BSP)

Work with or worker exposure to aerosol transmissible   pathogens-Laboratory requires a Biosafety Plan (BSP). The BSP must meet the requirements of the Cal/OSHA Aerosol Transmissible Diseases Standard and must be authorized before work or designated job duties are initiated. If a WPC work Activity meets BSP requirements it is considered the Cal/OSHA-required BSP. The Biosafety Plan/Activity includes the following elements: a list of all job classifications in which all or some employees have occupational exposure, a list of all tasks and procedures in which employees have occupational exposure, a list of ATPs-L known or reasonably expected to be present in laboratory materials and the applicable biosafety measures, engineering controls, safe handling procedures, decontamination and disinfection procedures for laboratory surfaces and equipment, appropriate PPE, respiratory protection if any, emergency procedures for uncontrolled releases, medical services program, hazard communication, inspection of lab facility and audit of biosafety procedures. All respiratory protection use must also comply with LBNL ES&H Manual Chapter 44, Respiratory Protection. 

• Training, Instruction, and Qualification

This section describes the requirements and administrative systems for institutional and operation-specific training, information, and instruction based on the biosafety-related standards and Berkeley Lab policies.

• Work leads, supervisors, and PIs must ensure their workers have sufficient skills, knowledge, and ability to perform their work safely. This includes understanding of the work, hazards, and controls through technical competence, training, instruction, and a commitment to safety in Integrated Safety Management (ISM) terms. Each worker’s competence must be commensurate with his or her responsibilities. This competence is a major component of biosafety containment and includes both required Berkeley Lab courses and sufficient operation-specific information and instruction. These courses, information, and instruction provide workers with awareness of the potential hazards, required training, and proficiency in the practices and techniques required for handling biological materials safely and in accordance with laboratory standard microbiological practices and special practices discussed in Work Process C.1, Laboratory Practices.

Work leads must provide or arrange for appropriate training and instruction for each person, including but not limited to the:

• • Completion of required Berkeley Lab courses specified on all work authorization documents, and
  • Job- and operation-specific instruction and information
    

• Work Planning and Control

Supervisors, work leads, and staff must use the WPC or SJHA to define work with biological materials, determine the potential for exposure to biological hazards, and establish biosafety controls for each worker or subcontractor. The Laboratory-wide WPC identifies workers who work with or have potential exposure to biological materials (e.g., BBP materials). The WPC process is based on each and work activity. It also lists general controls including any required EHS courses and Biosafety Work Authorizations for work or activities in which the worker participates.

• Training Courses and Tracking

Specific biosafety, biohazardous waste, and occupational health courses are developed and maintained by the EHS Division to meet requirements that can be fulfilled at an institutional level. Berkeley Lab course requirements are presented below and summarized in Table 11. See the EHS Training Web site for additional course information, to register for a course, or to take an online course.

• Researchers who work with biological material of any risk level (e.g., microorganisms, cells, cell lines, tissue cultures, recombinant nucleic acids, blood, body fluids or tissues, or animals) must complete EHS0739 (Biosafety Training for Researchers). In addition, EHS0730 (Medical/Biohazardous Waste Training) is recommended for anyone who works with biological material, and required for anyone who works with medical or biohazardous waste. PIs or other leaders of the work activity who have responsibility for overseeing the biosafety of the research must also complete these courses.All employees with occupational exposure to aerosol transmissible pathogens shall receive training at the time of initial assignment, at least annual thereafter, and when there are significant changes to engineering controls or work procedures. Working with aerosol transmissible pathogens (ATPs-L) will be addressed in EHS0739 and annual training requirement per the Cal/OSHA Aerosol Transmissible Diseases Standard is fulfilled by completing the Biosafety Training Refresher. 
• Anyone who works with or may be exposed to human blood or blood products or to human materials (e.g., cells, tissues, or fluids) defined by the Cal/OSHA Bloodborne Pathogens Standard as other potentially infectious materials (OPIM) (see Work Process B.3.f, Bloodborne Pathogens and Human Materials, for more information) must complete bloodborne pathogen training and EHS0745 (Hepatitis B Medical Surveillance). Researchers must initially complete EHS0735 (Bloodborne Pathogen Training for Researchers), and nonresearchers must complete EHS0738 (Bloodborne Pathogen Training Refresher). Bloodborne pathogen training must be renewed annually by completing EHS0738. Courses EHS0739 and EHS0738 are also available as Web-based challenge exams.
• PIs of non-exempt recombinant research must also complete EHS0749 (PI Recombinant DNA (rDNA) Responsibilities).

Table 11. Biosafety-Related Training Courses

Work Exposure or Role	EHS0739 Biosafety  Training for Researchers	EHS0730 Medical/ Biohazardous Waste Training	EHS0735 Bloodborne Pathogen Training for Researchers	EHS0738 Bloodborne Pathogen Training Refresher	EHS0745 Hepatitis B Medical Surveillance	EHS0749PI rDNA Responsi-bilities
Researchers who use biological materials of any risk level, generate medical/biohazardous waste, or are PIs or leaders of the work activity	X	X
Researchers who use or are exposed to BBP materials	X	X	X	X	X
Nonresearchers who use or are exposed to BBP materials				X	X
PIs of non-exempt recombinant research	X	X				X

Biosafety training course requirements for each worker are identified through each worker’s WPC Activity. Each worker’s course requirements and training status are then displayed in the worker’s Training Profile, and the WPC work Activity.

• Job-Specific Instruction, Information, and Practices

• • As discussed in Work Process D.2, Training, Instruction, and Qualification, supervisors and work leads must ensure that workers receive job- and operation-specific instructions. These instructions should include:

• Individual job duties and controls
• Hazards and controls in authorization documents including WPC Activities, BSPs, and ECPs. Controls in these documents include, for example, standard microbiological practices and special practices customized as needed for the work (see Appendix C of this manual). These authorizations must be available and accessible to each worker so that he or she can understand the work, hazards, and required controls. Each worker has access to his or her authorization, registration, and notification through the WPC.
• Good microbiological practices as needed to perform the work safely (see Work Process C.1, Laboratory Practices, and Appendix D, Good Microbiological Practice)
• Incident, accident, and emergency-response procedures (e.g., Berkeley Lab Emergency Guide)
• Any operation-specific safety procedure

Additional instruction or demonstration of proficiency may be needed for work that involves higher hazards. For example, workers must demonstrate proficiency in standard microbiological practices and special practices before working with RG2 agents (for more information, see Work Process C.1, Laboratory Practices). Due to increasing interdisciplinary use of biological etiologic agents, the IBC may request either a Statement of Qualification from research groups with limited experience working with these agents, use of lower-risk organisms, or collaboration with experienced researchers.

Labels and signs must also be used to advise workers of hazards and controls (see Work Process D.5, Labels and Signs).

• Occupational Health and Immunization
  

Employee consultation with Health Services. Source: Berkeley Lab EHS.

Berkeley Lab occupational health and immunization policies, programs, and services are provided by the Health Services Group of the EHS Division under the direction of the Site Occupational Medical Director (SOMD). These policies, programs, and services are described in the Health Services Web site, policies (e.g., immunization and serum banking), and the ES&H Manual Health Services program. The occupational health program related to biosafety is designed to proactively identify and prepare workers who may be exposed to certain biological materials or agents, and provide procedures for the treatment and management of workers who have been injured or may have been exposed. Employees who are aware of personal illnesses that may affect their ability to combat infection or receive medications or vaccines should visit Health Services for an evaluation of how this may affect their individual risk for work with biological agents.

Potential exposures to biological agents or materials that generate health concerns or may cause disease are assessed as part of the work review and authorization process discussed above in Work Process B, Work and Risk Assessment, and Work Process D.2, Training, Instruction, and Qualification. This assessment includes an evaluation and determination of the need for employee medical evaluations, immunizations, serum banking, or other occupational health controls. For research projects, this assessment is conducted by IBC members including the Biosafety Officer and the SOMD. The IBC review includes SOMD recommendations and is the basis of required or recommended occupational health controls for potentially exposed employees. These controls are then documented in the WPC Activity.

Requirements or recommendations for occupational health controls (e.g., vaccinations) for specific agents or materials are discussed in BMBL, Section VIII (Agent Summary Statements). Requirements for aerosol transmissible pathogens are provided by the Cal/OSHA Aerosol Transmissible Disease Standard by providing all vaccinations as recommended by applicable public health guidelines for the specific laboratory operations, and providing investigation in accordance with Berkeley Lab’s Injury Response and Review program and medical follow up for exposure incidents in laboratories. Requirements for BBP materials are provided by the Cal/OSHA Bloodborne Pathogens Standard. Cal/OSHA requirements and Berkeley Lab programmatic policies and systems for implementing these requirements are summarized below:

• Hepatitis B vaccination

Hepatitis B vaccine. Source Berkeley Lab EHS.

• The Cal/OSHA Bloodborne Pathogens Standard requires that the hepatitis B vaccination series be made available and offered to all Berkeley Lab employees who have occupational exposure to BBPs or materials that are regulated based on their potential to contain BBPs (e.g., human blood, tissues, and cells). This requirement is managed at Berkeley Lab by ensuring that workers who are potentially exposed to BBP materials are identified in their WPC Work Activity and are required to complete EHS0745 (Hepatitis B Medical Surveillance). Each worker fulfills his or her hepatitis B surveillance requirement by: (1) completing the online EHS0745 course; (2) indicating on the course’s integral surveillance form that he or she has been previously immunized, wishes to be vaccinated, or wishes to decline the vaccination; and (3) completing any required follow-up process (e.g., getting vaccinated or documenting previous vaccination). When a worker indicates previous immunization, Health Services will work with him or her to document vaccination and document the results of such efforts.
• Post-exposure evaluation and follow-up. The Cal/OSHA Bloodborne Pathogens Standard requires that postexposure evaluations and follow-ups be made available to all employees who have had an exposure incident. Employees who have had an exposure incident must report their exposure to their supervisors and Health Services in accordance with Berkeley Lab’s Injury Response and Review program.
  
• Sharps injury log. The Cal/OSHA Bloodborne Pathogens Standard requires a Sharps Injury Log for the recording of all exposure incidents involving sharps contaminated with BBP material (see 8 CCR 5193). The information in the Sharps Injury Log must be recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The Sharps Injury Log must contain date and time of the incident, the type and brand of device involved in the incident, the job classification of the exposed employee, the department or work area where the exposure incident occurred, an explanation of how the incident occurred, the body part involved, details on engineered sharps injury protection of the sharp in question, and employee’s opinion about controls that could have prevented the injury. This log may be maintained in the incident investigation reports or case records, all the required information mentioned above is recorded, and sharps injury records may be easily separated from other types of work-related injuries and illnesses. Berkeley Lab maintains sharps injury information in the case records/incident investigation reports in accordance with Cal/OSHA regulations. In addition, the Berkeley Lab Health Services Group maintains a separate, confidential log containing sharps injury information required by Cal/OSHA.
• Consult the Berkeley Lab Health Services Group ([510] 486-6266), Health Services Web site, and ES&H Manual Health Services Program) for additional information. See Work Process D.10, Incident, Accident, and Emergency Response, for additional information on worker exposure, injury, and illness reporting.

• Personal Protective Clothing and Equipment

Use of safety equipment including personal protective equipment (PPE) is another element of BL1 and BL2 containment. PPEis clothing or equipment worn by workers to protect the body from injury by hazardous agents or materials. PPE may include foot, hand, eye, face, body, and respiratory protection.

PPE must be used, maintained, and disposed of in accordance with federal regulations, biosafety standards, and Berkeley Lab-specific PPE policies to prevent the spread of contamination and accidental infection. Berkeley Lab policies related to PPE when working with biological materials are described in this section and the following documents:

Minimum area PPE: Safety glasses, long pants, and closed-toe shoes. Source: Berkeley Lab EHS.

• ES&H ManualPersonal Protective Equipment program
• ES&H ManualRespiratory Protection program
• Medical and Biohazardous Waste Generator’s Guide (PUB-3095)

The following PPE requirements are related to biosafety:

• Area-specific PPE requirements must be established for all Technical Areas (e.g., laboratories) and must be posted on the Berkeley Lab entrance placard. Minimum PPE for laboratories where biological materials are stored or handled includes safety protective eyewear, long pants, and closed-toe shoes. Area PPE requirements apply to the entire Technical Area unless an exception for a specific location(s) within the area is assessed established, posted, and noted in the Biosafety Work Authorization in accordance with the ES&H Manual Personal Protective Equipment Program, Appendix A and B.
• Activity- or operation-specific PPE requirements are assessed and defined in the Biosafety Work Authorization, which covers what PPE must be used (e.g., gloves, laboratory coats, and safety glasses) and any maintenance (e.g., laundering) or disposal requirements.

General requirements and conditions for use of PPE related to biosafety include:

• The supervisor or work lead is responsible for:

• Determining what PPE is required to prevent occupational exposure
• Providing at no cost to an employee the PPE required by this section or specified in the Biosafety Work Authorization. This PPE must be readily available in appropriate sizes.
• Ensuring that employees and visitors properly use and store required PPE

• The EHS Division is available to assist supervisors or work leads in evaluating work activities and selecting appropriate PPE.
• Employees and visitors are responsible for using PPE when required and whenever the work poses a reasonable probability of eye injury or exposure.
• In general, removed PPE must be:

• • Decontaminated when needed, or
  • Disposed of in accordance with Berkeley Lab medical/biohazardous, hazardous, and radiological waste management requirements

• PPE that protects against exposure to BBP materials is considered appropriate if it does not permit BBP material (e.g., human blood or cell-culture solution) to pass through the employee’s work clothes, street clothes or undergarments, skin, eyes, or other mucous membranes under normal conditions of use and for the duration of time in which the PPE will be worn.
  

• Body Protection

Lab coat worn when working with biological materials. Source: Berkeley Lab EHS.

Protective laboratory clothing is a garment such as a lab coat, gown, smock, or uniform designed to keep personal clothing, forearms, or other exposed bodily surfaces protected from contamination by biological materials or exposure to other hazards. The term “protective laboratory clothing” typically applies to garments worn in the laboratory, but may also apply to garments worn in nonlaboratory work (e.g., health care).

The following biosafety criteria are applicable to wearing protective laboratory clothing:

• Protective laboratory clothing should be worn to prevent contamination of personal clothing when working at BL1.
• Protective laboratory clothing must be worn when working at BL2 or when working with RG2 or other hazardous materials. This clothing must be removed and left in the laboratory before leaving for nonlaboratory areas (e.g., cafeteria, library, administrative offices).

• Protective laboratory clothing removed after use at BL2 or with biohazardous materials must be handled in one of the following ways:

• Stored for reuse if not contaminated. Such clothing stored for reuse should be stored in a manner that would not contaminate other items in case the protective clothing has unknown contamination (e.g., separate coat hook).
• Placed in a laundry bag or container for cleaning by a qualified laundry service
• Disposed of in accordance with Berkeley Lab medical/biohazardous, hazardous, and radiological waste management requirements
  

Lab coats hung on separate hooks, placed in laundry bag at BL1, placed in laundry bag that is red or marked with biohazard label at BL2 (i.e., RG2 and BBP materials), and disposed as biohazardous waste. Source: Berkeley Lab EHS.

• Protective laboratory clothing and other laundry contaminated with RG2 materials should be handled as noted below, and laundry contaminated with BBP materials must be handled as follows:
• Handled as little as possible with a minimum of agitation
• Bagged or containerized at the location where it was used but not sorted or rinsed in the location of use
• Placed in bags or containers that have biohazard labels, are red in color, or are identified by an alternative laundry-labeling or color-coding system that uses universal precautions
• Placed and transported in bags or containers that prevent soak-through or leakage of fluids to the exterior if the laundry is sufficiently wet
  

• Eye and Face Protection

Eye protection using safety glasses.

Face splatter protection using face mask and shield. Source: Berkeley Lab EHS.

Eye protection is a safety device such as safety glasses with side shields or goggles worn over the eyes to prevent injury to the eye or exposure to biological agents. Face protection is a safety device such as a face mask, face shield, or other splatter guard worn over all or part of the face to protect the face from injury or exposure to biological agents. Face masks or respirators that are occasionally used for face protection are discussed in Work Process D.4.e, Respiratory Protection, Respiratory, and Face Masks.

Eye and face protection are used by laboratory and other workers to protect the eyes and face from splashes, splatters, or flying debris and hand-eye contact with biological materials. Contact by these means may result in injuries to the eyes and face or accidental inoculation via the eyes, nose, or mouth and subsequent infection and disease.

The risks noted above are prevented by using eye and face protection in accordance with the following requirements:

• As a minimum requirement, safety glasses with side shields must be worn at all times when in a Technical Area such as a laboratory. Area PPE requirements apply to the entire Technical Area unless an exception for a specific location(s) within the area is assessed established, posted, and noted in the Biosafety Work Authorization in accordance with the ES&H Manual Personal Protective Equipment Program, Appendix A and B. Additional eye or face protection may be necessary when handling chemicals or biological materials (e.g., goggles, face shield).
• Eye protection must be worn when conducting procedures that have the potential to create splashes of biological agents, biohazardous materials, or other hazardous materials.
• Eye and face protection (e.g., goggles, face mask, face shield, or other splatter guard) must be used when it is anticipated that splashes, sprays, splatters, or droplets of infectious or other hazardous materials may be generated and could contaminate the eyes, nose, or mouth (e.g., when RG2 microorganisms must be handled outside the biosafety cabinet or containment device). This eye and face protection must be included in the Biosafety Work Authorization risk assessment and disposed of with other contaminated laboratory waste or decontaminated before reuse.

Prescription safety glasses at Health Services. Source: Berkeley Lab EHS

Berkeley Lab provides prescription safety glasses when needed via the EHS Health Services Group and a staff optometrist. Personnel who need consultation or require prescription safety glasses should schedule an appointment with the optometrist by calling the Health Services Group at (510) 486-6266.

• Hand Protection

• • Hand protection is a glove or other safety device used on the hand to prevent injury to the hand or direct skin contact with biological materials. Hand protection is used by laboratory and other workers to protect the hands from harmful physical, chemical, biological, radiological, or other agents or hazards. These agents or hazards may cut, lacerate, abrade, or burn the skin; absorb through the skin; pass through breaks in the skin; or be spread as contamination. Although relatively few microbes can penetrate unbroken skin, many circumstances can cause a break in the skin, such as a cut or puncture from a sharp (see Work Process D.6.f.i, Sharps). In the case of biological materials, gloves prevent the worker’s hands, fingers, and nails from being contaminated. Spread of biological contamination from the worker’s exposed hands or contaminated gloves to the worker’s mucous membranes or other surfaces may also cause infection and disease in the worker or other people.
  • Gloves should be selected based on the hazards involved; they may need to serve multiple purposes. For example, gloves used for handling chemical and biological materials may need to be resistant to the chemicals being handled, liquid permeation, and physical damage. The remainder of this section is focused only on glove criteria that are important for biosafety and gloves that provide protection from biological materials or liquids.

From left: White latex gloves are worn to protect hands from exposure to biological materials, organisms, patient mucous membranes, and blood. Purple nitrile gloves are used for the same purposes and provide an alternative to latex. Double gloves are worn for extra protection. Source: Berkeley Lab EHS.

The following criteria apply to glove selection, use, and disposal:

See NIOSH Latex Allergy Prevention Guide. Source: NIOSH Web site 2013.

• In general, gloves should be worn to protect the hands from exposure to biological materials or organisms that may present a biological risk. Gloves must be worn to protect hands from exposure to hazardous materials, including: organisms containing recombinant DNA, recombinant experimental animals, RG2 materials, BBP materials or surfaces and items contaminated with BBP materials, when touching mucous membranes and non-intact skin of patients, and when performing vascular access procedures such as phlebotomies.
• Glove selection should be based on an appropriate risk assessment. Use of standard nitrile or latex examination gloves is considered adequate for handling most biological materials, and is assumed in the Biosafety Work Authorization. The need for gloves with any additional safety features to handle biological materials should be documented in the Biosafety Work Authorization. The JHA process should be used to assess other hand hazards and glove requirements.
• Alternatives to latex gloves should be available because some workers are known to develop allergic reactions to latex. Exposures to latex may result in skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.
• When working at BL1 and BL2, workers should remember the following:

• • Change gloves when contaminated, when their integrity has been compromised, or when otherwise necessary. When working at BL2, wear two pairs of gloves when appropriate.
  • Remove gloves and wash hands when work with hazardous materials has been completed and before leaving the laboratory. Gloves that were used in BL1 or BL2 work must not be worn outside the laboratory.
  • Do not wash or reuse disposable gloves. Dispose of used gloves with other contaminated laboratory waste. Hand-washing protocols must be rigorously followed.

Remove gloves and wash hands with soap and water when work is complete and before leaving the laboratory. Source: Berkeley Lab EHS.

• Foot Protection

Closed-toe shoes. Source: Berkeley Lab EHS.

Footwear appropriate to the worker’s work activities and conditions must be worn at all times. In a Technical Area such as a laboratory, or areas where chemical or biological materials are stored or handled, closed-toe shoes must be worn at all times; open-toe shoes and sandals are not permitted. In some cases, Berkeley Lab requires workers to wear safety shoes for other hazards such as falling heavy objects. See Work Process B.2.b, Foot Protection, of the ES&H Manual Personal Protective Equipment (PPE) program, for additional information.

• Respiratory Protection, Respirators, and Face Masks

Workers who conduct procedures that may generate aerosols containing harmful levels of infectious agents must use controls such as biosafety cabinets (BSCs), enclosed containment systems, or respirators to avoid inhaling the agents. In general, a BSC should be used as the principal device in laboratories to contain infectious splashes or aerosols generated by numerous microbiological procedures (see Work Process D.6.d.ii, Hoods and Biosafety Cabinets, and Appendix E, Biosafety Cabinets, of this program for additional BSC information). Other engineered containment devices such as safety centrifuge cups should also be used. When engineering controls are not feasible or appropriate for the work, respirators may be needed to provide respiratory protection (e.g., potential exposure to airborne transmissible disease agents during patient care).

A BSC is the principal laboratory device used to contain splashes or aerosols. Source: Berkeley Lab EHS.

Respirators or face masks are occasionally worn by workers while conducting work with biological materials. There are important differences in design, purpose, and requirements among types of respirators and face masks that may be used for biological materials:

• A respirator is a device designed and certified to protect the wearer from the inhalation of harmful atmospheres. A respirator may be a required respiratory control or worn voluntarily by the worker. A respirator might also provide face or product protection. Types and examples of some respirators:
• A negative-pressure, air-purifying respirator is a tight-fitting respirator in which the air pressure inside the facepiece is negative during inhalation with respect to the ambient air pressure outside the respirator, and an air-purifying filter or cartridge removes specific air contaminants. Examples include the following types of cartridge and filtering facepiece respirators:

• A negative-pressure, air-purifying, cartridge respirator is a respirator that uses a filter, sorbent, or catalyst housed inside a cartridge to remove contaminants from the air. Examples are respirators using an N95 or P100 cartridge particulate filter that is 95% and 100% efficient, respectively.

N95 filtering facepiece respirator

• A filtering facepiece respirator is a negative pressure, air-purifying respirator with a particulate filter as an integral part of the facepiece or with the entire facepiece composed of the filtering medium. A filtering facepiece respirator is sometimes incorrectly referred to as a dust mask or an N95 respirator bThe term “dust mask” is an inaccurate term because a filtering facepiece respirator is a respirator, not a face mask. In addition, filtering facepiece respirators are not to be confused with N95 respirators, because only cartridge-type respirators use N95 filters.

• A positive-pressure respirator is a respirator designed to maintain positive pressure inside the facepiece during exhalation and inhalation. Examples include a powered air-purifying respirator or a supplied-air respirator, which are not normally used atBerkeley Lab for biosafety purposes.

Face mask with face shield, which is not a respirator.

Source: Berkeley Lab EHS.

• A face mask is a loose-fitting, disposable device that covers the worker’s nose and mouth and is not a respirator. Examples of face masks include products labeled as surgical, medical, dental, or isolation masks. A face mask might be worn in combination with eye protection to protect the nose and mouth from splatters or sprays, or the face mask might prevent the wearer from contaminating a product, patient, lab animal, or surface from particles (e.g., droplets) expelled from the nose or mouth. Face masks are not intended to protect the wearer from inhalation of airborne agents and must not be used for respiratory protection.

• The following requirements are applicable to respirator uses, regardless of why the respirator is worn:

• The respirator must be issued and worn in accordance with the ES&H ManualRespiratory Protection Program. See these polices for additional information and consult your EHS industrial hygienist. Voluntary use of a filtering facepiece that is not a required respiratory control requires a hazard evaluation and training before use, but unlike other required respirator uses, does not require a medical evaluation or fit-testing.
• A risk assessment for the respirator must be documented in the Biosafety Work Authorization if the respirator use is related to the handling of biological materials.
  

• Labels and Signs

Biohazard label. Source: 29 CFR 1910.1030(g)(1)

Biological materials, agents, waste, potentially contaminated items, and laboratory rooms must be properly identified with labels, signs, or colors. Identification is needed so that responsibilities, material identities, hazards, or controls are communicated to workers, visitors, and others. These labels, signs, and colors must be displayed in accordance with Berkeley Lab policies and applicable requirements in the biosafety standards as summarized in this section.

A biohazard label or red color is typically required to provide warning when a biohazardous condition may be present. A biohazard label is a sign that is predominantly fluorescent orange or orange-red. It also contains a biohazard symbol and the word “Biohazard” in a contrasting color. The label shown here displays the required biohazard legend.

The following are biosafety criteria for labels, signs, and colors:

• Information or labels should be visible on containers of biological materials or agents so that their contents can be identified.
• A biohazard label should be posted as a best-management practice on primary equipment that uses, stores, or may be contaminated with RG2 agents or materials.
• Work with BBP materials requires:

• Biohazard labels, red containers, or red bags for waste containers, refrigerators, freezers, or other containers used to store, transport, or ship BBP materials
• Biohazard labels, red containers, or red bags for containers or bags used for laundry that may be contaminated with BBP materials\
• Biohazard labels used to indicate which equipment parts remain contaminated with BBP materials

• Caution placards and other information must be posted at laboratory entrances, including a biohazard label for BL2 work areas. See additional details in the next paragraph.
• Consult the Medical and Biohazardous Waste Generator’s Guide (PUB-3095) for details on labels and colors for sharps containers, waste containers, and waste bags in designated red-bag or clear-bag areas.

.  .  .

Information or labels visible on containers of materials or agents that identify contents. Biohazard labels and red colors provide warning that a biohazardous condition may be present. Source: Berkeley Lab EHS

The following criteria must be implemented when posting an entrance to BL1 or BL2 laboratory area:

• A Caution placard must be posted at the entrance to a Technical Area as specified in the Berkeley Lab CHSP.
• Area PPE requirements must be included on the Caution Placard as specified in the ES&H Manual Personal Protective Equipment Program.
• A biohazard label must be posted (typically on a placard) at the entrance to each BL2 work area to advise entering personnel of potential biological hazards.
• When infectious agents (i.e., human pathogens) are present or there are organisms that require special provisions for entry (e.g., vaccination), additional biological hazard warning signage is required at the entrance to the laboratory. This signage must incorporate the universal biohazard symbol and include: the laboratory’s biosafety level; the identity of the agent(s) or the words “Infectious Agent(s)”; the name and telephone number of the supervisor, work lead, PI, or other responsible personnel; and any special requirements or procedures for entering and exiting the laboratory. The CHSP Caution Placard will be used to accomplish these additional signage requirements. Any requirements for posting identities of agents or posting special entry and exit procedures will be specified in the BUA.
• Other Berkeley Lab requirements for signage (e.g., radiological) may also apply to the entrance to be posted.
  

Caution placard at laboratory entrance with minimum area PPE requirements and biohazard label indicating BL2 work area. Source: Berkeley Lab EHS.

• Facilities, Laboratory Equipment, and Related Practices

This section describes in a topical manner biosafety engineering and work practice controls related to standard facility design and laboratory equipment. Properly designed and used facilities, facility equipment, laboratory equipment, and lab tools provide protection for laboratory workers, persons outside the laboratory, the public, and the environment.

See Work Process C.1, Laboratory Practices; Work Process C.2, Safety and Personal Protective Equipment; and Work Process C.3, Facility Design and Construction, for a general discussion of the principles of standard laboratory practices, equipment, and facilities. See Appendix C, Laboratory Biosafety Level 1 and Biosafety Level 2 Criteria, of this program for a summary of standard laboratory practices, equipment, and facilities categorized as BL1 and BL2. See Work Process C.3 for a discussion of the facility design process at Berkeley Lab related to biosafety.

• Cleanable Surfaces and Furnishings

Cleanable surfaces and furnishings. Source: Berkeley Lab EHS.

In general, laboratory facilities and furnishings should be designed and maintained so that they are durable, will not trap contamination, and can be easily cleaned. The following BL1 and BL2 laboratory criteria specified by BMBL and apply to this objective:

• The laboratory should be designed so that it can be easily cleaned or decontaminated.
• Carpets and rugs in laboratories are not permitted.
• Laboratory furniture must be capable of supporting anticipated loads and uses.
• Spaces between benches, cabinets, and equipment should be accessible for cleaning.
• Benchtops must be impervious to water and resistant to heat, organic solvents, acids, alkalis, and other chemicals.
• Chairs used in laboratory work must be covered with a nonporous material that can be easily cleaned and decontaminated with an appropriate disinfectant.
  

• Doors and Windows

• Laboratory doors and windows provide a means to control personnel access to the laboratory, control vectors such as insects and rodents, and maintain laboratory air-flow balance. These controls are elements of standard BL1 or BL2 laboratory practices or facilities.
• The following biosafety criteria from BMBL and Appendix C are applicable to laboratory doors and windows:

• BL1 and BL2 laboratories should have doors for access control. BL2 laboratory doors should be self-closing and have locks in accordance with Berkeley Lab standards. When the laboratory is unoccupied during nonbusiness hours, access to the laboratory should be controlled (e.g., by locking doors to the laboratory areas and/or doors to the building entrance).
• BL1 laboratory windows that open to the exterior should be fitted with screens. BL2 laboratory windows that open to the exterior are not recommended. However, if a BL2 laboratory has windows that open to the exterior, they must be fitted with screens.
  

.       .

Laboratory doors that are needed to control access, ventilation, vectors, or fire are kept closed. BL2 doors are self-closing and have locks. Source: Berkeley Lab EHS.

• Plumbing Systems and Equipment

Plumbing-related systems and equipment that have requirements related to biosafety include handwashing sinks, sanitary sewer drains, water systems and backflow protection, emergency eyewash and shower units, and pipes. These systems provide needed utilities and containment when used properly. When used incorrectly, these systems may provide a route of exposure to personnel or the environment.

                                   

• Sinks and Hand-washing

• • BL1 and BL2 laboratories must have a sink with running water for hand-washing. In BL2 laboratories, the sink should be located near the exit door and may be manually, hands-free, or automatically operated. Hand-washing sinks should be provided with a soap dispenser and paper towel dispenser as a best management practice. When working with BBP materials, the sink facility is called a hand-washing facility. A hand-washing facility must have an adequate supply of potable running water, soap, and single-use towels or hot-air drying machines.

Handwashing sink and facility. Source: Berkeley Lab EHS.

• • Personnel working at BL1 or BL2 laboratories must wash their hands (a) after working with potentially hazardous materials, recombinant materials, and animals; (b)after removing gloves; and (c) before leaving the laboratory.
  • When work involves potential exposure to BBP materials outside of the laboratory (e.g., health care) and hand-washing facilities (e.g., potable water and a sink) are not feasible, an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes may be provided. When antiseptic hand cleansers or towelettes are used, hands must be washed with soap and running water as soon as possible.

• Drains and Disposal

• • Laboratory sinks must typically be drained into the sanitary sewer system. In general and as a best-management practice, liquids that contain biological material that is potentially viable or biologically active and not contaminated with other hazardous or radioactive material should be properly decontaminated with a disinfectant before disposal into the sanitary sewer system (see Work Process D.7, Decontamination, Waste, and Decommissioning) below. All biological liquid material considered medical/biohazardous waste must be decontaminated before disposal (see the Medical and Biohazardous Waste Generator’s Guide [PUB-3095]).

• Water Systems and Backflow Prevention

Laboratory faucet with backflow-prevention device. Source: Berkeley Lab EHS.

• • Backflow-prevention devices are required in building water systems or connection points to prevent contaminated liquid or water from being inadvertently sucked into the potable-water system of the building. For example, a backflow-prevention device called a vacuum breaker is often integrated into the gooseneck of the laboratory sink faucet. This device prevents liquids from being drawn up into the faucet’s water system in case a laboratory worker connects tubing to the faucet’s serrated hose end.
  • Potable water is typically supplied to each laboratory building. This water supply is separated through backflow-prevention devices in the building’s plumbing system into potable- and industrial-water systems or sources. Plumbing fixtures that must be supplied with potable water include emergency eyewashes and showers and fixtures used in restrooms, in kitchens, or as drinking sources (e.g., toilets, sinks, or drinking faucets). Water connected to other fixtures or equipment in the laboratory or building must be separated from the fixtures that require potable water by proper backflow-prevention devices. When the water system is correctly designed and labeled, water pipes labeled as industrial water are separated from the potable-water system by a backflow-prevention device(s) in the building’s water system. Connection of laboratory sinks, laboratory equipment, or industrial equipment to pipes that also provide water to potable fixtures requires proper installation of a backflow-prevention device. Contact your building’s facilities service provider (e.g., Berkeley Lab Facilities) for proper plumbing advice and hardware.

• Emergency Eyewashes and Showers

Using eyewash to flush face and eyes. Source: Berkeley Lab EHS.

• • An emergency eyewash is a plumbing unit designed to properly flush chemical, biological, or other hazardous agents off the face and out of mucous membranes such as the eyes. Use of an eyewash prevents injury to the eye or exposed body surfaces. It also prevents an agent from penetrating into the body. An emergency eyewash must be readily available to BL2 work areas.
  • Ready access to a sink and emergency eyewash without strict distance-to-use requirements is normally sufficient for washing biological contamination from the body, because:
  • Intact skin is considered a good barrier to most biological agents

• • • Biological agents do not cause immediate tissue damage to skin or eyes
    • An eyewash unit works well to flush the face (e.g., eyes, nose, and mouth areas)
  • However, in areas where there is also a splash hazard to certain chemicals (e.g., corrosives, eye irritants, chemicals that are toxic via skin or eye contact), the CHSP specifies that a combination emergency eyewash and shower unit must be reachable within 10 seconds via an unobstructed path. When combination eyewash and shower units are provided for potential chemical exposures, the number and placement of units is often sufficient to also meet the biosafety requirement for an emergency eyewash being readily available in BL2 work areas. Installation, maintenance, and use of all emergency eyewash and shower units must comply with the eyewash and shower requirements in the CHSP.

• Ventilation and Hoods

• • Room ventilation and hoods provide for control of potential biological aerosols, other harmful atmospheres, odors, and smoke caused by fires by providing general room air dilution, directional air flow, and enclosure to contain and exhaust airborne agents. Room ventilation and hoods must be designed and maintained to established standards, guidelines, and Berkeley Lab policies.

• Room Ventilation

The volume and balance of laboratory room ventilation are important safety controls. There may be specific ventilation requirements for specific laboratory uses, but the following design requirements generally apply to laboratory rooms that use biological and hazardous materials:

• Laboratory rooms must be negative in pressure relative to any fire-exit corridor.
• Laboratory rooms should be negative in pressure relative to nonlaboratory rooms (e.g., offices).
• BL2 rooms should be negative in pressure relative to other areas. If
• researchers indicate that a BL2 area should be positive in pressure for research purposes (e.g., contamination control), a negative-pressure anteroom leading to the BL2 area may be required, or the risk-assessment process may indicate that it is acceptable for air to flow from the BL2 area into another laboratory area.
• Air exhausted from laboratories should not be recirculated to rooms outside the laboratory.
• Laboratory exhaust ventilation flow rates must meet minimum requirements (e.g., 1 cubic foot per minute of exhaust air per square foot of laboratory space).

• Hoods and Biosafety Cabinets

Hoods are enclosures or shaped inlets designed to conduct contaminated air into an exhaust duct system, or a filter that safely captures the contaminant. This section discusses hoods designed to provide for the safety of the worker or the environment such as biosafety cabinets, laboratory fume hoods, exhausted equipment enclosures, gloveboxes, and other local exhaust points. This section does not cover ventilated enclosures such as laminar flow clean benches that are not designed to protect the worker or the environment from contaminated air.

Hoods used for safety must be designed, installed, tested, and surveyed in accordance with Berkeley Lab ES&Hstandards and policies for all hoods and high-efficiency particulate air (HEPA) filters (ES&H Manual Ventilation, Hoods, and HEPA Filters program). The EHS Industrial Hygiene Group manages the ventilation safety program and records hood locations, surveys, and testing in the Ventilation Database. Supervisors or work leads should ensure that hood safety survey stickers or labels indicate that the hood has been surveyed or tested and determined to be safe for use.

Biosafety cabinet survey and certification labels. Source: Berkeley Lab EHS.

• Biological Safety Cabinets and Other HEPA-filtered Containment

• Biological safety cabinets or biosafety cabinets (BSCs/) are hoods with HEPA filters that are designed to provide personnel, environmental, and product protection when appropriate practices and procedures are followed. Appendix E of this program summarizes BSC types and provides additional BSC information. Various types of BSCs and similar hoods are used at Berkeley Lab. Listed below are more common types:

• Typical BSCs used at Berkeley Lab are Class II Type A2 BSCs built by BSC manufacturers. These BSCs discharge exhaust directly though a HEPA filter and into the laboratory.
• Class II Type B2 BSCs are used less commonly than Class II Type A2 BSCs. These BSCs discharge exhaust air through a HEPA filter, but exhaust air is then ducted to the roof so that toxic chemicals that cannot be filtered by the BSC’s HEPA filter are not exhausted back into the laboratory.
• Researchers sometimes acquire or build equipment such as cell sorters or robotic enclosures that cannot be categorized as a BSC. These specialized pieces of equipment should be tested and managed using many of the same BSC ventilation, testing, and management principles.

• BSCs or other safety equipment, PPE, or other physical containment devices (e.g., safety centrifuge cups) must be used whenever procedures with a potential to create infectious aerosols or splashes are conducted, or whenever high concentrations or large volumes of infectious agents are used. Examples of such procedures include pipetting, centrifuging, grinding, blending, shaking, mixing, vortexing, sonicating, opening containers with pressure differentials, or harvesting infected tissues. The BSC is the principal BL2 device used to provide containment of infectious splashes or aerosols generated by many microbiological procedures.

Biosafety cabinet. Source: Berkeley Lab EHS.	Aerosols and aerosol generation. Source: unidentified.

BSCs must be:

• Designed, installed, tested, and surveyed in accordance with Berkeley Lab ES&H standards for all hoods and HEPA filters (i.e., ES&H Manual Ventilation, Hoods, and HEPA Filters program)
• Designed, constructed, installed, operated, used, decontaminated, and tested in accordance with BSC guidelines in Appendix A of BMBL and summarized in Appendix E of this manual
• Managed in accordance with the following list of BSC policies:

• • The Biosafety Work Authorization must include specific BSC uses and information, and an assessment of procedures for RG2 materials that have the potential to produce aerosols or splashes.
  • The EHS Industrial Hygiene Group is responsible for maintaining records of BSC locations, surveys, and testing in the Ventilation Database, and managing surveys, tests, and gaseous decontaminations of BSCs. BSC testing, certification, and gaseous decontaminations are performed by a subcontractor. The EHS Division normally pays for each BSC’s annual safety test and certification when the BSC is used for safety.
  • Line management owners of BSCs have primary responsibility for paying costs and ensuring the proper purchase, use, maintenance, testing, and decontamination of BSCs.
  • BSCs used for BL1, BL2, or other safety levels must be tested and certified before initial use, after being moved, and on a nominal one-year cycle.
  • BSCs and their filters must be decontaminated with a gaseous decontaminant before being moved or repaired internally, unless an alternative procedure is approved by the Biosafety Officer.
  • BSCs must be installed and operated according to the manufacturer’s recommendations.

When a new BSC is needed or a BSC needs to be moved, contact the EHS Industrial Hygiene Group or Biosafety Office for assistance with selecting, testing, and decontaminating BSCs.

• Laboratory and Other Hoods

Other hoods that are not exhausted through HEPA filters are typically used for most nonbiological laboratory airborne hazards or concerns. These hoods are generally used for control of chemical hazards, gas hazards, process emissions, odors, and heat. Examples of such hoods include laboratory-type (“fume”) hoods, gas chromatograph local exhaust points, and autoclave canopy hoods. These hoods can be used for chemicals including biological toxins, but are not adequate for control of potential infectious biological aerosols or toxic particulate.

• Food Facilities and Eating

Eating, drinking, and food storage outside the laboratory. Source: Berkeley Lab EHS.

Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption are not permitted in BL1 and BL2 laboratory areas. Food must be stored outside the laboratory area in cabinets or refrigerators designated and used for this purpose.

Laboratory Tools and Equipment

• Sharps

This section describes types and hazards of sharps, states requirements from biosafety standards, and outlines Berkeley Lab’s policies on sharps related to biosafety. A sharp is an object that can penetrate the skin. A sharp is often a tool, device, or material that typically has a sharp edge or point such as a needle, scalpel, razor, blade, broken glass piece, broken capillary tube, or an exposed wire end.

Sharps examples. Source: Berkeley Lab EHS.

Sharps may cause cut or puncture wounds. In addition, sharps contaminated with a biological material may result in the parenteral inoculation of a worker with an infectious or recombinant agent that may cause a laboratory-acquired infection or another disease. Parenteral is an adjective that refers to a route of administration that involves piercing the mucous membranes or skin barrier through events such as punctures, lacerations, abrasions, and bites.

Sharp tools are often designed with a built-in safety feature or mechanism that effectively reduces the risk of accidental skin penetration and a biological exposure incident. These tools are called safety-engineered sharps or safety-engineered needles. Examples include devices that blunt, sheathe, or withdraw the sharp when the sharp edge or point has been used or is not in use. The Cal/OSHA Bloodborne Pathogens Standard has specific definitions and requirements for the use of safety-engineered sharps that are discussed in the next section.

• Sharps Risk Assessment and Documentation

Use of sharps should be assessed as part of the risk assessment for work with biological materials. The following general process should be followed:

• The use of sharps is assessed and controls are defined in each:

• • Worker’s JHA for use of sharp tools
  • BUA and ECP for all sharps involved with RG2 and BBP materials

• The sharps risk assessment that is conducted when developing the BUA or ECP should:

• • Evaluate what sharps may be needed or might be present
  • Evaluate if a safer alternative to the sharp can be used to accomplish the work. For example, plasticware should be substituted for glassware whenever possible at BL2.
  • Evaluate available sharp tools and pick the safest device that will accomplish the work. For example:

• • • Safety-engineered needles rather than needles that cannot be sheathed after use
    • Scalpels with longer handles that are often more controllable than razor blades
    • Razor-blade holders rather than unprotected blades

• • Evaluate the machine’s point-of-operation guarding if there is an exposed sharp edge or point on a machine. For example:

• • • A cutting blade on a microtome
    • Needles on a colony picking robotic machine

Microtome enclosure, guarding, and blade. Source: Berkeley Lab EHS.	Safety-engineered medical needles (sharps with ESIP). Source: Berkeley Lab EHS.

Use of sharps with RG2 materials should be documented in the BUA. In addition, use of sharps with BBP materials must be documented in the BUA or ECP, and the annual review and update of these plans must reflect changes in technology that eliminate or reduce exposure to BBPs (e.g., newly available devices designed to reduce exposure).

In addition, when the BUA or ECP covers medical procedures or devices that involve exposure to BBP material:

• Sharps withengineered sharps injury protection (ESIP) must be specified and used with a few exceptions. Cal/OSHA defines sharps with ESIP as a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. See the OSHA fact sheet on safety needles and needleless systems for additional information. When a needle must be used as described above, a needle device with ESIP must be used unless one of the following four Cal/OSHA exceptions is documented in the BUA or ECP:

• • No needleless systems or sharps devices with ESIP are available in the marketplace for the procedure.
  • A licensed health-care professional directly involved with a patient’s care determines that available needleless systems or sharps devices with ESIP would compromise the patient’s care or safety.
  • Available needleless systems and sharps devices with ESIP are not more effective in preventing exposure to BBPs than the alternative being used.
  • Sufficient information is not available on the safety performance of needleless systems or sharps devices with ESIP available in the marketplace, and the supervisor or work lead is actively evaluating such devices.

• The WPC Activity or ECP’s annual review and update must:

• • Reflect changes in technology that eliminate or reduce exposure to BBPs (e.g., newly available medical devices designed to reduce needlesticks).
  • Document consideration and implementation of appropriate, commercially available, effective, and safer medical devices.
  • Document how input was solicited from nonmanagerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls.
    

• Sharps Use and Disposal

Sharps must be used and disposed of in accordance with the Laboratory BL1 and BL2 criteria listed below and the Medical and Biohazardous Waste Generator’s Guide (PUB-3095).

• Policies for the safe handling of sharps, such as needles, scalpels, pipettes, and broken glassware, must be developed and implemented. Whenever practical, laboratory supervisors should adopt improved engineering and work-practice controls that reduce the risk of sharps injuries.
• Careful management of needles and other sharps are of primary importance. Needles must not be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand before disposal.
• Used disposable sharps must be carefully placed in conveniently located puncture-resistant containers used for sharps disposal.
• Nondisposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving.
• Broken glassware must not be handled directly. Instead, it must be removed using a brush and dustpan, tongs, or forceps. Plasticware should be substituted for glassware whenever possible.
  

Needles are not recapped. Used needles are placed directly in a sharps container. Sharps containers are closed when two-thirds full. Broken glassware is removed using a broom and dust pan. Source: Berkeley Lab EHS.

• Sharps Injury Reporting and Log
  • See Work Process D.10, Incident, Accident, and Emergency Response, for requirements and procedures related to injury and accident reporting, and Work Process D.3.C, Sharps Injury Log, for requirements and responsibilities related to logging sharps injuries.

• Centrifuges

Rotational energies involved with most centrifuges can generate two serious hazards: mechanical failure, and dispersion of aerosols or droplets. This section describes general classes of centrifuges, and general operation and maintenance guidelines to minimize centrifuge hazards. Elements of these guidelines may or may not be applicable to specific centrifuge operations. Information in this section was adapted from the University of Minnesota’s Bio Basics Fact Sheet: Centrifuge Safety.

There are three general classes of centrifuges:

• Low-speed centrifuges that do not exceed 5,000 rpm are commonly made for benchtop use.
• High-speed centrifuges that do not exceed 25,000 rpm may include benchtop or floor models.
• Ultracentrifuges that may exceed 100,000 rpm are often found in core equipment areas. These centrifuges are the most expensive and potentially the most dangerous.
  

Centrifuges. Source: Berkeley Lab EHS.

• Centrifugation Operation Guidelines

• Before centrifugation:

• Each operator should review or be instructed on proper operating procedures and necessary information from the user manual.
• Use only rotors compatible with the centrifuge. Check the expiration date for ultracentrifuge rotors.
• Check tubes, bottles, and rotors for cracks and deformities before each use.
• Make sure that the rotor, tubes, and spindle are dry and clean.
• Examine O-rings. Replace if worn, cracked, or missing.
• Never overfill centrifuge tubes (do not exceed three-fourths full).
• Cap tubes before centrifugation.
• Balance buckets, tubes, and rotors properly.
• Check that the rotor is seated on the drive correctly, put lid on rotor, close the lid on the centrifuge, and secure it.
• When using swinging bucket rotors, make sure that all buckets are hooked correctly and move freely.
  

Large and small centrifuge rotors, bottles, and tubes. Bottles and tubes with caps and seals. Source: Berkeley Lab EHS.

During centrifugation:

• Keep the lid closed at all times during operation. Never open a centrifuge until the rotor has stopped.
• Do not exceed safe rotor speed.
• The operator should not leave the centrifuge until full operating speed is attained and the machine appears to be running safely without vibration.
• Stop the centrifuge immediately if an unusual condition (e.g., noise or vibration) begins, and rebalance the load if needed. If a loud noise indicates significant mechanical failure such as rotor or container breakage, follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills) of this manual. Report other unusual conditions to the work lead. Evaluation by a manufacturer’s representative may be needed.

After centrifugation:

• Allow the centrifuge to come to a complete stop before opening.
• Wear gloves to remove rotor and samples.
• Check inside of centrifuge for possible spills and leaks. Disinfect centrifuge and rotor thoroughly if necessary.
• Wash hands after removing gloves.

Centrifuging RG2 materials:

Follow the safety procedures noted above plus:

• Place a biohazard label on the centrifuge.
• Wear gloves when handling tubes or rotors.
• Avoid the use of celluloid tubes with biohazards. If celluloid tubes must be used, an appropriate chemical disinfectant must be used to decontaminate them.
• Use sealed safety cups, safety buckets, or sealed rotors with O-ring as secondary containment.
• Fill centrifuge tubes, load into rotors, remove from rotors, and open tubes within a biological safety cabinet.
• Wipe exterior of tubes or bottles with disinfectant prior to loading into rotor or bucket. Seal rotor or bucket, remove outer gloves, and transport to the centrifuge.
• Wait at least 10 minutes after the run to allow aerosols to settle before opening the centrifuge. Check for possible spills or leaks.
• Decontaminate centrifuge interior, safety cups or buckets, and rotors if spills or tube breakage occurs. Follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills).

• Centrifuge Maintenance Guidelines

Centrifuge operation and maintenance manual. Source: Berkeley Lab EHS.

Moisture, chemicals, strong cleaning agents, and other substances can promote corrosion of centrifuge parts and cause centrifuge failure. Long-term centrifuge use may also cause centrifuge failure. The following are general maintenance recommendations:

• Follow manufacturer’s instructions for maintenance and cleaning.
• Keep the centrifuge clean and dry.
• Clean up all nonhazardous spills immediately. Follow guidelines in Appendix G, Section G.5 (Centrifuge Malfunction or Spills), for biohazardous spills.
• Decontaminate rotors used with biological or radioactive materials (e.g., use 10% bleach for 30 minutes followed by 70% ethanol; let air dry to clean rotors and cups).
• Never clean rotors and associated parts with abrasive wire brushes.
• Store the rotor upside down in a dry place, with lids or plugs removed, to prevent condensation.
• Remove adapters after use. Inspect them for corrosion.
• Inspect rotors regularly. Remove rotors from use if they show any signs of defects. Report the defective rotors to a manufacturer’s representative for inspection.
• To avoid rotor failure, record the length of time and speed for each high-speed rotor in a log book. Track and discard rotors according to the manufacturer’s recommended schedule.
  

• Waste Containers

• Containers used to hold medical/biohazardous waste, sharps waste, or pathological waste must be placed in biohazardous waste containers and bags in accordance with the Medical and Biohazardous Waste Generator’s Guide (PUB-3095).

• Equipment Connected to Building Vacuum Systems

Flask disinfectant trap with inline HEPA filter to protect the house vacuum system. Source: Berkeley Lab EHS.

House vacuum systems used to evacuate air from containers, enclosures, or lines that contain biological materials should be equipped with a HEPA filter (or equivalent filter) to prevent biological materials or aerosols from being sucked inadvertently into the vacuum line. This is a general guideline for all biological materials, but the BMBL criteria for BL2 laboratory facilities specifically states that vacuum lines should be protected with a HEPA filter or equivalent, the filter must be replaced as needed, and liquid disinfectant traps may be required. Liquid disinfectant traps and filters typically used in conjunction with tissue culture work inside a BSC are further detailed in Appendix E, Section E.3.3, of this Biosafety Program.

7. Decontamination, Waste, and Decommissioning

• Work surfaces, work areas, furniture, equipment, materials, and wastes involved in most work with biological materials must be routinely decontaminated during the work, and prior to transfer or disposal. This section (1) discusses principles of decontamination; (2) provides examples of antimicrobials used to decontaminate; and (3) summarizes or references requirements from the standards related to antimicrobials and decontamination of surfaces, equipment, and wastes. See the following policy sections and standards for additional information:

• Appendix F of this manual for more detailed information on decontamination processes and antimicrobials
• BMBL, Appendix B, for BMBL guidance on strategies for decontaminating laboratory surfaces, items, and areas

• Decontamination Processes and Antimicrobials 

Decontamination is a process that uses an antimicrobial to reduce or inactivate biological contaminants or components to an acceptable level so as to reduce or eliminate the possibility of transmitting pathogens to undesired hosts. An antimicrobial is a chemical or physical agent that is used in a decontamination process to prevent microbial growth. Prevention of microbial growth and pathogen transmission is needed to control contamination of the work, and to prevent disease in hosts such as laboratory workers, the general public, and other organisms in the environment. The decontamination process, level, antimicrobial, frequency, and specific method should be based on the work activity, agents that need inactivation, and decontamination objectives or requirements. Decontamination and waste disposal must be conducted in accordance with the following standards and requirements:

• BL criteria in BMBL (Section IV, Laboratory Biosafety Level Criteria), NIH Guidelines (e.g., Appendix G, Physical Containment), and Biosafety Program (e.g., Appendix C, Laboratory Biosafety Level 1 and 2 Criteria).
• Decontamination requirements in BMBL (e.g., Appendix B) and the Biosafety Program (this section and Appendix F, Decontamination and Antimicrobials).
• Housekeeping, decontamination, and disposal requirements in the Cal/OSHA Bloodborne Pathogens Standard and Biosafety Program.
• Specific permit conditions listed on permits issued to individuals by the USDA Animal and Plant Health Inspection Service (APHIS) for organisms, agents, or materials that are considered pests.
• Requirements for waste covered in the California Medical Waste Management Act and the Berkeley Lab Medical and Biohazardous Waste Generator’s Guide (PUB-3095).

Antimicrobial information. Source: Berkeley Lab EHS.

Definitions of decontamination processes and levels, along with common examples of antimicrobials and processes, are listed in Table 12 below. Refer to Appendix F of this manual for additional information on decontamination and antimicrobials.

When using a chemical or physical antimicrobial to ensure decontamination is accomplished for biosafety purposes (i.e., protection of workers, public, agriculture, or environment):

• There should be information indicating that the selected antimicrobial will be effective when used in a certain manner for the biological materials or agents and equipment or surfaces that need to be decontaminated; and
• The antimicrobial should be used in accordance with its antimicrobial activity capabilities and conditions of use.

Antimicrobial information in Appendix F of this manual, information provided by manufacturers (e.g., labels or technical specifications), and other information may be used for selecting and using the appropriate antimicrobial. Effective decontamination can also be ensured by using an Environmental Protection Agency (EPA)–registered or Food and Drug Administration (FDA)-cleared antimicrobial product within its manufacturer-specified limits. See Appendix F, Section F.2.3, of this manual for additional information on commercial disinfectants and sterilants registered or cleared by the EPA and FDA.

Table 12. Decontamination Processes, Levels, and Antimicrobial Examples*

General Decontamination Process and Level	Antimicrobial Example	Example Decontamination Process
Sterilization is the process of completely destroying or eliminating all living microorganisms and viruses.	Wet heat-steam	Autoclave at 121°C (250°F) for 15 minutes or more.
	Dry heat	Bake at 171°C for at least 1 hour, or Incinerate.
	Wet or dry heat	Place solid waste in a biohazardous-waste container for autoclaving or incineration by a licensed Berkeley Lab subcontractor.
Disinfection is the process of generally destroying or irreversibly inactivating nearly all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores) on inanimate surfaces or objects.	Chlorine in sodium hypochlorite	Wipe clean hard work surfaces and equipment with a 1% solution of fresh household bleach, and allow to air dry for intermediate-level disinfection.
		Add household bleach to liquid biohazardous spills or liquid waste until a 10% concentration of household bleach is achieved for 20 minutes for high-level disinfection.
	Ethyl or isopropyl alcohol	Wipe clean hard work surfaces with a 70% solution of alcohol for low-level disinfection.
		Submerge precleaned items in 70% alcohol for 10 minutes for intermediate-level disinfection.
	Iodine	Wipe clean hard work surfaces with an idophor such as Wescodyne® for intermediate-level disinfection.
	Formaldehyde	Use formaldehyde in water (i.e., formalin) or in alcohol at 1% to 8% for low- to high-level disinfection, respectively.
	Ultraviolet (UV) light	UV light inside biosafety cabinet. Not recom-mended as a biosafety control because disinfection is limited, and light damages human tissue.
Sanitization is the process of generally reducing, but not necessarily eliminating, microbes from the inanimate environment to levels that are considered safe by public health standards.	Sanitizer products designed for food or nonfood contact	Using a sanitizer in a toilet bowl tank, laundry-service clothes washer for laboratory coats, laboratory dishwasher for laboratory glassware, kitchen dishwasher for food dishes, cage washer for animal cages, or clean-in-place process units for large-scale fermenters
Antisepsis is the application of a liquid antimicrobial chemical to human or animal living tissue.	Iodine	Wash hands with Betadine® skin cleanser containing povidone-iodine (PVP-I), or apply 10% PVP-I solution in water to the injection site on a research animal.

* See Appendix F of this manual for additional information and specific conditions.

Decontamination processes and antimicrobials: autoclave sterilization with wet heat-steam, low-level surface disinfection with alcohol, glassware sanitization by washing with cleaners. Source: Berkeley Lab EHS.

Steam heat used in autoclaves is also a common laboratory antimicrobial. An autoclave is a piece of equipment with a chamber used to sterilize items by applying wet heat (i.e., high-pressure steam) at temperatures above the normal boiling point of water and pressures above normal atmospheric pressure. Autoclaves are used to sterilize laboratory equipment or materials such as glassware, media, reagents, or waste. See Appendix F, Section F.5, of this manual for general information and guidelines on autoclave principles, operation, and maintenance typically needed to sterilize equipment and ensure operator safety.

The Cal/OSHA Bloodborne Pathogens Standard requires that work surfaces contaminated with BBP material (as defined in Work Process B.3.f) must be cleaned with an “appropriate disinfectant.” Appropriate disinfectants include household bleach diluted to concentrations ranging from 1% (i.e., 1:100) to 10% (i.e., 1:10) in water and certain disinfectants registered by the EPA or FDA. Household bleach at these concentrations is one of the most common and effective disinfectants used in the laboratory. Household bleach is a water-based solution of sodium hypochlorite (NaOCl) with a typical concentration of 5.25% by weight of the active sodium hypochlorite ingredient. In the U.S., Clorox® bleach is the best-known brand. See Appendix F, Section F.3.2.1, of this program for additional details on the properties and use of bleach.

How to mix, use, and store bleach so that it is effective Wipe hard work surfaces and equipment with 1% solution of fresh household bleach and allow to air dry Add household bleach to liquid biohazardous spills or liquid waste until a 10% concentration of bleach is achieved for 20 minutes. Household bleach is a water-based solution of sodium hypochlorite (NaOCl) with a typical concentration of 5.25% by weight of the NaOCl active ingredient. Manage bleach’s decay in antimicrobial activity by: Mixing fresh, daily solutions of diluted bleach Storing bleach under favorable conditions, dating bottles, rotating stock, and disposing of older bleach (e.g., greater than 6 to 12 months)

Source: Berkeley Lab EHS

• Surface and Equipment Decontamination

In general, surface and equipment decontamination guidelines for BL1 and BL2 areas include:

• The work area should be cleaned and maintained in a sanitary condition.
• Surfaces or equipment where work with biological materials is conducted should be routinely decontaminated.
• Surfaces, furniture, or equipment contaminated with biohazardous materials should be decontaminated after spills and before repair, maintenance, or removal from the laboratory.
  

Work areas cleaned and maintained in a sanitary condition. Surfaces are routinely decontaminated. Source: Berkeley Lab EHS.

Work surfaces are decontaminated after completion of work or potential contamination. Source: Berkeley Lab EHS.

• Laboratory standard microbiological practices from BMBL and NIH Guidelines (see Appendix C of this manual) specifically require the following surface and equipment decontamination practices:

• At BL1 and BL2, work surfaces must be decontaminated with an appropriate disinfectant after completion of work and after any spill or splash of a potentially infectious or viable recombinant material.
• At BL2, laboratory equipment should be decontaminated on a routine basis and after spills, splashes, or other potential contamination.

• Spills involving infectious materials must be contained, decontaminated, and cleaned by staff properly trained and equipped to work with infectious material.
• Equipment must be decontaminated before repair, maintenance, or removal from the laboratory.
  

3. Waste Decontamination and Disposal

• Laboratory standard microbiological practices and special practices from BMBL and NIH Guidelines (see Appendix C of this manual) for BL1 and BL2 specifically require that all cultures, stocks, and other potentially infectious or viable recombinant materials must be decontaminated before disposal using an effective method. Effective decontamination methods are covered in Work Process D.7, Decontamination, Waste, and Decommissioning; and Appendix F, Decontamination and Antimicrobials, of this manual. Responsibility for decontamination starts with the waste generator. In some cases, the waste generator performs the actual decontamination. In other cases, the generator selects the decontamination system and then prepares the waste materials for treatment by others.

• Contaminated items considered medical/ biohazardous waste. Michigan State University, Office of Radiation, Chemical, and Biological Safety (May 2010).
• Berkeley Lab uses the term “medical/biohazardous waste” to describe wastes that are biological materials or that may be contaminated with biological materials and requires inactivation (i.e., decontamination) in an approved manner prior to final disposal. See the Medical and Biohazardous Waste Generator’s Guide (PUB-3095) for Berkeley Lab definitions and requirements for disposal of medical/biohazardous waste. Decontamination, collection, and disposal of medical/biohazardous waste will be conducted in accordance with PUB-3095, methods approved or known to inactivate the materials, and any requirements specified in regulatory permits (e.g., USDA) issued to individuals
• The EHS Division Waste Management Group manages the disposal of Berkeley Lab medical/biohazardous waste. It also manages the contract with a licensed subcontractor that transports, treats, and disposes of Berkeley Lab’s solid waste as regulated medical waste. Examples of such solid waste include materials that are placed in lined and labeled biohazardous waste containers, biologically contaminated sharps in sharps containers, and pathological materials such as carcasses.
• Although the Waste Management Group manages the waste component of the Biosafety Program, it is the responsibility of the waste generator to ensure that medical/biohazardous waste is properly:

• Inactivated before disposal (e.g., treatment of liquid culture with bleach prior to sanitary sewer disposal), or
• Contained in durable leakproof containers, labeled, and documented in the work area before further handling by the EHS Division or the licensed Berkeley Lab subcontractor.

Sharps container	Biohazardous waste container with clear biohazard bag	Biohazardous waste container, red biohazard bags, and gray pickup container

Labeled and color-coded biohazardous sharps container, waste containers, and autoclave bags. Source: Berkeley Lab EHS. Consult the Medical and Biohazardous Waste Generator’s Guide (PUB-3095) for details on labels and colors for sharps containers, waste containers, and waste bags in designated red-bag or clear-bag areas. A determination must be made in the Biosafety Work Authorization as to whether the work will generate either regulated medical waste (i.e., red-bag waste that is regulated by the California Department of Health Services) or nonregulated biohazardous waste not (i.e., clear-bag waste).

The Joint Genome Institute (JGI) is the only Berkeley Lab site that does not use a licensed subcontractor to dispose of solid biological waste as regulated medical waste. Instead, JGI uses autoclaves to sterilize solid, recombinant, biohazardous waste prior to disposal as detailed in PUB-3095.

• Laboratory and Equipment Decommissioning and Moves

All surfaces and equipment should be cleaned and put into a safe condition prior to vacating laboratory spaces or relocating equipment. The Laboratory’s Space Management Policy in the Requirements and Policies Manual requires that laboratory and shop spaces be cleared of debris and contamination prior to transfer of ownership. The decommissioning section of the CHSP provides a good general description of requirements and resources for decommissioning laboratories and equipment.

Decommissioning should include decontamination and waste-disposal methods appropriate for the biological materials that may be present and the materials or equipment to be decontaminated. Decommissioning may include requirements that:

• Laboratory surfaces and equipment should be decontaminated. Household bleach is commonly used in the concentrations and manners discussed in Appendix F, Section F.3.2.1, of this manual. Appendix F also provides other decontamination methods.
• Biohazard labels should be posted on any equipment or containers that still contain or may be contaminated with RG2 agents or materials as discussed in Work Process D.5, Labels and Signs.
• Dispose of medical/biohazardous waste as described in Work Process D.7.c, Waste Decontamination and Disposal
• BSCs and their filters must be decontaminated with a gaseous decontaminant prior to being moved, unless approved by the Biosafety Officer (see Work Process D.6.d.ii, Hoods and Biosafey Cabinets).

Custodians of equipment that will be moved by the Berkeley Lab Transportation Department must verify that the equipment is free of biological, chemical, and radiological hazards. This verification is accomplished when the equipment custodian places a completed Berkeley Lab Transportation Authorization Form on each piece of equipment to be transported (see ES&H Manual Hazardous Materials Transportation Program). Transportation Authorization Forms are issued to equipment custodians when they request an equipment move through the Work Request Center.

• Access and Security

Laboratory supervisors and work leads conducting work at BL1 or BL2 must enforce Berkeley Lab institutional policies that control access to the site and to laboratory facilities as described in the Berkeley Lab Site Security Plan. Policies and practices include, for example, the hosting of visitors and the issuance of gate passes, badges, and/or keys to control access to the site, building, and/or room based on each individual’s business needs. In addition, laboratory areas should have doors for access control. Consult the Integrated Safeguards and Security Management Web site for security policies and additional information.

Laboratory supervisors and leaders control access to the laboratory and advise entering persons of the hazards and entry requirements. Source: Berkeley Lab EHS.

• In addition to the above access requirements, the following additional controls are applicable when working at BL2:

• Laboratory doors should be self-closing and have locks designed in accordance with Berkeley Lab standards. When the laboratory is unoccupied during nonbusiness hours, access to the laboratory should be controlled (e.g., by locking doors to the laboratory areas and/or doors to the building entrance).
• All persons entering the laboratory must be advised of the potential hazards and meet any specific entry/exit requirements as communicated through laboratory door postings specified in Work Process D.5, Labels and Signs, of this manual. Minimum biosafety hazard advisories include a required biohazard symbol posted at the entrance to the BL2 laboratory. Any additional biosafety requirements necessary for advising and protecting personnel entering and exiting the area will be specified in the BUA based on a risk assessment.

Additional security assessments and security measures should be considered when select agents, other agents of high public health or agricultural concern, or agents of high commercial value are introduced into the laboratory. In this case, advisory recommendations of Section VI (Principles of Laboratory Biosecurity) of BMBL should be considered. In addition, when a security risk assessment has determined that additional physical security measures are needed to mitigate specific vulnerabilities, the laboratory or facility may be designated a property protection area. Lastly, when the agents are select agents or toxins (see Work Process B.3.d, Pathogenic Agents and Toxins), then the security requirements of the select agent regulations must be implemented as outlined in a specific security plan for the laboratory or building. The term “biosecurity” is often used to describe the administrative and physical security measures used to protect higher-consequence microbial agents or toxins from loss, theft, diversion, or intentional misuse.

• Pest Management

Biosafety level (e.g., BL1 and BL2) criteria in BMBL and the NIH Guidelines require a program to control pests such as insects and rodents. Pests such as flies, cockroaches, ants, or mice can mechanically transmit biological materials and pathogens.

Fly paper in greenhouse. Source: Berkeley Lab EHS.

Appendix G of BMBL provides guidance and requirements for Integrated Pest Management (IPM). IPM is a comprehensive program approach that integrates housekeeping, maintenance, and pest control services. The primary goal of IPM is to prevent pest problems by managing the facility environment to make it less conducive to pest infestation. Along with limited applications of pesticides, pest control is achieved through proactive operational and administrative intervention strategies to correct conditions that foster pest problems. Research supervisors, work leads, and Berkeley Lab Facilities are each responsible for elements of IPM for each operation.

The Berkeley Lab Facilities Division is responsible for the general construction and maintenance of facilities including the design of laboratory buildings, periodic floor cleaning, disposal of general trash, and pest management. Pest management includes maintenance of a contract with a licensed California state/county applicator to provide insect and rodent control services. The licensed applicator conducts preventative services (e.g., periodically spraying the foundation of a building) and controls reported infestations. The Facilities Division also maintains the Facilities Work Request Center (510-486-6274) to track and respond to requests to repair and clean facilities and control infestations.

Facilities pest control services. Source: Berkeley Lab EHS.

Research supervisors and work leads must ensure implementation of the following IPM elements:

• Program area surfaces and equipment can be easily cleaned (see Work Process D.6.a, Cleanable Surfaces and Furnishings) and are routinely cleaned and decontaminated (see Work Process D.7.b, Surface and Equipment Decontamination) .
• Medical/biohazardous wastes are routinely placed in designated waste collection barrels (see Work Process D.7.c, Waste Decontamination and Disposal).
• The Facilities Work Request Center is contacted if additional services are needed from the Facilities Division to repair or clean the facility, or to control a pest infestation.

The following general guidelines may be used to prevent or control rodent infestations:

• Use rodent-proof containers with tight-fitting lids for storing food, washed utensils, and garbage so that rodents are not attracted to the building. Dispose of trash as soon as possible.
• Seal, screen, and cover all building openings greater than a quarter of an inch.
• Place sheds, woodpiles, or other structures and debris away (e.g., 100 feet) from buildings. Cut grass, brush, and dense shrubbery.
• If a building has been abandoned or closed for long periods, open doors and windows to help ventilate the building, and then wait for at least 30 minutes before entering. Use mechanical ventilation if needed.
• Use spring-loaded traps or appropriate EPA-approved rodenticides to control the rodent population.

See Appendix G, Biological Spills and Cleanup, of this manual for guidelines on the cleanup of small dead animals, nests, or droppings.

• Incident, Accident, and Emergency Response

• This section outlines policy-related incident response and reporting. Biosafety-related incidents may include worker exposure to biological material, injuries or illnesses involving or resulting from exposure to biological material, spillage of biological material, or release of biological material outside of biosafety secondary containment. Such incidents may require reporting, medical evaluation and treatment, emergency response, incident review and documentation, and/or corrective actions.
• Response to biosafety-related incidents will be managed in accordance with this section and the following guidelines, policies, and authorizations:

• Berkeley Lab Emergency Guide
• ES&H ManualInjury Response and ReviewProgram
• ES&H ManualEmergency Management Program
• PUB-533, Master Emergency Program Planfor Berkeley Lab
• OCA Lessons Learned Program
• ES&H Manual Occurrence ReportingProgram
• Safeguards and Security Program Planning and Management, DOE Program 470.4-1, Section N (Incidents of Security Concern)
• Applicable Biosafety Work Authorizations (see Work Process D.2, Training, Instruction, and Qualification)

• General Incident Response and Reporting

• • ES&H ManualInjury Response and Review program also provides general requirements for incident reviewing and reporting such as responding to emergencies and reporting and reviewing incidents and occupational injuries or illnesses.
  • Worker instructions for reporting incidents and general emergency response are covered in the Berkeley Lab Emergency Guide. This guide provides response guidelines for a variety of common emergencies, including biological spills and personal injury. It also provides both emergency and nonemergency telephone numbers. The guide is available on the Emergency Services Web site and as a wall-mountable flip chart. The Emergency Guide must be posted in areas wherever work with biological materials is conducted, and emergency response guidelines should be employed when responding to incidents.
  • ES&H ManualInjury Response and Review program also provides general requirements for incident reviewing and reporting such as responding to emergencies and reporting and reviewing incidents and occupational injuries or illnesses.
  • Division directors and their designees are also responsible for reporting certain adverse or abnormal occurrences in accordance with ORPS polices and system. In addition to ORPS reporting, incidents of security concern must be reported to Berkeley Lab Security.

• Worker Exposure, Injury, or Illness

• • Puncture wound and potential exposure to biological materials. Source: Berkeley Lab EHS.
  • Workers are responsible for immediately reporting all occupational injuries, illnesses, and exposures to biological materials of concern to their supervisor and Health Services. The Biosafety Officer must also be notified of exposures to biological materials of concern or any related illness. Health Services will manage the occupational health case and initiate a Supervisor Accident Analysis Report (SAAR). In addition, an incident review team will be assigned to review the case and determine the causes and any needed actions. See ES&H ManualInjury Response and Review program for additional information.
  • Biological materials of concern related to exposures include materials or animals that may contain agents or properties that have known, potential, or unknown health risks. Examples of materials include all recombinant genomic materials, viable biological microbes in research, or RG2 or higher agents or materials. Examples of worker exposures to such biological materials of concern include:

• • Biological materials in contact with mucous membranes such as eyes, nose, or mouth
  • Biological materials in contact with an open area of skin (e.g., cut or abrasion)
  • Cuts or punctures with sharp objects that may be contaminated with biological materials
  • Exposures to humans or animals in research in a manner that is known to transmit disease
  • Exposure to the blood of other people

• • Additional information on biosafety-related accidents, response, and reporting is contained in the applicable BUA or ECP (see Work Process D.1, Work Authorizations)

• Biological Spills and Cleanup
  

• Supervisors, work leads, and PIs must ensure that spill-response procedures and materials needed to safely respond to biological spills are maintained in operations where biological materials are used.

• Biological spill. Source: Berkeley Lab EHS.
• The Emergency Guide, which must be posted in work areas, provides guidance and materials needed to safely respond to and clean up most biological spills at Berkeley Lab. Additional guidance regarding a variety of biohazardous spills inside and outside of biosafety cabinets is provided in Appendix G. Any additional guidance or materials needed to safely respond to or clean up biological spills must be included in the operation’s Biosafety Work Authorization (see Work Process D.2).
• Response to biological spills should be conducted in accordance with applicable guidelines or requirements contained in the BiologicalIncidents section of the Emergency Guide, Appendix G of this manual, and the operation’s Biosafety Work Authorization.

• Additional Biosafety Incident Reporting

• Line management, the Biosafety Officer, the Responsible Official, Waste Management, the IBC, and other Berkeley Lab employees have various internal and regulatory responsibilities for reporting biosafety-related incidents. The following incidents must be reported to the Biosafety Officer in the EHS Division:

• Worker exposure to biological materials of concern (see Work Process D.10.b, Worker Exposure, Injury, or Illness.
• Injuries or illnesses involving or resulting from exposure to biological materials (see Work Process D.10.b).
• Release occurring outside of secondary biosafety containment of medical/biohazardous waste, biohazardous materials, recombinant genomic materials, or other regulated biological materials that have not been inactivated.
• Incidents related to select agents or toxins(see descriptions in Work Process B.3.d.v, Select Agents and Toxins)
• Biosafety-related regulatory inspections or findings.

• Release outside of secondary containment includes, for example:

• Spill of a material outside of its laboratory facility and outside of its primary and secondary containers.
• Medical/biohazardous waste that has not been decontaminated but is disposed of in a sanitary sewer or in trash outside the laboratory where the work is conducted.
• Environmental release of a viable agent, animal, plant, or pest material that is regulated against release or may cause damage to humans, plants, animals, or the environment.

• Procurement, Transportation, and Transfer

• Procurement

• Procurement of biological agents, biological toxins, and other selected laboratory equipment or supplies are controlled at Berkeley Lab using a graded approach through the procurement process. These controls are designed to screen for biosafety and other hazards. They also provide a means for EHS to assist requestors in implementing biosafety controls or complying with regulations. The following Berkeley Lab procurement controls are related to biosafety:

• Expenditures for goods and services must be performed in accordance with Berkeley Lab procurement policies and through the Procurement and Property Management Department.
• Only personnel authorized by the Chief Financial Officer or the Procurement and Property Manager may commit the Laboratory to goods or services. These authorized personnel categorize items to be procured so that assigned EHS personnel will be notified of the procurement.
• EHS personnel notification or pre-approval for EHS-related items that are on the restricted items list. EHS personnel are notified of items such as, but not limited to, biosafety cabinets, hoods, HEPA filters, chemicals, gases, eyewashes, safety showers, respirators, dust masks, and laboratory refrigerators. Items specific to biosafety that are on the restricted items list include:

• Select agents and toxins. Only individuals in Berkeley Lab Procurement may purchase select agents or toxins (see Work Process B.3.d.v, Select Agents and Toxins; and Appendix B, Section B.2, NIH Guidelines Human Etiologic Agents, of this program) with approval from the Biosafety Officer.
• Biosafety cabinets. Selected EHS industrial hygienists are e-mailed a notification that procurement of a BSC has been initiated, and the hygienist contacts the requestor as needed.
  

• Transportation and Shipping

• Employees who wish to transport or ship a biological material must ensure the material is moved safely and in accordance with Berkeley Lab biosafety transportation and shipping policy detailed in Appendix H of this manual. Appendix H should be used to assess whether the material is a regulated biological material and how it should be moved. Berkeley Lab’s policy for workers handling materials at the Laboratory is based on biosafety requirements and U.S. and international transportation and shipping regulations. A number of biological materials may be transported directly by Berkeley Lab researchers in accordance with Laboratory requirements, but all biological materials shipped by a contracted shipping company (e.g., a common carrier such as FedEx or UPS) must be moved through Berkeley Lab Receiving, Transportation, and Shipping. See Appendix H for additional information.

• Import, Export, and Transfer Restrictions

• Materials being transferred (i.e., imported, exported, or transferred) from one location or person to another may be subject to regulatory restrictions or permit requirements. U.S., state, and foreign government agencies restrict and permit the movement of certain biological materials across borders to prevent threats to public health, agriculture, environment, and national security.
• The supervisor, work lead, person transferring the biological material, person requesting transfer of the biological material, and permit holder all have Berkeley Lab or legal responsibilities for complying with transfer requirements, obtaining any required permits, and following the conditions of the permit. Regulatory requirements, permits, and permit conditions related to the transfer of biological materials should also be included in the Biosafety Work Authorization. The Berkeley Lab Biosafety Office and IBC will review the researcher’s assessment and documentation of transfer requirements during the work-authorization review process.
• Appendix I of this manual provides an outline of U.S.-based regulatory restrictions, permits, and lists related to the transfer (i.e., import, export, or transfer) of biological and related materials. Appendix I may be used by Berkeley Lab personnel as a starting point for determining whether biological materials are potentially regulated by U.S. agencies. It may also be used to determine whether there are restrictions or permits applicable to transfer of the material. Contact the Berkeley Lab Biosafety Office for additional advice.
• General controls for exporting from Berkeley Lab are outlined in the Berkeley Lab Export Control Program. Export controls are based on government rules and regulations that govern the transfer of the following items to non-U.S. entities or individuals, regardless of where or how the transfer takes place:

• Goods (systems, components, equipment, or materials)
• Technologies (technical data, information, or assistance)
• Software/codes (commercial or custom)

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Work Process E. Assessment and Improvement

• The fifth core function of Integrated Safety Management (ISM) requires that feedback and continuous improvement are incorporated into the work cycle for activities that involve work with biological materials or exposure to biological materials. This function is accomplished when supervisors, work leads, PIs, line management, EHS, and others assess and continuously improve the biosafety of work conducted at Berkeley Lab.
• Established assessment and continuous improvement systems are used at Berkeley Lab and incorporated into the Biosafety Program to assess ISM implementation and effectiveness, identify improvement opportunities, and implement appropriate improvement strategies. The Berkeley Lab assessment and improvement requirements and systems are defined in institutional and ES&H assurance systems documents.
• This section provides an overview of how assessment and improvement are incorporated into work with biological materials and the Biosafety Program. These are based primarily on the Berkeley Lab’s Environment/Health/Safety/Security Assurance Systems Manual. Berkeley Lab uses the self-assessment process to ensure that ISM is fully implemented and effective at all levels of Laboratory activities and operations. Two self-assessment programs are described in this section: Division Self-Assessments and Program Self-Assessments (PSAs). Two other self-assessments, Division ES&H Peer Reviews and DOE/UC annual contract performance measures, are mentioned briefly below.

• Division Self-Assessments

• The Division Self-Assessment Program requires each Berkeley Lab division to evaluate how well the division is maintaining an Integrated Safety Management System (ISMS) in its operations and work activities. Each division manages a Division Self-Assessment Program as part of the Berkeley Lab Self-Assessment Program. The Division Self-Assessment Program includes performance criteria related to the ISM plan, goals and opportunities identified by the division, and annual institutional division ES&H self-assessment performance measures. Requirements for the Division Self-Assessment Program are described in the Division ES&H Self-Assessment Manual (PUB-3105).
• Division self-assessments include biosafety as one aspect of ES&H that needs to be managed and assessed. These assessments include, for example, regular safety walkarounds, annual formal inspections of all operations and workspaces, tracking and analysis of deficiencies, lessons learned, and conformance with formal authorizations such as BUAs.

2. Program Self-Assessments

• The EHS Division manages Program Self-Assessments as one component of Berkeley Lab assurance systems. Program Self-Assessments evaluate ES&H programs and processes Laboratory-wide to ensure they comply with guiding regulations, are effective, and are properly implemented by Laboratory divisions. Requirements for Program Self-Assessments are described in the Environment/Health/Safety/Security Assurance Systems Manual.
• The EHS Division conducts periodic assessments of biosafety program elements as defined in the program self-assessment plans. Plans that are applicable to the Biosafety Program are listed in Table 11.

Table 11 Biosafety-related Program Self-Assessments

Program Self-Assessment	EHS Group	Examples of Assessed Biosafety Program Elements
Biosafety	Health & Safety	Field assessments of operations that have Biosafety Work Authorizations. Data review including biosafety training, biosafety authorization renewals, and biosafety cabinet certifications
Ventilation	Health & Safety	Random sampling of hood and biosafety cabinet condition, performance, installation, and compliance with internal survey or certification requirements
Medical/ Biohazardous Waste	Waste Management	Periodic compliance inspections of medical and biohazardous waste generation areas using inspection forms. Documentation and data review including waste-generator registration, biosafety authorizations, and medical/biohazardous waste training to monitor issues related to medical or biohazardous waste.

• In general, Program Self-Assessments determine whether the ES&H program (e.g., the Berkeley Lab Biosafety Program) under evaluation is compliant and effective, operations (e.g., work authorizations) and divisions are compliant, corrective actions and lessons learned are implemented and effective, and opportunities for improvement in the Berkeley Lab ES&H program or process are available. Inspections, data reviews, and document reviews are performed as part of the Program Self-Assessment. Data reviews include issues documented in the Corrective Action Tracking System (CATS), injuries or illnesses in the Comprehensive Environment, Health, and Safety System (CHESS) system, items in the Lessons Learned and Best Practices Database, and occurrence reports in the Occurrence Reporting and Processing System (ORPS). This assessment also reports any needed corrective action to the responsible management chain responsible for entering actions into CATS.

• Other Environment, Safety, and Health Self-Assessment Programs

• Berkeley Lab uses two other types of ES&H self-assessments: Division ES&H Peer Reviews and annual DOE/UC Contract ES&H performance measures. Peer reviews are management-level peer reviews focused on how well division managers implement the division’s ISM plan. Contract performance assessments evaluate performance against annual goals, objectives, measures, and targets for ES&H. These two types of assessments provide broad ISM support to the Berkeley Lab Biosafety Program.
• Supervisors, work leads, and PIs must:

• Conduct periodic ES&H assessments of their operation as specified in the Division Self-Assessment Program, including assessment of the safety of tasks being performed, safety of the work area and equipment, training, and compliance with the Biosafety Work Authorization and standards
• Participate in periodic biosafety and other program self-assessments assessments of their operation when scheduled by EHS
• Continuously improve the biosafety of their work, including correcting deficiencies and tracking actions in CATS when required
• Update their Biosafety Work Authorization with changes in personnel, training requirements, locations, and significant changes in the work

• Supervisors, work leads, and PIs may use the following key resources to assess the biosafety and compliance of their operations:

• The Biosafety Work Authorization for the operation
• The training requirements and tracking feature for personnel listed on the work authorization in the Biosafety Authorization System (BAS)
• Laboratory BL1 and BL2 criteria listed in Appendix C of this manual

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Work Process F. Institutional Biosafety Committee

• Institutional Biosafety Committee (IBC) Charter
• Policy and Purpose

IBC meeting. Source: Berkeley Lab EHS.

• Berkeley Lab requires the maintenance of a qualified Institutional Biosafety Committee (IBC) to perform key biosafety functions as required by and in accordance with this charter and the NIH, CDC, DOE, and Berkeley Lab standards.
• The IBC is responsible for oversight, administration, and review of Berkeley Lab policies and projects involving research with biological materials that may pose safety, health, or environmental risks. The IBC reports to the Laboratory Director to provide institutional assurance that research is conducted safely. To this end, the IBC assists and advises researchers and line managers in meeting their responsibilities to ensure that the biological aspects of the research are conducted in a safe manner using established biosafety standards, principles, and functions of Integrated Safety Management (ISM), and work authorization (e.g., ES&H Manual, Safe Work Authorizations). Safe research includes worker safety, public health, agricultural and environmental protection, ethics, and compliance with applicable biosafety standards and Berkeley Lab policies. A graded process is used to define, document, review, and approve biological work and controls as detailed in ES&H Manual, Biosafety. This process involves IBC approval and line management authorization of biological work.

• Functions
  • Functions of the IBC include:
    • Administering a program to review, approve, and monitor all Berkeley Lab research projects involving biological materials that may pose differing levels of safety, health, or environmental risk to plants, animals, or humans. The goal is to assure work is conducted in a safe manner.                                                                                                       
    • In this program, the IBC performs initial and periodic review and approval of required project biosafety documentation that demonstrates the work will be conducted in a safe manner. Researchers and line managers are responsible for identifying and submitting project documentation to the IBC prior to performing biological work and periodically thereafter. The IBC’s review includes:
    • Assessment of the containment levels, facilities, procedures, practices, training, and expertise of personnel involved in the proposed research and in comparison to biosafety standards;Concurrence or approval of research projects that have adequate
    • controls and conform to the biosafety standards; and
    • Notifying the PI of the results of the IBC’s review or approval
    •  Serving as a forum to review, make recommendations to appropriate stakeholders, and raise awareness related to biosafety concerns, institutional needs, emerging biosafety issues, and new biosafety requirements

• • • Reviewing and approving Berkeley Lab biosafety policies, and making recommendations to the Laboratory Director on strategic biosafety matters
    • Reviewing and adopting Berkeley Lab emergency plans covering accidental spills and personnel contamination resulting from research and development activities with potentially hazardous biological materials. Site safeguards and security plans for biological etiologic agents (i.e., human pathogens) will also be reviewed.
    • Coordinating Berkeley Lab response to inquiry from the public or external entities related to the IBC
    • Reviewing violations or incidents and determining level of significance and required reporting. Investigating and reporting any significant problems with or violations of the NIH Guidelines and any significant research-related accidents or illnesses involving recombinant genomic materials to line management, the Biosafety Officer, the Laboratory Director, and the NIH Office of Biotechnology Activities (OBA) within 30 days, unless the IBC determines that the PI or lead researcher has already filed a report.
    • Submitting an annual report to the Laboratory Director that includes a roster of IBC members, member roles, and a report of significant IBC and Biosafety Program activities
    • Submitting an annual report to NIH OBA that includes a roster of IBC members, member roles, and biographical sketches of each member
    • Maintaining reviews, minutes, and reports in an orderly and retrievable fashion

IBC Membership

• The Laboratory Director formally appoints all IBC members, and IBC membership is for a minimum three-year period of service. IBC member nominations are managed in the following manner:

• The IBC Chair and Deputy Chair nominations are recommended by the EHS Division Director to the Berkeley Lab Director, who appoints the Chair and Deputy Chair for a three-year period.
• Other IBC members are nominated by their respective division directors to the IBC Chair or Deputy Chair. During the first IBC meeting following such nomination, the IBC will decide by simple majority vote on recommendation of the candidate to IBC membership. The IBC Chair then requests a final decision from the Laboratory Director on appointment of the nominee to serve on the IBC.

• As required by NIH, the IBC must have at least five members that are selected to collectively have the experience, expertise, and capability needed to assess the breadth and safety of recombinant and other Berkeley Lab research with biological materials, agents, and organisms as needed to identify any potential risks to workers, public health, or the environment. Based on the types of research activities at Berkeley Lab, the IBC will normally have the following minimum representation:

• A technical representative from each Berkeley Lab division that conducts research with potentially hazardous biological materials
• The EHS Biological Safety Officer and Program Manager
• An expert in animal-containment principles
• An expert in plant-containment principles (if recombinant plant research is conducted)
• An expert in human research protocols
• A health professional from EHS Health Services
• At least two members not affiliated with Berkeley Lab, who represent the interests of the surrounding community with respect to health and protection of the environment.

IBC practices include:

• In the absence of the IBC Chair, the Deputy Chair will perform Chair duties.
• All IBC members are voting members. Decisions such as approval of research projects or policies are approved when a majority of IBC members vote for approval. No member of the IBC may be involved (except to provide information requested by the IBC) in the review or approval of a project in which he/she has been or expects to be engaged or has a direct financial interest.
• If an institutional member does not attend three meetings throughout the calendar year or participate in reviews of research projects, the IBC Chair may consult the member’s division director to ask that a replacement be nominated.
• The IBC Chair is responsible for ensuring that the IBC members are appropriately trained.

• The IBC may use consulting experts or establish working groups to execute its responsibilities or acquire needed expertise for select tasks. Consultants or working group members may include, for example, persons knowledgeable in institutional commitments and policies, applicable law, standards of professional conduct and practice, community attitudes, the environment, or any scientific area where the IBC members do not have expertise. Consultants or working group members are not IBC voting members unless nominated and appointed as described previously.

IBC Meetings

• The IBC will conduct meetings approximately quarterly and as needed for the conduct of business. A proposed agenda will be developed and distributed before the meeting. Meetings will proceed with no less than five voting members present. Meeting minutes will be taken to accurately reflect the topics of discussion. Meeting minutes will be reviewed, approved by the members, and maintained on file. Meetings will be opened to the public, and minutes will be provided to the public, when requested by the public and in accordance with the scope and requirements of the NIH Guidelines.

IBC and Biosafety Standards

• The following standards have specific requirements for IBCs and biological work:

• NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules(NIH Guidelines), Federal Register (current version)
• Biosafety in Microbiological and Biomedical Laboratories, 5th Edition, CDC and NIH
• Worker Safety and Health Program, DOE 10 CFR 851
• Berkeley Lab ES&H Manual, Chapter 26, Biosafety

• Additional biosafety standards related to Berkeley Lab biological work are summarized below:

• Aerosol Transmissible Diseases Standard, CCR Title 8 Section 5199
• Bloodborne Pathogens Standard, OSHA CCR Title 8 Section 5193
• Select Agents and Toxins, Health and Human Services (HHS) 42 CFR 73, and U.S. Department of Agriculture (USDA) 7 CFR 331 & 9 CFR 121
• Plant Pathogens and Pests, USDA 7 CFR 330
• Animal Pathogens, USDA 9 CFR Parts 92, 94, 95 96, 122 and 130
• Importation of Human Pathogens , U.S. Public Health Service (PHS) 42 CFR 71
• Medical Waste Management, California Administrative Code (CAC) Sections 117600 – 118360

IBC Charter Approval

• IBC members will review proposed amendments to this charter and make recommendations regarding adoption of amendments. The IBC Chair will submit IBC recommendations regarding charter amendments to the Laboratory Director. The Laboratory Director will approve amendments to the IBC Charter.

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