Queen's University Biosafety Manual
Queen's University Biosafety Manual
Biosafety Manual
2013
Queens University
Biosafety Manual 2013
Table of Contents
INTRODUCTION to the Queens Biosafety Program and Manual....................................................... 6
BIOSAFETY OVERVIEW and BASIC CONCEPTS ........................................................................... 7
What is a biohazard? .......................................................................................................................... 7
Risk Groups - How hazardous is it? ................................................................................................... 8
Risk Group 1 .................................................................................................................................. 9
Risk Group 2 .................................................................................................................................. 9
Risk Group 2+ .............................................................................................................................. 10
Risk Group 3 and 4 ....................................................................................................................... 10
Sources of Risk Group Information.............................................................................................. 11
Risk Mitigation and Containment: How can biohazards be used safely? ........................................ 12
Health and Medical Surveillance...................................................................................................... 13
Laboratory-Acquired Infection Case Studies ............................................................................... 13
Medical Surveillance Program at Queens ................................................................................... 14
Local Risk Assessment  the material and what is being done with it ............................................. 15
How is the use of biohazards regulated at Queens? ........................................................................ 17
Government Safety Regulations and Policies on Biohazardous Material .................................... 18
RESPONSIBILITIES ........................................................................................................................... 19
Biohazard Committee ....................................................................................................................... 19
Biosafety Officer .............................................................................................................................. 20
Department of Environmental Health and Safety............................................................................. 20
Department Heads ............................................................................................................................ 20
Principal Investigators ...................................................................................................................... 20
All Other University Personnel and Students working as Biohazard Team Members..................... 22
TRAINING REQUIREMENTS ........................................................................................................... 22
Queens Biosafety Training Program ............................................................................................... 22
CONTAINMENT AND ENGINEERING CONTROLS ..................................................................... 24
Lab Design ....................................................................................................................................... 24
Level 1 Labs ................................................................................................................................. 24
Level 2 Labs ................................................................................................................................. 24
Level 2+ Labs ............................................................................................................................... 25
Lab Design Changes ..................................................................................................................... 25
Queens University Biosafety Manual 2013
promote and reinforce safe work practices, improve safety performance, and increase regulatory
compliance through a combination of training, documentation, inspections, evaluation, review,
and communications.
The Queens University Biohazards Committee reviews biohazard applications dealing with
microorganisms that infect humans or both humans and animals (zoonotic pathogens). In addition, the
University Biosafety Officer will assist labs in meeting the legislative requirements for microorganisms
that are strict animal, aquatic animal, or plant pathogens.
Good microbiological laboratory practices are the foundation for all safe work practices involving
biological material.
All personnel who handle potentially infectious material or toxins must be able to demonstrate
proficiency in the Standard Operating Procedures and the lab-specific procedures in which they
have been trained,
And their training must be documented.
The training necessary for an individual to be authorized to work independently with biohazardous
material is related to the containment level in which the individual is working and to the particular
equipment and procedures that they will employ.
When first starting work, check the sign(s) on the door to your lab(s) to determine the
containment level(s).
Note that the training you require is determined by the containment level of the lab in
which you will be working, not by the material with which you will be working. So if you are
working in a level 2 lab with only level 1 material, you still need to do the level 2 training.
Be aware of the biohazard door signs in other labs that you may need to enter, and ensure
that you follow any required entry procedures or precautions while in the lab.
Pathogenicity/Virulence: Is the pathogen able to infect and cause disease in humans or animals
(i.e., pathogenicity)? What is the degree of disease severity in individuals (i.e., virulence)?
Route of Infection: How does the pathogen gain entry into the host (i.e., ingestion, inhalation,
mucous membranes, subcutaneous, genitourinary)?
Mode of Transmission: How does the pathogen travel to the host (e.g., direct contact, indirect
contact, casual contact, aerosolized droplet or airborne transmission, vectors, zoonosis,
intermediate host)?
Survival in the Environment: How stable is the pathogen outside the host? Under what
environmental conditions can it survive and for how long?
Infectious Dose: What amount of pathogen is required to cause an infection in the host (measured
in number of organisms)?
Availability of Effective Preventative and Therapeutic Treatments: Are effective preventative
measures available (e.g., vaccines)? Are effective treatments available (e.g., antibiotics,
antivirals)?
Host Range: What are the primary, intermediate, and dead-end hosts? Does the pathogen cause
infection in a wide range of species, or is the host range more restricted?
Natural Distribution: Is the pathogen present in Canada? Is it prevalent in a particular location,
region, or human or animal population? Is the pathogen non-indigenous?
Impact of Introduction and/or Release into the Environment or the Canadian Public: If the
pathogen were introduced into the population or released into the environment (within Canada),
what would be the economic, clinical, and biosecurity impact?
While most infectious material will clearly fall into one of the four risk groups outlined below, in some
cases, the level of risk associated with the different risk factors can vary dramatically within a risk
assessment. As a result, certain risk factors may be considered more important when determining
the final risk group. For example, if a pathogen is unlikely to cause disease in humans or animals, it may
Queens University Biosafety Manual 2013
be irrelevant that it can survive in the environment for a long period of time or that there is no available
treatment.
Risk Group 1
Risk Group 1 low individual and community risk
A microorganism, nucleic acid, or protein that is either:
 not capable of causing human or animal disease; or
 capable of causing human or animal disease, but unlikely to do so.
o Those capable of causing disease are considered pathogens that pose a low risk to the
health of individuals and/or animals, and a low risk to public health, livestock or poultry.
o RG1 pathogens can be opportunistic and may pose a threat to
immunocompromised individuals.
o Neither of the RG1 subsets is regulated by the PHAC or the CFIA due to the low risk to
public health, livestock or poultry.
 The culture of RG1 microorganisms and work with research animal tissues that are likely to
contain large quantities of RG1 bacteria (gut tissue), are regulated by the Queens University
Biohazards Committee to ensure that due care is exercised and safe work practices (e.g., good
microbiological practices) are followed when handling these materials. Work with other tissues
from research animals and with the animals themselves is overseen by the University Animal
Care Committee.
 Examples include:
o bacteria such as Bacillus subtilis, Lactobacillus casei, cloning strains of E. coli (K12
strains)
o viruses such as Baculovirus
o fungi such as Schizosaccharomyces
Risk Group 2
Risk Group 2 moderate individual risk and low community risk.
A pathogen that:
 poses a moderate risk to the health of individuals and/or animals and a low risk to public health,
livestock or poultry
 is able to cause serious disease in a human or animal but is unlikely to do so
 the risk of spread of diseases caused by these pathogens is low
 Effective treatment and preventative measures are available
 Examples include:
o Bacteria such as Salmonella typhi, Staphylococcus aureus, Bordatella pertussis
o Viruses such as Herpes simplex virus, Adenovirus, Epstein-Barr virus
o Fungi such as Aspergillus, Candida albicans
o Parasitic agents such as Leishmania species, Giardia lamblia
For Risk Group 2 organisms the primary exposure hazards are through the ingestion, inoculation and
mucous membrane routes. Therefore the risk mitigation measures in the lab are designed to interrupt
these potential routes of infection.
Biological Toxins are classified as Risk Group 2 because they can be effectively handled in a level 2
laboratory.
Risk Group 2+
Risk Group 2+ This is the term commonly used to refer to microorganisms that require a level 2
physical containment facility with level 3 operational practices. These conditions are imposed for
microorganisms:
 for which the hazard is higher than for Risk Group 2 organisms, but which usually are not
transmitted by the airborne route or are lab adapted so likely to have reduced virulence
o e.g. replication incompetent lentiviral vectors carrying a hazardous transgene
o Lymphocytic choriomeningitis virus (lab adapted, nonneurotropic strains)
 for Risk Group 3 microorganisms that are used in low concentration and not cultured.
o e.g. HIV positive blood may be used at containment level 2+, but HIV may not be
cultured except in a level 3 containment facility.
Although it is in common use, the 2+ designation is not recognized by Public Health Agency of Canada
(PHAC) or the Canadian Food Inspection Agency (CFIA) so you will not see this short form used in
official federal documents like the Canadian Biosafety Standards and Guidelines, or on import permits.
 The level 3 operational practices required are only those that can be done in a level 2 facility.
 The personal protective equipment required depends on the organism and the work being done
with it.
 According to the requirements issued by PHAC, no one may enter a 2+ laboratory until they have
been trained about the specific hazards and procedures involved and have demonstrated
knowledge and understanding (i.e. by writing a quiz).
 The training requirement and other requirements might change in the future for some organisms,
so be sure to read and comply with the stipulations on the Canadian import permit and the
Queens University Biohazard Permit for the organism you are using.
 In brief, all work with 2+ organisms must be:
o done in a biological safety cabinet
o centrifugation must be done in closed tubes in sealed safety cups that are opened only in
the biological safety cabinet
o At Queens, specific individualized operational procedures are written and approved by
the Biohazard Committee for each 2+ laboratory as part of the biohazard permit
application process.
o Everyone entering the 2+ lab must be trained on the hazards in the lab and procedures
specific to the lab, and there must be written documentation of this training
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Biohazards are contained so that they do not infect personnel inside the laboratory or escape into the
environment outside the laboratory. The methods used for containment are more stringent for biological
material in higher risk groups. Note that containment level is also called the biosafety level (BSL) and
the BSL term is most commonly used in the United States.
The containment required depends in part on the risk group of the material and in part on what will be
done with the material. The containment level required is often the same as the risk group, but sometimes
the nature of the procedures or the quantity of the organism might increase or decrease the containment
required. For example, HIV is a Risk Group 3 organism. All culturing of HIV must occur in a level 3
containment facility. However, work with HIV infected blood is considered less hazardous and can be
done under level 2+ containment conditions.
Biological containment. If possible, risk should first be mitigated by employing biological containment
methods, which involve decreasing the potential consequences of exposure by using genetically modified
or otherwise attenuated or lab adapted organisms that are less hazardous (e.g. using K12 derived strains of
E. coli for molecular biology; using late generation replication incompetent viral vectors; using lab
adapted strains or attenuated strains of bacteria or viruses as models for more virulent strains).
Physical containment is provided by physical barriers that prevent or minimize the escape of
biohazardous materials from the work area. Lab design requirements vary depending on the containment
level and whether or not animals are intentionally infected.
Physical containment often requires labs with:
 surfaces that can be readily decontaminated
 sinks for hand washing
 eyewashes (and safety showers depending on lab use)
 lockable doors
 storage areas for personal protective equipment (PPE)
 specialized equipment like biological safety cabinets
 once-through ventilation so that air is not recirculated into offices
 labs having negative air pressure relative to the corridor
A containment laboratory must meet specific physical design requirements and provide equipment for
containment as described in the Canadian Biosafety Standards and Guidelines (CBSG), 2013, Chapter 3
of the Standards section.
Before a laboratory is used for work with biohazardous materials it must be inspected by members
of the University Biohazard Committee to ensure that the Standards are met.
Operational containment refers to the practices used when working with biological materials to
minimize exposure, including the type of equipment, where and how it is used, and the personal
protective equipment to be worn. The operational procedures required for each level of containment are
described in detail in Chapter 4 of the Canadian Biosafety Standards and Guidelines (CBSG), and later in
this manual. Biosafety level 1 containment involves good general laboratory practices that include the
use of appropriate personal protective equipment. Biosafety level 2 containment involves enhanced
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practices to avoid splashes, the generation of aerosols and environmental contamination. Biosafety level
2+ employs the level 3 operational practices that can be employed in a level 2 physical facility.
Aerosols are fine droplets of liquid that can carry infectious organisms and stay suspended in the air
for various periods of time depending on the size of the droplet. Aerosols are produced when force is
applied to a liquid (e.g., pipetting, blending, sonicating, vortexing, centrifugation).
The effective containment of any aerosols that are produced due to the nature of the activity, and the
minimization of aerosol generation where possible, are key considerations in determining the appropriate
procedures and containment practices to employ.
 Fine aerosols are an inhalation hazard for agents that are infective via this route.
 Aerosols carrying infectious agents can settle on bench tops and become an ingestion or mucosal
exposure hazard through contamination of the hands.
There is general agreement that aerosol generation by procedures is the probable source of many
laboratory acquired infections, particularly in cases involving workers whose only known risk factor was
that they worked with an agent or in an area where that work was done (i.e. there was no known exposure
incident). If the production of significant Risk Group 2 aerosols is unavoidable, then aerosols must
be contained by using equipment such as a biological safety cabinet (BSC).
1. A researcher was using a strain of Salmonella as a host for DNA coding for the production of an
enzyme of interest for a pharmaceutical use. When asked if the strain of Salmonella was
debilitated in some way, the researcher indignantly said Why of course it is. However lab
members reported that although they had been told it was debilitated, every new person in the lab
had a little diarrhea when they first started working there, but got over it and didnt have any
other problems. Fortunately they never had any lab members who were immunocompromised or
they might have had much more serious disease caused by the infection. (Anecdote provided by a
Biosafety Officer at another University)
2. On September 18, 2009, the Chicago Department of Public Health (CDPH) was notified by a
local hospital of a suspected case of fatal laboratory-acquired infection with Yersinia pestis, the
causative agent of plague. The patient, a researcher in a university laboratory, had been working
with an attenuated pigmentation-negative (pgm-) attenuated Y. pestis strain. The strain had not
been known to have caused laboratory-acquired infections or human fatalities and would be
classified as Risk Group 2.
Although the route of transmission for the infection remains unclear, deficiencies in biosafety
practices, including inconsistent use of gloves, could have resulted in inadvertent transdermal
exposure.
A U.S. federal investigation determined that the cause of death likely was an unrecognized
occupational exposure (route unknown) to Y. pestis, leading to septic shock. The severe outcome
experienced by the patient was unexpected, given that he had worked with an attenuated Y. pestis
strain that 1) is widely used by laboratory researchers, 2) has not been associated with previous
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In both of the case studies above, the infections were caused by not using the appropriate CL2
containment practices for the organisms, and the responses to infection were suboptimal.
 In the first case, lab personnel were unwise to accept becoming ill, even for a short period of
time, as a necessary part of the introduction to the lab. The symptoms were an indication of
improper technique and should have been reported so that improvements in facilities, equipment
and/or operational practices could be made.
 Personnel should recognize that infections that cause mild disease in one individual can cause
serious disease in others. Underlying medical conditions may not be recognized until someone
becomes uncharacteristically ill, so lab-acquired infections should not be tolerated and must
be reported to their supervisor and the Biosafety Officer.
 It is important for everyone to remember the symptoms of the disease that can be caused by the
microorganisms with which they work, and to inform their physicians about it if they become
ill. The fatal outcome from Y. pestis infection in the first case might have been averted had the
researcher recognized the possibility that his symptoms were caused by a microorganism with
which he worked and reported this to the physicians whom he consulted.
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If the organism being worked with has been attenuated or genetically altered to be less
hazardous than wild-type, individuals should be aware of the mechanism of attenuation
(if known) and any conditions that might make the attenuated organism more pathogenic
for them.
Changes in health status that might affect immune responsiveness (immune-compromised) should
be reported.
o For these individuals, some risk group 1 microorganisms which do not normally
cause disease can be pathogenic and Risk group 2 microorganisms can cause much
more severe disease than normal, or even death.
o Note that, without the need to reveal personal medical information, the occurrence of a
change in an individuals health that might influence their susceptibility to infection
should be reported to your supervisor so that, if necessary, appropriate adjustments in the
operations or risk mitigation methods can be made in consultation with their personal
physician and/or the Queens University Occupational Health Services provider or other
medical experts as necessary.
o Conditions of concern include:
 Pregnancy (pregnant women may need to take extra precautions or be reassigned
to other duties early in their pregnancy because certain microorganisms can
damage the fetus and because their own immune responsiveness may be altered)
 Immune-deficiency
 Immune-suppressive drugs (e.g. with organ transplantation)
 Anti-inflammatory medications
 Cancer
 Treatment for cancer
 Age (the elderly; also very young children are more susceptible to infection,
which is one of the reasons that they are not permitted in research laboratories)
 Other conditions as determined by your physician
o
Occupational Health services for personnel working in and around Queens research
laboratories is available through Walsh and Associates Occupational Health Services.
o Details and a map are located at http://www.safety.queensu.ca/walsh/ .
o Charges will be billed to departments through the Department of Environmental Health
and Safety and payment is the responsibility of the supervisor.
Local Risk Assessment  the material and what is being done with it
Biological risk assessment is the basis for the safeguards developed by the federal agencies of many
countries and by the microbiological and biomedical community to protect the health of laboratory
workers and the public from the risks associated with the use of hazardous biological agents in
laboratories. Experience shows that established safe practices, equipment, and facility safeguards work.
Biological risk assessment is a subjective process requiring consideration of the many characteristics of
agents and procedures, and judgments are often based on incomplete information.
It is important to think about what you will be doing with biohazardous material and how you will
reduce the probability that you or someone else might be exposed to and/or infected by the
microorganisms you are culturing or the microorganisms that might be present in biological
material:
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Some thinking will have been done for you and presented in the form of a written local risk
assessment and risk mitigation strategy as part of a Queens biohazard permit application.
It is important that you internalize this thought process and apply it to your day-to-day work
because:
o Safe work practices protect you and your colleagues
o unexpected situations may arise
o you may need to make educated judgments about how to act
o or decide whether it is necessary to consult your supervisor or the Biosafety Officer.
It is a requirement of the Public Health Agency of Canada (PHAC) and the Canadian Food Inspection
Agency (CFIA) that each laboratory performs a detailed local risk assessment (LRA) to determine the
biohazard containment level required for both facilities and operational practices for the biohazardous
agents in use.
The local risk assessment of all work with biohazardous material (Risk Group 1 and 2 and 2+), is to be
documented as part of a Queens University Biohazard Permit Application.
A local risk assessment will:
 identify the Risk Group of the microorganism (or tissue that might contain this microorganism)
 describe the potential hazard associated with the microorganism, including symptoms of disease
(which it is important for all lab members to know so that they will be aware of any potential lab
acquired infection so that it can be diagnosed and treated appropriately)
 indicate whether the material will be used only in vitro, or also in vivo
o what is being done with the material and where; consider the procedures potential for
generating aerosols that might contain and spread infectious agents
o indicate whether or not sharps will be used and the precautions associated with them
o in vivo use of infectious materials increases the risk of exposure, so the facilities and
operational practices for in vivo work must be described separately from that for in vitro
work
 describe the overall risk mitigation strategy and details of this strategy including:
o physical containment and engineering controls (i.e. lab design) This can be indicated
simply by stating which containment level 1 or 2 laboratories will be used for the
different types of work, because the Biohazard Committee inspects all laboratories.
o operational requirements
 containment equipment and supplies
 equipment might include e.g. Biological Safety Cabinet, centrifuge cups
with aerosol resistant lids containing o-rings
 supplies might include e.g. closed, screw-capped tubes
 appropriate personal protective equipment (PPE)
 describe what is to be worn and for which procedures and materials if
there are different PPE requirements
 decontamination and disposal methods
 medical surveillance (e.g. immunization, titre checks, first aid and medical
response to accidental exposure)
 training needs
At Queens the Principal Investigators local risk assessment is documented and appended to the
Biohazard Permit Application along with any applicable microorganism risk assessments from reputable
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sources (e.g. PHAC PSDS) and lab specific procedures/SOPs. Example local risk assessment documents
are available in TRAQ/Romeo Useful Links or from the Biosafety Officer, to assist laboratories when
preparing a Biohazard Application.
 In general, more detail is required for material and activities that pose a greater risk.
 The risk assessment and associated documents are reviewed and approved by the Biohazard
Committee.
 After approval, these documents become an integral part of the training of lab personnel.
 Following approval of a Biohazard Application or a Biohazard Amendment that changes the type
or risk group of material used in the lab (reviewed by the Biohazard Committee), each member of
the biohazard lab team is required to:
o read the approved Biohazard application/amendment and associated documents that are
posted on the TRAQ/Romeo site
o have any questions that they might have answered by their P.I. and/or the Biosafety
Officer
o submit the Biohazard Team Member Attestation form through the TRAQ/Romeo system,
to indicate that they understand and will abide by the requirements for working safely
with the biohazardous material.
If you are new to the lab, as part of your lab orientation you will be required to register so that you have
access to read the approved biohazard permit application and all associated documents on the
TRAQ/Romeo site, have your questions answered, and sign the Biohazard Team Member Attestation
form so that you can be authorized to work in the lab.
The information required in the local risk assessment is described in a template document available in
Useful Links through the TRAQ/Romeo system. If you have questions after reading this document, or
if you would like a pre-review of your risk assessment before formal submission to the Biohazard
Committee, contact the University Biosafety Officer (ext. 77077).
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Those wishing to use any biological material must contact the University Biosafety Officer in the
Department of Environmental Health and Safety (ext. 77077) to determine whether they need to obtain a
permit from the Queens Biohazard Committee prior to importing or commencing work with the material.
Approval from the Biohazard Committee is required before grant funds will be released by the
Office of Research Services.
There are two aspects to biohazard approval:
1. The first is approval of an application to the Biohazard Committee that includes a biohazard
permit application form, a list of biohazardous materials, and a risk assessment and risk
mitigation statement. This process has been paper based and is transitioning to electronic
submission through the TRAQ/Romeo system in late 2013.
2. The second aspect of biohazard approval is an inspection, by two members of the Biohazard
Committee, of the physical set up and operational practices in the laboratory. The frequency of
re-inspection depends on the containment level of the laboratory.
When new biohazardous material is introduced into the lab (e.g. a new cell line, new bacterial strain,
new viral vector), or when there is a new procedure that might affect the risk of exposure (e.g. sonication,
starting to use sharps, starting in vivo work), an application to amend the existing biohazard permit
must be made.
Any PHAC- or CFIA-imposed containment requirements will be monitored by the Queens Biohazard
Committee and will require a Queens Biohazard Permit Application and laboratory inspection.
See Queens SOP-Biosafety-05 for a more detailed description of what biological material is regulated
through the Biohazard Committee.
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Canadian Biosafety Standards and Guidelines (CBSG), 1st Edition, 2013 will form the basis of
regulations under the Human Pathogens and Toxins Act.
o The CBSG describes the best practices for work with all human or terrestrial animal
pathogens and, under Canadian law, must be followed for Risk Group 2 pathogens and
above.
o Updates and harmonizes three previous Canadian biosafety standards and guidelines for the
design, construction and operation of facilities in which pathogens or toxins are handled or
stored.
o Replaces the following documents:
 Human pathogens and toxins: Laboratory Biosafety Guidelines, 3rd Edition, 2014
(PHAC)
 Terrestrial animal pathogens: Containment Standards for Veterinary Facilities, 1st
Edition , 1996 (CFIA)
 Prions: Containment Standards for Laboratories, Animal Facilities and Post Mortem
Rooms handling Prion Disease Agents, 1st Edition, 2005 (CFIA)
The CBSG contains:
o The Standards (matrices in Part I of the CBSG) that are the risk-based containment
requirements (physical and operational ) for any laboratory using,
 human pathogens (Risk Group 2 and above)
 prions
 terrestrial animal pathogens if they are imported into Canada
 non-indigenous terrestrial animal pathogens
 toxins from microorganisms listed in Schedule 1 of the HPTA
 Requirements for the importation, exportation, transfer between laboratories and
institutions within Canada, and the transportation of the pathogens it regulates.
o
A Transition Index, (in the middle of the CBSG), that provides information on:
 why a requirement from the Standards is needed
 supplementary information
 where to find further guidance on the subject in the Guidelines.
 The Transition Index does not include additional requirements but rather provides
information and recommendations only.
 It is strongly recommended that when reading an item in the Standards, you
always also read the Transition Index for that item for clarification.
The Guidelines (Part II of the CBSG) that provide overall guidance on how to achieve the
biosafety requirements outlined in Part I (the Standards). The guidelines describe concepts
and information that are fundamental to the development and maintenance of a
comprehensive, risk-based biosafety management program.
RESPONSIBILITIES
Biohazard Committee
Advisory responsibility for the control of biohazardous material lies with the Biohazard Safety
Committee and the University Biosafety Officer who is a member of this committee
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Biosafety Officer
Work with the Queens University Biohazard Committee to translate the requirements of external
bodies and legislation into specific policies and procedures for the University
Promote a high standard of safe practice within University laboratories which handle
biohazardous agents
Provide information and advice on safe import, export, handling, decontamination and disposal of
biohazardous agents
Review applications for Biohazard Permits
Monitor compliance by conducting site visits
Act as the primary emergency response person for incidents involving biological materials
Department Heads
Read and be familiar with the contents of this Biosafety Manual and ensure that it is followed in
their Department
Read and ensure compliance with any relevant Standard Operating Policies and Procedures
released by the Department of Environmental Health and Safety
Make the Biohazards Safety Manual available to everyone in the Department, including support
staff, summer students, co-op students, undergraduate honours students, contract workers, etc.
Ensure that ALL faculty, students, technicians, and any others who may come into contact with
biohazards within their Department are properly trained in the handling of biohazardous material
Principal Investigators
Read and be familiar with the contents of this Biosafety Manual and ensure that it is followed in
their laboratories.
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Read and ensure compliance with any relevant Policies and Standard Operating Procedures
released by the Department of Environmental Health and Safety.
Identify known and potential biological hazards within their laboratory.
o Obtain and maintain a valid Biohazard Permit for these hazards (annual renewals
required)
o make these permits available to their lab personnel for their review and answer any
questions that they may have about them
o make available any amendments with their associated risk assessment summaries, and
any laboratory-specific SOPs
o maintain a list of the biohazardous materials in their laboratory:
 to fulfill the inventory requirements of the CBSG (R4.1.12)
 to be provided to the Biohazards Committee as part of the Biohazard Permit
process through the Romeo system
 to be updated when materials are added or destroyed
Adequately train those who work in their lab in the lab-specific safe handling of biohazardous
agents as described in the approved Biohazard Permit and associated documents
o For Containment Level 2 laboratories, perform a training needs assessment at a minimum
annually as required by the CBSG. i.e. decide whether or not anything has changed in
your program that requires an update of the training statement associated with your
biohazard permit in the Romeo system. This review process will be performed and
documented through the annual biohazard renewal application.
o Maintain documentation of training on the safe handling of biohazardous materials,
chemicals, toxins etc., using the checklist [PDF][Word] available on the Department of
Environmental Health and Safety website (http://www.safety.queensu.ca/).
 Add and delete items on this training checklist to make it appropriate for your
laboratory.
Ensure that all individuals under their supervision complete the biosafety training described on
the Department of Environmental Health and Safety website under the Biosafety dropdown
menu.
Ensure that all individuals working in their laboratory receive the appropriate immunizations,
antibody titre checks, and any other medical surveillance that may be required.
Ensure that all people working in the lab who may come into contact with biohazards attend
WHMIS training offered by the Department of Environmental Health and Safety. Information
regarding the timing of these training sessions can be obtained on the Department of
Environmental Health and Safety website (http://www.safety.queensu.ca/) under Training
Adequately supervise personnel and correct work errors or deficiencies in conditions that could
pose a risk to employees, students and/or the environment or result in noncompliance with the
regulations and guidelines pertaining to your research.
Ensure that Emergency Procedures are:
o customized for the laboratory
o reviewed and updated annually (date and print a new version after review)
o posted in the laboratory and that all personnel know the location of this procedure
o training on these procedures is refreshed annually and documented
Report all exposure incidents or serious near misses involving biological or other hazards in
writing to the Department of Environmental Health and Safety within 24 hours of the incident
even if medical attention is not required.
Report any stolen or missing Risk Group 2 material to Department of Environmental Health and
Safety within 24 hours of the incident.
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All Other University Personnel and Students working as Biohazard Team Members
Take Biosafety training, as described on the Environmental Health and Safety website and ensure
that they:
o read the lab biohazard permit and associated documents (on the TRAQ/Romeo system),
o read the Queens Biosafety Manual and SOPs,
o take quizzes as required.
Ensure that their training on Emergency Response Procedures is refreshed annually, and that they
know where this document is posted in their laboratory.
Comply with all University and Laboratory-specific biosafety SOPs and procedures.
Take WHMIS training.
Ensure that other training is refreshed as required including:
o training through Environmental Health and Safety
o lab-specific training
Laboratory workers should be protected by appropriate immunization where possible, and
antibody titres should be checked to determine whether or not there has been an adequate
response to immunization.
Ensure that if their health status changes they promptly review the implications for the hazards
with which they work and have the risk mitigation measures re-evaluated through their
supervisor, the BSO, and their personal physician or Queens Occupational Health Care provider.
o This should not require you to reveal personal medical information to non-medical
personnel.
Promptly inform their supervisor of any exposure to hazardous materials or other accidents or
significant near misses in the laboratory and assist them in filling out forms to report these to
the Department of Environmental Health and Safety.
TRAINING REQUIREMENTS
The inherent risks of working with hazardous agents can be reduced by:
 training
 knowledge of the hazardous agent and the procedure-associated hazards
 good work habits and use of all the risk mitigation measures indicated for a particular activity
 personal attributes of caution, attentiveness, and concern for the health of themselves and
coworkers
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Note that the checklist should be modified by adding any specific training required for work in
your laboratory (e.g. Cholera Toxin SOP, lentiviral vector SOP and quiz, hands on training on
procedures associated with cell culture)
A detailed description of the requirements for biosafety training is to be read from the Training
Requirements section of the Biosafety dropdown menu.
All personnel working in biohazard laboratories must read this Biosafety Manual and take one of the
centralized biosafety quizzes through the Department of Environmental Health and Safety to
demonstrate their knowledge. Biosafety quizzes are located in the training section of the Environmental
Health and Safety website .
 Those working in level 1 laboratories are not required to know certain sections of this Biosafety
Manual, so you are advised to consult the website.
Emergency Procedures
A template document for Emergency Procedures is available on the Environmental Health and Safety
Website.
This document must be modified to be specific for your laboratory, updated annually, dated, and posted in
the laboratory where everyone knows its location and its content.
Refresher training on these Emergency Procedures must be provided annually and documented on
the Biohazard Permit Renewal form.
If you wish further information, videos and other biosafety training is available on the Public Health
Agency of Canada (PHAC) website. These can be accessed at http://labbio.pensivo.com/index.php?fuseaction=public.home&id=1. Click on Not registered? and follow the
instructions to access the videos. Once signed in, click Tools and Resources at the top right corner of
the page and select Videos. If you cannot see the Control Functions for the video player, make sure that
your browser is at 100% zoom or higher.
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Lab Design
At Queens University, laboratories must meet the design requirements of the Canadian Biosafety
Standards and Guidelines (CBSG), 1st Edition, 2013; and, where applicable, other requirements that
might be imposed by the Public Health Agency of Canada (PHAC), the Canadian Food Inspection
Agency (CFIA) or other regulatory authority.
When new facilities are constructed or extensively renovated, the CBSG Standards must be met, and
adopting the recommendations of the Guidelines is encouraged where feasible. The Department of
Environmental Health and Safety should be consulted early in the design process and before drawings are
put out for tender.
The descriptions below highlight some of the essential features of containment laboratories.
Level 1 Labs
Level 1 labs should:
 Be separated from public areas by a door which should be kept closed when biohazards are in use
 Have surfaces that can be readily cleaned and resistant to any disinfectants or other chemicals in use
 Have fly screens on any windows which can be opened
 Provide hooks for lab coats separate from personal clothing
 Have hand-washing stations, ideally near the exit
 Where indicated by the chemical hazards in the laboratory, must have Emergency eyewash facilities
and emergency shower equipment in accordance with Queens Universitys Emergency Eyewash
Stations and Safety Showers Standard Operating Procedure SOP-LAB-03 .
 Have all appropriate door signage (e.g. biohazard sign, containment level, contact information, type
of biohazardous material in use and any entry requirements such as PPE.
Level 2 Labs
A summary of the physical requirements for a level 2 laboratory is provided below so that personnel will
know what facility systems they should ensure are maintained. More detail regarding the CBSG
requirements for CL2 laboratory facilities, including laboratory location and access; surface finishes
and casework; heating, ventilation, and air conditioning; the containment perimeter and laboratory
services (i.e. water, drains, gas, electricity, and safety equipment), are in the CBSG Standards Chapter 3.
Level 2 labs must:
 Meet all the facility requirements described above for Level 1 laboratories
 Doors must be closed at all times with access limited to authorized personnel only, and doors must be
locked when the lab is not occupied.
 Have non-absorptive work surfaces that are scratch, stain, chemical, moisture, and heat resistant.
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Where possible meet the recommendation for directional air flow into the lab (i.e. lab under negative
pressure relative to the corridor). This may be required depending on the nature of the work (in vitro
vs. in vivo small animal vs. large animal) and a local risk assessment.
An acceptable means of waste treatment or disposal must be provided.
Biological safety cabinets are recommended and are often required, depending on the risk assessment.
Level 2+ Labs
Level 2+ labs have the same physical requirements as level 2 labs and also should have directional air
flow into the lab. The lab must have a biological safety cabinet and centrifuge rotors must have aerosolresistant lids.
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BSCs are designed to have only one person working in them at a time. Long (six
foot) cabinets are for experiments that need a large surface area, not for two people.
More than one person working in a BSC at one time can lead to disruption of the air
curtain, potentially contaminating the cultures or personnel.
In general, the use of a BSC to contain Risk Group 2 biohazardous aerosols is recommended (and is
usually required, depending on a risk assessment), rather than working on the open bench and relying
on good technique to reduce aerosol generation and personal protective equipment to prevent exposure.
When working with biohazard risk group 2 materials, an important consideration in the risk
assessment is whether or not a BSC is required for the work. The decision is based on the actual
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material being used, the concentration and volume of pathogen in use, and whether or not the procedures
generate significant aerosols (see CBSG R4.6.23).
The type of Class II BSC to be used and whether or not it needs direct exhaust also needs to be part
of your risk assessment. It will be determined based on the use of hazardous volatile chemicals or
radioisotopes.
Fume Hoods
Fume hoods are NOT to be used for level 2 biohazard containment when aerosols will be generated.
Fume hoods are for collecting potentially harmful chemical gases, vapours, mists, aerosols and
particulates generated during the manipulation of chemical substances. These harmful substances are
usually directly exhausted to the outside of the building where their dilution has been assessed as being
sufficient protection by a Certificate of Approval from the Ministry of the Environment.
A biological safety cabinet, not a fume hood, must be used to contain biohazardous aerosols since this
traps potentially infectious microorganisms in a HEPA filter.
A fume hood may sometimes be used for fixing tissues that might contain biohazardous agents. Consult
the Biological Safety Officer.
Some work may require a biological safety cabinet with fume hood abilities (for example, using
biohazards with chemicals that produce toxic fumes or volatile compounds labeled with radioisotopes).
All fume hoods must be in compliance with the Queens University Fume Hood Standard Operating
Procedure, SOP-LAB-01 .
When using a fume hood be sure that:
 The sash is at the correct height
 you work well back in the fume hood
 the exhaust is not blocked by extraneous material (do not store things in the fume hood)
 surfaces are protected to permit easy clean-up of spills
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Tubes
Tubes with proper closures are containment devices. For known infectious material, avoid using tubes
with push-in and screw-in closures because when these tubes are opened, the film of liquid trapped
between the tube and closure breaks and releases aerosols. Use tubes with outside screw-on closures.
 Use a vortex mixer instead of inverting tubes; wait at least 30 seconds after shaking a tube before
opening the cap
 Open tubes of hazardous infectious material in a biological safety cabinet only
Centrifuges
For low speed centrifugation, as is commonly used in cell/tissue culture, sealed centrifuge buckets with
o-rings (safety caps) are recommended for level 2 material and for all cell lines. Safety caps are strongly
recommended for known infectious level 2 material (e.g., viruses, viral vectors, and bacteria). For level
2+ work, safety caps are required and centrifuge buckets must be opened only in a biological safety
cabinet.
Microcentrifuges
Microcentrifuges should not be placed in the BSC for operation, because air convection during operation
compromises the integrity of the containment provided by the BSC. Safety cups for microcentrifuges are
now available.
Autoclaves
Autoclaves used for the decontamination of biohazardous materials must have their efficacy on a
representative load verified using Biological Indicators weekly and records must be maintained.
Queens University SOP-Biosafety-09 describes the requirements for Autoclaves used for Biohazardous
Waste Treatment and labs must be in compliance.
All autoclaves and autoclave users must be in compliance with the Queens University Autoclave
Standard Operating Procedure, SOP-Lab-02 .
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OPERATIONAL PRACTICES
Good Microbiological Practices for Biohazard Laboratories (Level 1 and 2)
Both physical containment and good laboratory practices are important for reducing the risk of laboratory
acquired infections. Note that laboratory technique can significantly alter the risk of exposure to
biohazards.
Good microbiological practices include the use of PPE, hand washing, disinfecting work areas, the use of
procedures that minimize the creation of aerosols, and proper decontamination and disposal of materials.
Of these, proper hand washing after removing gloves and before leaving the laboratory is
considered the most important practice for preventing the spread of infectious agents.
The worker who is careful and proficient will minimize the generation of aerosols. A careless and
hurried worker will substantially increase the aerosol hazard. For example, the hurried worker may
operate a sonic homogenizer with maximum aeration whereas the careful worker will consistently operate
the device to assure minimal aeration. Experiments show that the aerosol burden with maximal aeration is
approximately 200 times greater than aerosol burden with minimal aeration. Similar results were shown
for pipetting with bubbles and with minimal bubbles. A hurried worker who moves quickly within or
in front of a biological safety cabinet, will disrupt the air flow that is essential for containment.
The following list of general practices outlines requirements for all laboratories handling infectious
substances (both level 1 and 2) at Queens University. Although the CBSG is now in force, this list is
based on the previous Public Health Agency of Canadas Laboratory Biosafety Guidelines (3rd Edition,
2004), which more thoroughly described good microbiological practices than does the CBSG. The
reason for this change in the Federal documents is that the Public Health Agency of Canada does not have
the authority to regulate Risk Group 1 microorganisms under the Human Pathogens and Toxins Act.
Nevertheless, these practices remain the foundation of good work with infectious substances and their use
is an important safety measure. Some of the guidelines listed below are covered in greater detail and/or
clarified in other sections of this manual.
Good Microbiological Practices:
1. A documented procedural (safety) manual must be available for all staff, and its requirements
followed; it must be reviewed and updated regularly.
2. Personnel must receive training on the potential hazards associated with the work involved and
the necessary precautions to prevent exposure to infectious agents and release of contained
material; personnel must show evidence that they understood the training provided; training must
be documented and signed by both the employee and supervisor; retraining programs should also
be implemented.
3. Eating, drinking, smoking, storing of food, personal belongings, or utensils, applying cosmetics,
and inserting or removing contact lenses are not permitted in any laboratory; the wearing of
contact lenses is permitted only when other forms of corrective eyewear are not suitable; wearing
jewelry is not recommended in the laboratory.
4. Oral pipetting of any substance is prohibited in any laboratory.
5. Long hair is to be tied back or restrained so that it cannot come into contact with hands,
specimens, containers or equipment.
6. Access to laboratory and support areas is limited to authorized personnel.
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7. Doors to laboratories must not be left open (this does not apply to an open area within a
laboratory).
8. Open wounds, cuts, scratches and grazes should be covered with waterproof dressings.
9. Laboratories are to be kept clean and tidy. Storage of materials that are not pertinent to the work
and cannot be easily decontaminated (e.g., journals, books, correspondence) should be
minimized; paperwork and report writing should be kept separate from biohazardous materials
work areas.
10. Protective laboratory clothing, properly fastened, must be worn by all personnel, including
visitors, trainees and others entering or working in the laboratory; suitable footwear with closed
toes and heels must be worn in all laboratory areas.
11. Where there is a known or potential risk of exposure to splashes or flying objects, whether during
routine operations or under unusual circumstances (e.g., accidents), eye and face protection must
be used. Careful consideration should be given to the identification of procedures requiring eye
and face protection, and selection should be appropriate to the hazard.
12. Gloves (e.g., latex, vinyl, co-polymer) must be worn for all procedures that might involve direct
skin contact with biohazardous material or infected animals; gloves are to be removed when
leaving the laboratory and decontaminated with other laboratory wastes before disposal; metal
mesh gloves can be worn underneath the glove.
13. Protective laboratory clothing must not be worn in non-laboratory areas; laboratory clothing must
not be stored in contact with street clothing.
14. If a known or suspected exposure occurs, contaminated clothing must be decontaminated before
laundering (unless laundering facilities are within the containment laboratory/zone and have been
proven to be effective in decontamination).
15. The use of needles, syringes and other sharp objects should be strictly limited; needles and
syringes should be used only for parenteral (through the skin) injection and aspiration of fluids
from laboratory animals and diaphragm bottles; caution should be used when handling needles
and syringes to avoid auto-inoculation and the generation of aerosols during use and disposal;
where appropriate, procedures should be performed in a BSC; needles should not be bent,
sheared, recapped or removed from the syringe; they should be promptly placed in a punctureresistant sharps container (in accordance with Canadian Standards Association [CSA] standard
Z316.6-95(R2000)) before disposal.
16. Hands must be washed after gloves have been removed, before leaving the laboratory and at any
time after handling materials known or suspected to be contaminated.
17. Work surfaces must be cleaned and decontaminated with a suitable disinfectant at the end of the
day and after any spill of potentially biohazardous material; work surfaces that have become
permeable (i.e., cracked, chipped, loose) to biohazardous material must be replaced or repaired.
18. Contaminated materials and equipment leaving the laboratory for servicing or disposal must be
appropriately decontaminated and labeled or tagged-out as such.
19. Efficacy monitoring of autoclaves used for decontamination with biological indicators must be
done regularly (i.e., consider weekly, depending on the frequency of use of the autoclave), and
the records of these results and cycle logs (i.e., time, temperature and pressure) must also be kept
on file.
20. All contaminated materials, solid or liquid, must be decontaminated before disposal or reuse; the
material must be contained in such a way as to prevent the release of the contaminated contents
Queens University Biosafety Manual 2013
31
during removal; centralized autoclaving facilities are to follow the applicable containment level 2
requirements.
21. Disinfectants effective against the agents in use must be available at all times within the areas
where the biohazardous material is handled or stored.
22. Leak-proof containers are to be used for the movement/transport of infectious materials within
facilities (e.g., between laboratories in the same facility).
23. Spills, accidents or exposures to infectious materials and losses of containment must be reported
immediately to the laboratory supervisor; written records of such incidents must be maintained,
and the results of incident investigations should be used for continuing education.
24. An effective rodent and insect control program must be maintained. (At Queens if you see
evidence of rodents or insects call the Department of Environmental Health and Safety who will
notify the exterminator on contract.)
In addition, consideration should be given to limiting the use of personal electronic devices in the
laboratory.
Where there is an increased risk when working with the RG1 biological material (e.g.
immunocompromised individual working with an opportunistic RG1 pathogen), consideration should be
given to moving the work into a CL2 zone in a Biological Safety Cabinet. Without needing to reveal
personal medical information, consult your supervisor, the Biosafety Officer. Medical advisors will be
consulted.
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Hand washing
In the diagram below, areas commonly missed in hand washing are shown with darker shading. When
washing, take care to clean these areas.
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Bacteria are single-celled prokaryotic organisms lacking a nucleus and other membrane-enclosed
organelles. Morphologically 0.55.0 m in size, bacteria are spherical (cocci) or appear as rods (bacilli)
that may be straight, curved, spiralled, or tightly coiled. Based on Gram staining and morphology, more
than 4,000 bacterial species have been classified into one of the following three phenotypes: Grampositive, Gram-negative or mycoplasma (bacteria lacking a cell wall). Bacteria vary in their requirements
for oxygen, being described broadly as either aerobic, microaerophilic or anaerobic. Some bacteria can
also induce an extreme immune response (e.g., inflammation), secrete exotoxins, produce surfaceassociated endotoxins (i.e., lipopolysaccharides or lipooligosaccharides), or form spores that enhance
survival and transmission outside the host for extended periods of time.
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Bacteria that can infect and cause disease in humans and/or animals are referred to as pathogenic
bacteria. Many pathogenic bacteria that colonize the body do not cause disease unless a disruption occurs
in the hosts immune system or natural barriers to infection, or the host is exposed to an excessively high
dose of the pathogen, as may occur through activities conducted in a laboratory or an animal facility.
Infections with certain pathogenic bacteria almost always result in illness.
Viruses are the smallest of replicating organisms. Their small size (20-300 nm) allows them to pass
through filters that typically capture the smallest bacteria. Viruses have no metabolism of their own and,
once inside a host cell, they redirect existing host machinery and metabolic functions to replicate.
Structurally, the simplest viruses consist of nucleic acid enclosed in a protein capsid (nucleocapsid).
Enveloped viruses have a more complex structure in which the nucleocapsid is enclosed inside a lipid
bilayer membrane. This membrane facilitates the viruss interaction with the host cells, and also increases
susceptibility to decontamination.
Viruses are classified by their replication strategy and by the organization of their genome (i.e., doublestranded DNA, single-stranded DNA, reverse transcribing, double-stranded RNA, negative-sense singlestranded RNA, positive-sense single-stranded RNA, and subviral agents). There are many families of
viruses that are able to infect human and animal hosts. Some are species-specific while others infect a
wide range of host species. Some viruses are able to produce a persistent infection (i.e., host cell remains
alive and continues to produce virus over a long period of time) or a latent infection (i.e., there is a delay
of months or years between viral infection of the host and the appearance of symptoms), or they may be
carcinogenic (e.g., integration of an oncogene-carrying retrovirus into host genome).
Fungi are eukaryotic microorganisms that can be easily distinguished from bacteria and other
prokaryotes by their greater size and the presence of organelles, including a nucleus, vacuoles and
mitochondria. Of the 1.5 million estimated fungal species, approximately 300 are known to cause disease
in human and/or animal hosts. Several species of yeast, which normally grow as single cells, and of
moulds, which grows in branching chains, are known to be pathogenic to animals and humans.
Differences in the virulence of these fungal species are used to categorize them into two main categories:
frank pathogens, which can cause disease in healthy hosts, and opportunistic pathogens, which can cause
disease in immunocompromised hosts.
The main risk associated with fungi is the exposure to spores that can be transmitted via the airborne
route, inoculation, or casual contact, depending on the species. In addition, some fungal species may
produce and disperse mycotoxins, which can be toxic. In general, human and animal tissue and blood
samples are not considered a risk for the airborne dispersal of fungal spores.
Parasites include protozoa and helminths that live on or within a larger host organism at the hosts
expense. Protozoa are single-celled eukaryotic microorganisms that lack a cell wall and are generally
motile; helminths are eukaryotic worms that may grow large enough to be visible to the naked eye.
Parasites that live within the tissues or cells of their host are known as endoparasites and cause infections
that are generally treatable. Some endoparasites can persist for many years in the human body, even
following treatment, and will re-surface if the host becomes immunocompromised. Ectoparasites live on
the external surface, or within the skin of their host, causing an infestation. The type and degree of injury
inflicted on the host will vary based on the number of parasites present and can range from minor to
severe.
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Viral Vectors
Viral vectors are vehicles derived from viruses that are used to deliver genetic material into host cells for
subsequent gene expression. These systems have been used for both research and gene therapy
applications. Viral vector systems used for recombinant gene transfer are usually based on viruses present
in the human population such as adenoviruses, herpesviruses and retroviruses. Genetic modifications are
typically made to these vectors to improve gene delivery efficiency and to enhance the safety of the
system.
Retroviral vector systems, including lentiviral vectors derived from HIV-1, are competent gene transfer
vehicles which are widely used for their stable integration into the chromosome of non-dividing and
dividing cells and for their long-term transgene expression.
The risks associated with viral vectors depend on the type of virus from which that the vector was
derived, and how it has been engineered. Therefore a risk assessment for each type of viral vector in use
is required. In particular, viral vectors that can infect human cells need to be described in detail,
including:
 the biology of the parent virus and associated risks of the viral vector
 the packaging system
 whether or not the vector system is supposed to be replication incompetent
 how the engineering and production methods attempt to ensure that replication competent virus is
not produced (e.g. via recombination)
 the transgene and any deleterious outcome that might be associated with its accidental expression
in lab personnel
o Containment requirements may be increased depending on the nature of the transgene to
be expressed
o all new transgene use must be reviewed by the Biohazard Committee as an amendment
application to the biohazard permit
 if used in vivo, how long is the viral vector expected to be shed and if a replication competent
virus was transferred how would it be shed?
 requirements imposed by an import permit issued by PHAC or CFIA must be followed
Lab specific operational protocols, training and testing must be developed for viral vector systems in
consultation with the Biosafety Officer. To obtain an example SOP contact the Biosafety Officer.
Prions
When working with any neurological tissue, the possibility that prion proteins could be present should be
considered and good laboratory practices followed.
Prions are small, proteinaceous infectious particles that are generally accepted to be the cause of a group
of progressive neurodegenerative diseases in humans and animals known as Transmissible Spongiform
Encephalopathies (TSEs). When an infectious prion enters a healthy host, it induces the normally folded
prion protein to convert to the disease-associated, misfolded prion isoforms. The pathogenic isoform acts
as a template that guides the misfolding of more prion proteins, which eventually leads to an
accumulation of large amounts of the extremely stable, misfolded protein in infected tissue, causing tissue
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damage and cell death. Examples of TSE agents that infect animals include bovine spongiform
encephalopathy (BSE), scrapie, and chronic wasting disease (CWD). Examples of TSE agents that infect
humans include Creutzfeldt-Jakob disease (CJD), variant Creutzfeldt-Jakob disease (vCJD), Gerstmann
StrausslerScheinker syndrome, fatal familial insomnia, and kuru. There are no treatments and no
vaccines available for these diseases.
The most likely route of transmission to personnel handling infectious prions is through accidental
inoculation or ingestion of infected tissues. There is currently no intentional work with prions at Queens
so the details of the containment requirements are not presented in this manual.
If working with neurological material that might contain prions, consult the CBSG and the Biosafety
Officer about any additional mitigation measures that will be required and include these in the local risk
assessment associated with your Biohazard Permit.
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laboratory; however, they have the potential to contain pathogenic organisms such as bacteria, fungi,
mycoplasmas, viruses, prions, or recombinant virions. This can occur either naturally or through
contamination by adventitious organisms, transformation or recombination.
Commercially available cultured cell lines are generally very well characterized and the presence of
infectious contaminants is sometimes documented.
Freshly prepared cell lines from a primary culture may be at risk of contamination with infectious
contaminants, especially if the cell line was obtained from a specimen known to be or suspected of being
infected with a pathogen. There have been documented Laboratory Acquired Infections (LAIs) associated
with the manipulation of primary cell cultures.
Cell lines that are known or potentially contaminated should be manipulated at the containment
level appropriate for the contaminating organism of the highest risk.
Bacterial and fungal contamination in cell lines can be readily identified
Viruses are not as easily identified and can pose a significant hazard.
o Some human cell lines have the potential to harbor a human bloodborne pathogen.
o The handling of nude mice inoculated with a tumor cell line unknowingly infected with
lymphocytic choriomeningitis virus resulted in multiple laboratory acquired infections.
Growth conditions (e.g., pH, temperature, medium supplements) may cause altered expression of
oncogenes, expression of latent viruses, interactions between recombinant genomic segments, or
altered expression of cell surface proteins.
Although mycoplasmas are commonly identified as sources of cell culture contamination,
mycoplasma-contaminated cultures have never been reported as a source of a laboratory acquired
infection. Nevertheless, the fact that a number of mycoplasmas are human pathogens renders
them potential hazards in cell cultures.
o Mycoplasmas can significantly alter the behaviour of cells, so routine testing of cell lines
for mycoplasma contamination is advisable from a scientific point of view.
Culturing continuous cell lines without the routine use of antibiotics and fungicides is
recommended. These agents can mask poor tissue culture technique and result in a higher
probability that the culture will be contaminated with the more difficult to detect mycoplasma and
non-lytic viral pathogens.
Cell lines are commonly misidentified so you might not be working with what you think you
are and thus the hazard of the cell line could be higher than you think. Published reports have
estimated that 20 to 30% of cell lines were misidentified when deposited with cell banks and that
less than 50% of researchers regularly verify the identities of their cell lines using any of the
standard techniques such as DNA fingerprinting.
For these reasons, it is prudent to treat all eukaryotic cultures as moderate risk agents, even if they
have been classified as Risk Group 1 because they have not been shown to contain a pathogen. It is
recommended to use containment level 2 facilities and work practices when working with all cell
lines. This is usually relatively easy to do since continuous cell culture is done under sterile conditions in
a biological safety cabinet (BSC).
Consider what you are doing with the cells after you harvest them, if you would like to work outside
of the BSC:
 Are the cells fixed or lysed in a solution that would inactivate pathogens that might be present?
 Do the procedures create a risk of infectious aerosols?
o If so then how are you going to contain these aerosols  in a BSC?
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Can the work be done safety on the open bench in a level 2 lab?
o Is a barrier and/or eye and mucosal protection required?
Laboratory Animals
The care and use of animals at Queens University is regulated by the University Animal Care Committee
and the University Veterinarian. All work with biohazardous materials that involves animals or the use of
animals that carry serious zoonotic pathogens must also be approved by the Biohazards Committee to
ensure the protection of personnel.
Zoonoses
The term zoonoses describes diseases that are transmissible between living animals and humans (in
either direction). Zoonoses are caused by zoonotic pathogens.
There have been several documented laboratory acquired infections (LAIs) involving zoonotic pathogens
transmitted to humans by an infected animal.
The risk of zoonoses is greater with activities involving first generation wild-caught animals that
may be infected with and carry a pathogen indigenous to the animals natural environment. Due to the
nature of these pathogens, additional precautions may need to be implemented whenever known or
potentially infected animals are handled.
Documented zoonoses in humans have been caused by bacteria (e.g., Salmonella spp. can cause
salmonellosis; Yersinia pestis can cause plague), viruses (e.g., rabies virus can cause rabies), parasites
(e.g., Toxoplasma gondii can cause toxoplasmosis), and prions (e.g., BSE agent can cause vCJD).
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Animal Containment
Animal facilities for work with small and large animals are designed and operated in accordance with the
Canadian Biosafety Standards and Guidelines (CBSG) and the Guide to the Care and Use of
Experimental Animals, published by the Canadian Council on Animal Care, and other CCAC guidelines
and policies.
Small animals will be contained in cages with micro-isolator lids or, preferably, in vented racks under
negative pressure with HEPA filters. Level 2 work with small animals will be done in a biological safety
cabinet in the housing room unless it is not feasible to do so and then only after a specific protocol has
been approved by the University Animal Care Committee and the Biohazards Committee.
Containment facilities for large animals (e.g. dogs, rabbits, sheep) are unique, in part because of the large
quantity of infectious microorganisms that may be present in the animal cubicle. Unlike a laboratory
room, where the BSC and containment caging provide primary containment, the large animal cubicle
serves as both the primary and secondary barrier, so specific facility and operational containment
requirements in the CBSG Standards matrix under the CL2-Ag column must be followed. Particular
attention must be given to the use of protective clothing and equipment by staff entering an animal
cubicle contaminated with large volumes of infected animal waste. The handler must have knowledge of
the animal's general characteristics, such as mentality, instincts and physical attributes, and specific risk
mitigation procedures need to be developed.
Allergy
A high percentage of individuals who work with laboratory animals, particularly rodents, acquire a lab
animal allergy. Such allergies can be serious, including the development of asthma, and may be career
ending. Facilities and procedures should minimize exposure to allergens.
Individuals who are already allergic to any animals should consider the routine use of a fit-tested
respirator to prevent the development of allergies to a laboratory animal or to reduce their exposure and
symptoms if they are already allergic. Contact the Department of Environmental Health and Safety to be
enrolled in the Respiratory Protection Program as described in SOP-Safety-05 on the Safety website.
Biological Toxins
Biological toxins are poisonous substances that are a natural product of the metabolic activities of certain
microorganisms, plants, and animal species. Toxins can cause adverse health effects, severe
incapacitation, or death in a human or animal, even when present at relatively low levels in host tissues.
Some toxins can be artificially produced by chemical synthesis or by genetic engineering and rDNA
technology. Toxins are classified according to the organism from which the toxin is derived (e.g.,
bacterial, fungal, plant, animal), although toxins are typically associated with bacterial disease.
Two types of bacterial toxins exist: exotoxins and endotoxins.
 Exotoxins are often heat-labile proteins and polypeptides that are produced and secreted or
released by a variety of species, including both Gram-negative and Gram-positive bacteria.
 Bacterial exotoxins can be classified in five main groups based on their effect on the host, as
follows:
o damage to cell membranes
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When compared to microbiological pathogens, it is fairly easy to control the spread of toxins. Toxins do
not replicate, are not infectious, and are not transmitted from person to person. The most likely route of
transmission to personnel handling toxins is through accidental inoculation or by the exposure of mucous
membranes to aerosols.
Regulation of Toxin Use:
Biological toxins produced by microorganisms are the only type of toxins regulated under the HPTA.
They are listed on Schedule 1 of the HPTA and must be listed on a Biohazard Permit for local oversight.
The Biosafety Officer will register their use with the Public Health Agency of Canada.
Check whether any of the toxins you are using are listed in HPTA Schedule 1 (see Queens Toxin
Registration form under the Biosafety dropdown menu, or in Useful Links in TRAQ/Romeo).
o If so then you must have a Biohazard Permit application for their use.
o Although not listed in the HPTA, other biological toxins, such as those produced by
plants, coral, etc., may be just as hazardous or more so, but they are not regulated through
the Biohazards Committee. Nevertheless, an SOP for their safe handling and disposal
should be developed and the Biosafety Officer will assist you with if so requested.
To purchase Schedule 1 toxins, your lab will need a Containment Level 2 Compliance Letter
from PHAC. The Biosafety Officer will assist you with the application.
Factors to consider when doing a risk assessment for a biological toxin are described in the CBSG
section 4.2.1.1.
o An SOP for the handling of the toxin will be required as part of a Biohazard Permit
application or amendment.
o An SOP might already have been written by another investigator, so contact the Biosafety
Officer for assistance.
Decontamination/inactivation of toxins by thermal or chemical means is described in the CBSG
section 16.9
Further information, including details about the inactivation of specific biological toxins, can also
be found in Appendix I of the U.S. Centers for Disease Control and NIH document, Biosafety in
Microbiological and Biomedical Laboratories, 5th Edition, 2007 (BMBL)
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If applicable, post the first table below near where you store PPE.
If more complicated than the first table below, a written donning and doffing procedure for the
particular PPE worn in your laboratory must be developed and posted outside the lab as a
reminder.
o See the second table as an example for a more complex situation
o Figures with images may be used
Inner gloves
Lab coat (properly
fastened)
Outer gloves (fitted over
cuffs of lab coat)
Doffing Order
(Ascending)
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In the table below the numbers in brackets refer to the Regulatory requirement number in the Operational
Standards section of the CBSG. This table is from the CBSG.
Generic Example of the Donning Procedures when Multiple
Layers of PPE are Worn
Donning Order
(Descending)
Body
Lab coats should be worn in all general labs, and may be worn in hallways if hazardous materials are
being transported.
 Lab coats with knit cuffs are recommended so that a glove can be pulled up over the cuffs.
 Lab coats with snaps rather than buttons are recommended so that they can be removed quickly.
 For highly infectious agents, surgical gowns with back closures and knitted cuffs offer superior
protection.
 Plastic or rubber aprons are to be worn for activities that are likely to result in splashes of
infectious agents.
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There should be dedicated lab coats for level 2 laboratories that are left in that laboratory rather
than being used in level 1 laboratories.
Lab coats may not be worn in washrooms, lunchrooms, conference rooms, or offices or other
areas where food or beverages are consumed.
o Lab coats may not be worn while eating, drinking, or chewing gum.
Any lab coats which are known or suspected to be contaminated with pathogens must be successfully
decontaminated, by autoclaving or soaking in bleach (or other suitable disinfectant), before laundering.
Lab coats should not be taken home for any reason. Lab coats should be washed by an approved laundry
service.
Foot
Closed-toe and closed-heel shoes must be worn in all laboratories at all times.
Foot protection must be worn in compliance with Queens Universitys Foot Protection Standard
Operating Procedure, SOP-Safety-09.
Hand
Gloves of a suitable resistance material must be worn as appropriate for any materials which are being
handled. In general, vinyl, latex or nitrile gloves are suitable protection against infectious agents, but
remember to check compatibility with any chemical hazards that you are also using.
Recommended glove practices:
 Inspect gloves for cracks, tears and holes before wearing.
 When donning gloves, ensure that they fit so that no skin will be exposed. Do they fit over the
cuffs of your lab coat?
 Gloves should be changed when visibly contaminated and as soon as possible after handling
infectious agents.
o Change gloves often if wearing for a long period of time.
 Proper glove removal technique involves removing each glove without touching the outer
contaminated surface.
 Gloves can have pinholes so hands should be washed thoroughly immediately after removing
gloves.
 Double gloving should be considered for some agents or procedures.
 Reusing gloves is generally not recommended.
 Latex and vinyl gloves do not provide protection from sharps and needles; nitrile has better
abrasion, cut and puncture resistance; fine metal mesh gloves are recommended where both
dexterity and protection from sharps are needed.
Some toxic chemicals will pass rapidly through some glove material. This has resulted in fatalities.
Ensure that the glove material provides protection against any chemicals being used. A guide for
choosing the appropriate glove type can be found through North Scientific .
Insulating gloves or mittens should be worn when handling high-temperature materials (e.g., recently
autoclaved materials) or low-temperature materials (e.g., metal boxes from a -80oC freezer or liquid
nitrogen).
Queens University Biosafety Manual 2013
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Eye
Goggles and/or a face shield should be worn as required to protect from possible splashes, aerosols, or
other relevant hazards.
Face shields are considered secondary protectors and only provide adequate eye protection when worn
with safety glasses or goggles.
 Face shields should be worn when removing tubes from liquid nitrogen due to the risk of
tubes exploding if liquid nitrogen has leaked into them.
Safety glasses with side shields provide general eye protection but safety goggles offer superior eye
protection from splashes.
It may be advisable in some cases to wear eye protection even when working at a biological safety cabinet
to prevent individuals from touching their eyes with contaminated gloves.
The wearing of contact lenses does not provide adequate protection against biological, chemical, or
particulate hazards. The wearing of contact lenses in the laboratory where chemical or biological hazards
are used is permitted only when other forms of corrective eyewear are not suitable and CSA approved
protective eyewear is worn. Inserting or removing contact lenses is not permitted in any laboratory.
Respiratory
Respirator use must comply with SOP-Safety-05.
N95 or P100 respirators:
 are used for respiratory protection against infectious aerosols and micro-organisms that are
infectious via the airborne route.
 are also effective in preventing exposure to lab animal allergens.
 may be disposable,  face reusable with filter cartridges, or full face, depending in part on the
application, and also on the time period for which they will be worn.
 Perform a seal check every time the respirator is donned.
 Never reuse disposable respirators or masks.
 Remove respiratory protection at the point at which a risk assessment deems it safe to do so upon
exit from the containment zone.
An alternative method of respiratory protection is a Powered Air Purifying Respirator (PAPR). They
are expensive, but are comfortable to wear and can be worn by some people who cannot be fitted for a
regular respirator.
Anyone requiring such respiratory protection must be properly fitted for a specific respirator model
and size through the Department of Environmental Health and Safety (ext. 32999). Mask fit should be rechecked at least every two years or if significant weight changes or other factors change the shape of the
face. Respirators are not effective if the individual is not clean-shaven.
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Disinfectants effective against the infectious material used, and neutralizing chemicals effective
against the toxins in use, must be available in the containment zone and used (R4.8.2) for
contaminated or potentially contaminated material, including equipment, specimen/sample
containers, surfaces, rooms and spills.
Decontamination parameters (e.g., time, temperature, chemical concentration) consistent with the
technology/method used must be validated (R4.8.10) to be effective against the infectious
material and toxins of concern under the conditions present in that containment zone.
Clear and strict procedures must be in place to support routine decontamination (R4.1.8, R4.1.9)
and routine verification (R4.8.11).
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Where possible, technologies that are routinely verified using biological indicators (e.g.,
autoclave) should be used instead of liquid chemical disinfectants.
Autoclaving
Infectious material and toxins, together with associated waste (e.g., petri dishes, pipettes, culture tubes,
and glassware), can be effectively decontaminated in either a gravity displacement autoclave or a prevacuum autoclave. The effectiveness of decontamination by steam autoclaving is dependent on the
temperature to which the material is subjected as well as the length of time it is exposed. Proper
operation, loading, and monitoring of autoclaves are critical to ensure decontamination is achieved.
Particular attention should be given to packaging, including the size of containers and their distribution in
the autoclave. Items should be arranged in a manner that allows the free circulation and penetration of
steam. Pre-vacuum autoclaves resolve the air entrapment problems that prevent the penetration of steam
and are often encountered in gravity displacement autoclaves.
All personnel using autoclaves for decontamination or for sterilization must be trained on their use and
the training documented. They must be in compliance with the general autoclave SOP-Lab-02. A
location-specific operating procedure for each autoclave must be posted near the autoclave.
Any autoclave-based biohazardous waste treatment must also be in compliance with SOP-Biosafety-09 .
For autoclave-based decontamination of material:
1. Solid contaminated waste (excluding glass), should be placed in a clear bag, inside a solid
collecting container which must labeled with an orange biohazardous materials label.
2. When full, bags must be closed, and labeled with the name of contact person (the person
disposing of the waste, not the supervisor) and room number. DO NOT OVERFILL BAGS (2/3
full only), and do not compress them, as this will inhibit steam penetration.
3. Double bag for removal from the lab.
4. At the autoclave, bags for decontamination must be placed in the available trays and, immediately
before autoclaving, opened to allow steam penetration.
5. Disinfected material that is no longer biohazardous must be placed in a regular garbage bag after
ensuring that any biohazards warning labels are defaced.
6. The efficacy of the autoclave for decontamination of representative loads of biohazardous waste
must be monitored weekly using biological indicators (bacterial spores of Geobacillus
stearothermophilus commercially available for this purpose) as described in SOP-Biosafety-09
(CBSG R4.8.10, R4.8.11).
Solid waste that would give off hazardous fumes in the autoclave must NOT be autoclaved (e.g.,
hazardous chemicals, bleach, radioisotopes).
Chemical Disinfection
Chemical disinfectants are used for the decontamination of surfaces and equipment that cannot be
autoclaved (or incinerated), specimen/sample containers to be removed from the containment zone, spills
of infectious materials, and rooms and animal cubicles.
The use of disinfectants can impact worker safety directly (e.g., direct exposure to a hazardous
chemical) or indirectly (e.g., exposure to viable pathogens when an inappropriate disinfectant is
selected).
Queens University Biosafety Manual 2013
49
Containment zone personnel should learn about the products required for the disinfection of the infectious
material and toxins with which they will be working, including the recommended directions for use:
 application method
 concentration
 contact time
 PPE
 first aid
 disposal
and chemical characteristics:
 toxicity
 chemical compatibility
 storage stability
 active ingredient
 concentration
The choice of a chemical disinfectant depends upon the resistance of the microorganisms
concerned. To be effective, the disinfectant must be in contact with the biohazardous material for the
required contact time.
There are usually striking differences between the activities of disinfectants when used under actual
laboratory conditions as opposed to the controlled, standardized testing methods used to generate efficacy
data for product registration. It is therefore difficult to make generalizations about contact times and
concentrations needed to kill specific pathogens. When working with microorganisms where an assay is
possible, it is advisable for laboratories to conduct in-use disinfectant efficacy testing to evaluate a
products performance under specific conditions of use.
The selection of an appropriate chemical disinfectant is dependent on a variety of factors, including the
resistance of the infectious material or toxin, the application (e.g., liquid or gaseous), and the nature of the
material to be disinfected (e.g., hard surface, porous materials). Consideration should also be given to
organic load, concentration, contact time, temperature, relative humidity, pH and stability.
Susceptibility
Extremely
resistant
Microorganism
Prions
Protozoal oocysts
Highly resistant
Resistant
Bacterial
endospores
Mycobacteria
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Susceptibility
Microorganism
Non-enveloped
viruses
Fungal spores
Susceptible
Gram-negative
bacteria
Gram-positive
bacteria
Enveloped viruses
Highly
susceptible
Mycoplasma
Check the organisms Public Health Agency of Canada Pathogen Safety Data Sheets (PSDS, the MSDS
for pathogens), if available, for its disinfectant susceptibility.
Common disinfectants which are often suitable include 10% bleach (freshly diluted, typically 30 minute
contact time for liquid cultures and spills), 70% ethanol (10 minute contact time), glutaraldehyde, iodines,
phenolics, and formaldehyde. Manufacturers recommendations should be followed.
Note that 70% ethanol has limitations. It is commonly used as a surface disinfectant spray in
laboratories. It is effective against vegetative bacteria and enveloped viruses. However its efficacy is
limited by the fact that it evaporates quickly from surfaces, reducing the contact time. Also note that
alcohol is not very effective against non-enveloped viruses or bacterial spores, so it is important to think
about what microorganisms are likely to be present in your samples and select a different disinfectant if
appropriate.
Although bleach is cheap and effective against many microorganisms, it is corrosive to stainless steel
(such as in a biological safety cabinet) and less corrosive alternatives are commercially available for use
on metal surfaces. The concentration of NaClO degrades quite rapidly in diluted bleach, so a 1:10
dilution of bleach should be made up fresh (and not kept for more than a week). Cultures should be
decontaminated by the addition of fresh stock commercial bleach to a final 1:10 dilution (or cultures
should be autoclaved, not both  do not autoclave bleach).
Organic Load
Organic matter (e.g., tissue, blood, bedding, feces) protects microorganisms and toxins from contact with
disinfectants and can neutralize many germicides (e.g., NaOCl). Pre-cleaning with a detergent to remove
bedding, litter, and/or feed prior to disinfection reduces organic load and achieves proper disinfection.
Pre-cleaning should be carried out in a manner to avoid exposure and all cleaning materials must
be decontaminated prior to disposal (R4.8.8, R4.8.9).
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Pre-cleaning prior to disinfection may not always be appropriate and, in these cases, disinfectants
that remain active in the presence of considerable amounts of organic material should be selected
(e.g., phenolic disinfectants).
It may be appropriate to saturate the contaminated material with a disinfectant, allowing it to
remain wet for a long contact time (e.g., 30 minutes), then dispose of gross contamination and
thoroughly clean surfaces before reapplying the disinfectant.
Additional Information
For more information about considerations in selecting and using disinfectants, refer to Chapter 16 of the
CBSG. That chapter contains tables with information about the characteristics of different types of
disinfectants, their activity against different types of microorganisms, and the disadvantages of different
disinfectants.
A table of common disinfectants and their typical effective concentrations, is in Appendix B, Table 2 in
the BMBL 5th Edition.
Appendix I of the BMBL, tables 1 and 2, have information about the physical and chemical inactivation
of some toxins.
Irradiation
Ultraviolet irradiation (UV) should not be relied upon as the sole method of decontamination for materials
to be removed from containment equipment (biological safety cabinets) or facilities. UV has limited
penetrating power and is primarily effective against unprotected microbes on exposed surfaces or in the
air.
It can be effective in reducing airborne and surface contamination provided that:
 the lamps are properly cleaned,
 maintained and
 checked to ensure that the appropriate intensity is being emitted.
UV may be recommended in certain situations, however it is important to note that:
 the accumulation of dust, dirt, grease or clumps of microorganisms reduce its germicidal effects;
 UV light is not effective against all organisms; and
 exposure to UV light is hazardous: it may result in severe eye damage and burns to the skin.
The routine use of UV lamps to decontaminate is not recommended. They should only be used
secondary to chemical disinfection of surfaces. UV lamps must be turned off whenever the laboratory
is occupied, unless the BSC sash closes completely.
Gamma irradiation and microwave irradiation can also be used for decontamination in some cases.
Incineration
Biohazardous waste that must be disposed of by incineration includes human or animal anatomical waste,
material soaked with blood, biohazard sharps containers, and biohazardous waste that is contaminated
with chemicals that would not be compatible with autoclave decontamination.
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All hazardous waste, including biological waste to be incinerated, is picked up by an outside contractor
directly from laboratories and shops at the request of Queens employees. Waste needs to be labeled and
tagged, and the appropriate forms must be filled out on the Department of Environmental Health and
Safety website to request a pickup.
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Animals
All animal carcasses must be placed in 6 mil dark plastic bags (body bags) and frozen prior to being sent
for incineration. Bagged carcasses must be properly labeled and prepared for hazardous waste disposal.
Mixed Waste
For waste which is a mixture of chemical/radioactive and biohazardous waste, it is often possible to
destroy the biohazard first by chemical means and then treat and/or dispose of the waste as appropriate for
chemical or radioactive waste. If this is not possible, or if you are not sure that this can be done safely and
effectively, contact the Department of Environmental Health and Safety (ext. 32999) for assistance.
Queens University Biosafety Manual 2013
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Mixed waste should not be autoclaved, and should not be incinerated without consultation with the
Department of Environmental Health and Safety.
EMERGENCY PROCEDURES
Emergency response procedures must be in place for any incidents that might occur in the laboratory.
A template word document for Emergency Procedures is available on the Environmental Health and
Safety Website http://www.safety.queensu.ca/emergency/.
This document must be modified to be specific for your laboratory, updated annually, dated, and posted in
the laboratory where everyone knows its location and its content.
Refresher training of personnel on the Emergency Procedures must be done annually.
BIOSECURITY
Biosecurity breeches, e.g. the intentional misuse or theft of biohazardous materials or toxins, can lead to
serious undesirable consequences and a plan is in place at Queens to prevent such incidents. The plan
includes physical security such as locked doors, and also procedures to be followed by those working in
and around biohazard research laboratories and by Queens Security.
The biohazardous materials in use at Queens are quite common in the Canadian environment and are not
cultured in large quantities, so they are extremely unlikely to represent a significant community-wide
biosecurity risk.
The largest risk is that of individual illness due to an accidental laboratory acquired infection from certain
risk group 2 materials, and this risk is mitigated by the facilities and procedures described in this manual.
It would be possible for someone to take certain of the risk group 2 materials and intentionally (or
accidentally) make someone ill, either inside or outside the containment zone. Such infections would be
treatable and highly unlikely to produce fatalities. Nevertheless unauthorized access to such materials
should be prevented.
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The completed lab checklist to obtain a Federal CL2 Compliance letter and/or Import Permit application
must be signed by the Biosafety Officer and sent to the appropriate agency for approval.
The import permit will stipulate the containment requirements. A copy of the facility approval and the
import permit must be sent to the Biosafety Officer for the Principal Investigators Biohazard Permit file.
Some animal blood, serum, products or by-products also require an import permit because they
might contain pathogens exotic to Canada. The country of origin will be a factor in determining
whether or not an import permit is required for animal material. Consultation with CFIA will be required
and the Biosafety Officer can assist.
If importing non-pathogenic biological material, both CFIA and PHAC will issue a courtesy letter/nonpath letter to indicate that material is non-pathogenic. It is advisable to request such a letter using the
import permit application form if you are importing from a collaborator rather than a commercial
supplier, to ensure that material will not be delayed (and perhaps destroyed) when entering Canada.
Export
Export of pathogens falls under the Human Pathogens and Toxins Act and will be controlled by
regulations under this act when they are written.
When exporting biological agents from Canada it is your responsibility to:
1. Ensure that you are in compliance with the import regulations of the country to which you are
exporting.
2. Ensure that you are in compliance with international transportation regulations (see below).
3. Ensure that the person to whom you are shipping is aware of the hazards of the material.
4. Ensure that the person to whom you are shipping has the appropriate containment facilities to
handle the material safely.
5. Inform the Queens University Biosafety Officer.
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TDG regulations alter the classification of an infectious substance from Risk Groups 1-4 to a twocategory system in which Category A is for high risk substances and Category B is for other substances.
Unlike many chemicals, there is no small volume exemption for biological hazards. There are
exemptions i.e. changes in packaging and labeling requirements, for some biological/clinical samples
being sent for testing. Check the definition carefully to determine whether or not your sample qualifies.
Information can be found in the Biohazard Module of the TDG training slides.
Biohazard Permits
A Queens University Biohazard Permit is required for all research and teaching activities which involve
the use, manipulation and storage of biohazardous material, even risk group 1 material.
The types of material requiring a Biohazard permit are described in SOP-Biosafety-05 Queens
University Biohazard Risk Group Definitions .
The content of the biohazard permit application is the responsibility of the Principal Investigator and must
be submitted under their signature. However they may delegate the work of preparing the form and risk
assessment(s) to a member or members of their team. Part of the role of the Biosafety Officer is to assist
in the preparation of these applications when requested.
The permit is valid for four years if renewed annually (and if amended as necessary). Four years after
approval, a re-application must be submitted for review and approval by the Biohazard Committee.
Under the old paper-based system, the re-application was designed to ensure that the risk assessment and
associated documents still fully considered the biohazard risks in your laboratory, to consolidate any
amendments into one risk assessment document and to update the material with respect to any changes in
biosafety practices or regulations.
After we transition to the new electronic system, the risk assessment will be edited with each significant
amendment, so the risk assessment will be kept up to date. Nevertheless, re-application at the 4th renewal
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will still be required to update the information captured on the electronic biohazard form and to update
the material with respect to any changes in biosafety practices or regulations.
Under the electronic system, all laboratory personnel will be required to read the approved
biohazard permit documents and submit an electronic attestation form indicating that they
understand the risks and will follow the risk mitigation measures described.
Biohazard Renewal
Biohazard permits must be renewed annually by the anniversary date of approval. Renewal event forms
must be submitted by the Principal Investigator for review and approval by the Biosafety Officer.
Instructions will be provided when the Principal Investigator and Secondary Biohazard Contact are
reminded that the renewal date is approaching.
Biohazard Amendment
Changes to an approved biohazard permit may be made with a biohazard amendment event form. If the
amendment application requests a change in the type or risk group of biohazardous material, or if it
requests in a change in procedures that alter the risk (e.g. beginning in vivo work with biohazardous
material that was previously only used in vitro) then it will be reviewed by the Biohazard Committee,
otherwise the Biosafety Officer may approve it.
Equipment Decommissioning
Prior to shipping out for service, or relocating to another laboratory, any equipment that has been used
with biohazardous material must be thoroughly decontaminated and labeled as decontaminated before
being removed from the containment zone. Consult the Biosafety Officer if you have any questions.
Prior to disposal, any research equipment or furniture that may have been in contact with or may contain
biohazardous or other hazardous substances must be decommissioned by the Department of
Environmental Health & Safety. Queen's University must ensure that all hazards are removed in order to
prevent any spread of contaminants into the environment and to comply with existing regulations. There
is no cost to individual departments, and a few simple procedures, outlined here, must be followed:
http://www.safety.queensu.ca/decom/decomrequest.htm.
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Laboratory Decommissioning
Any laboratory that is undergoing significant renovations may need to be decommissioned first. Contact
the Department of Environmental Health and Safety regarding any renovations to your laboratory.
Any Principle Investigator closing a laboratory, leaving the university, or transferring to another location
within the University must be in compliance with the Queens University Standard Operating Procedure
for Laboratory Decommissioning, SOP-LAB-04.
A Laboratory Procedures Decommissioning Checklist, to be filled out and signed by officials from the
Department of Environmental Health and Safety, the Principal Investigator, and the Department Head to
document that the lab has be properly cleared of all hazardous material.
Failure to follow the required procedure may result in significant financial charges if members of the
Department of Environmental Health and Safety are required to decontaminate the lab and package and
remove hazardous material.
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APPENDIX I
Centrifuges
Improperly used or maintained centrifuges can present significant hazards to users. Failed mechanical
parts can result in release of flying objects, hazardous chemicals, and biohazardous aerosols. The highspeed spins generated by centrifuges can create large amounts of aerosol if a spill, leak or tube breakage
occurs.
Materials for centrifugation must be placed in screw-capped tubes (or sealed tubes if appropriate for
ultracentrifugation), which must not be overfilled or leak. Disinfect and clean up any leaks immediately.
To avoid the creation of aerosols after centrifugation, decant supernatants carefully and avoid vigorous
shaking and blowing bubbles with your pipette when resuspending packed cells and/or work in a
biological safety cabinet to contain aerosols.
For low speed centrifugation as is commonly used in tissue culture, sealed centrifuge buckets (safety
cups) are recommended for level 2 material and for all cell lines. Safety cups are strongly recommended
for known infectious level 2 material (eg. virus, viral vectors, and bacteria). For level 2+ work safety
cups are required, and must be opened only in a biological safety cabinet.
Microcentrifuges should not be placed in the BSC for operation, as air convection during operation
compromises the integrity of the BSC. Safety cups for microcentrifuges are now available.
In the event of a centrifuge equipment malfunction, follow instructions outlined in the Emergency
Response Procedures posted in your lab, in the section on Equipment Associated Emergencies.
To avoid contaminating your centrifuge:
Check glass and plastic centrifuge tubes for stresslines, hairline cracks and chipped rims before
use. Use unbreakable tubes whenever possible.
Avoid filling tubes to the rim.
Use caps or stoppers on centrifuge tubes. Avoid using lightweight materials such as aluminum
foil as caps.
To reduce aerosol generation upon opening, use screw-capped tubes and bottles rather than plugs
or snap caps when feasible.
Use sealed centrifuge buckets (safety cups) or rotors which can be loaded and unloaded in a
biological safety cabinet. Decontaminate the outside of the cups or buckets before and after
centrifugation. Inspect o-rings regularly and replace if cracked or dry.
Ensure that the centrifuge is properly balanced.
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Do not open the lid during or immediately after operation, interfere with the interlock safety
device or attempt to stop a spinning rotor by hand or with an object.
Clean spills promptly.
Cryostat
Frozen sections of unfixed human tissue or animal tissue infected with an infectious agent pose a risk
because accidents can occur and aerosols may be generated. Freezing tissue often does not inactivate
infectious agents. Freezing propellants under pressure should not be used for frozen sections as they may
cause spattering of droplets of infectious material. Gloves and a lab coat or gown should be worn during
preparation of frozen sections. Depending on the infectious agent, consider whether a mask and eye
protection needs to be worn. When working with biohazardous material in a cryostat, the following is
recommended:
Consider the contents of the cryostat to be contaminated and decontaminate it frequently with a
disinfectant suitable for the agent(s) in use.
Consider trimmings and sections of tissue that accumulate in the cryostat to be potentially
infectious and remove them during decontamination.
Decontaminate the cryostat with a tuberculocidal type disinfectant regularly and immediately
after tissue known to contain bloodborne pathogens, M. tuberculosis or other infectious agents is
cut.
Handle microtome knives with extreme care. Stainless steel mesh gloves should be worn when
changing knife blades.
Consider solutions for staining potentially infected frozen sections to be contaminated.
If liquid nitrogen enters a vial during storage, then upon warming it can explode. This has caused
eye and hand injuries. Always wear protective goggles or a full face shield when removing vials
from liquid nitrogen, until they have been safely opened in a biological safety cabinet.
Check the recommendations from the manufacturer of the cryovials that you use. Some cryovial
manufacturers recommend using internally threaded cryovials for storage in the vapour phase of
liquid nitrogen only, but many labs store vials in the liquid phase. If storage in the liquid phase is
required, consider how to reduce the risk. Nunc sells tubing to seal vials that must be stored in
the liquid phase. It has been reported in a web-based article on the University College London
site that vials with male caps that fit inside the vial, have a relatively thick thread and a sealing
O ring are less likely to explode than vials with a female cap. However, preventing the
contamination of the material in the vial when inserting and removing a male cap requires care.
If vials have been stored in the liquid phase, then manufacturers recommend moving the vials to
the vapour phase for 24 hours to allow any liquid nitrogen inside the vial to evaporate before
removing the vial from the tank to open. A more practical approach might be to loosen the cap
immediately upon removal from liquid nitrogen (if appropriate for the material involved 
consider how pathogenic it is) and/or to immediately place the vial in a closed, shatter-proof
container in case of explosion.
If the cryovials leak then viruses, bacteria and cells can escape, contaminating the liquid nitrogen
and potentially contaminating other vials in the tank. If storing highly pathogenic material in
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liquid nitrogen use commercially available tubing designed to seal the vials. It is also wise, if
feasible, to store known infectious pathogenic material in a different tank from material that will
be treated only as a level 1 biohazard.
Note that DMSO, commonly used when freezing cell lines, can solubilize organic material and
carry it through rubber (latex) and the skin, into the circulation. Take care to avoid contact with
DMSO and check the permeation time of the disposable glove material that you use.
Flow cytometers in which the sample flows in a stream through air, rather than in tubing present a risk to
the operator of exposure to aerosols that may contain infectious microorganisms associated with the cells.
Cell sorters are used to physically separate a defined subpopulation of cells from a larger, heterogeneous
population.
The risk associated with cell sorters and flow cytometers (depending on their design) can be attributed to
both the nature of the sample (i.e., the presence and nature of the infectious material or toxins contained
within the sample) and to the equipment itself (e.g., use of droplet-based cell sorting, which uses jet-in-air
technology, and has the potential to produce a large amount of aerosolized droplets). Droplet-based cell
sorting involves the injection of a liquid stream carrying the cells through a narrow nozzle vibrating at a
high frequency. High-speed cell sorters with jet-in-air technology use even higher pressures and nozzle
vibration frequencies, and consequently produce a larger amount of aerosolized material.
If you need to conduct flow cytometry or cell sorting with unfixed samples, you must contact the
University Biosafety Officer for assistance with a local risk assessment.
Freeze-Driers (Lyophilizers)
Aerosols may be produced during operation of a freeze drier and when material is being removed from
the chamber. When lyophilizing biohazardous materials:
Fume Hoods
Fume hoods are for collecting potentially harmful chemical gasses, vapours, mists, aerosols and
particulates generated during the manipulation of chemical substances. Fume hoods are NOT to be
used for biohazard containment. A biological safety cabinet must be used to contain biohazards. Some
work may require a biological safety cabinet with fume hood abilities (for example, using biohazards with
chemicals that produce toxic fumes or volatile compounds labeled with radioisotopes). Contact the
Biological Safety Officer if this is the case.
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Avoid flaming a loop in an open flame  use a loop microincinerator or pre-sterilized plastic
loops
If flaming is necessary, to eliminate the spattering and aerosolization associated with flaming of
loops, char the material before fully inserting the loop into the flame: i.e., before flaming, hold
the loop close to (but not into) the flame.
Do not use a flame in a biological safety cabinet
Streak plates where the surface of the medium is smooth (i.e. avoid bubbles)
Microscopes
Microscope eyepieces may provide a potential route of transmission of both bacterial and viral
infections. Large outbreaks of conjunctivitis have been attributed to the sharing of microscopes
among employees.
Disinfect the eyepieces, knobs, stage, and any other contaminated parts. Select a disinfectant that
will be non-toxic, effective on the pathogens in use and non-corrosive to the microscope.
Gloves used to handle contaminated specimens should be removed before using the microscope.
Mixing Apparatus
Homogenizers, shakers, blenders, grinders and sonicators can release significant amounts of aerosols
during their operation.
When using any mixing equipment, remember to:
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Hypodermic needles and syringes present hazards of spill, autoinoculation and aerosol generation, and
should be used only when absolutely necessary, such as for parenteral injection or withdrawal of body
fluids. When withdrawing liquids from septum-capped or diaphragm bottles, consider using an opener
made especially for this type of bottle; this allows for use of a pipette rather than a syringe/needle
assembly. Use cannulas or blunt-end needles for introduction or removal of fluids through small apertures
in equipment.
When working with syringes and needles, the following precautions are recommended:
Improper handling of pipettes has led to a number of laboratory acquired infections. These are avoidable
by using a mechanical pipetting aid (never pipette by mouth) and by using proper pipetting procedures to
avoid the generation of hazardous aerosols.
A pipetting device used with biohazardous material should be autoclavable and be provided with
aerosol protection (filter) to reduce the possibility of contaminating the pipetting aid
Check the quality of seal formed with pipettes to be used; liquid should not leak from the pipette
tip
Plug the top end of pipettes with cotton or use aerosol resistant disposable pipettes
Keep pipettes upright while in use and between steps of a procedure to prevent contamination of
the mechanical aid. Consider the use of easier-to-handle shorter pipettes when working inside a
biological safety cabinet.
Avoid loss of material from the tip of the pipette onto hard work surfaces; if this cannot be
avoided then a disinfectant soaked paper should be placed on the working surface
The contents of the pipette or tip should be expelled gently down the sides of tubes or discharged
slowly close to the surface of a liquid
Do not bubble air from a pipette to mix fluids
Avoid mixing by alternate suction and expulsion through a pipette, or work in a biosafety cabinet
Submerge used non-disposable pipettes horizontally in disinfectant solution; dropping them in
vertically may force out any liquid remaining in the pipette
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For infectious level 2 material, submerge contaminated pipettes in disinfectant solution inside the
bsc
When feasible for work with infectious micro-organisms, plastic transfer pipettes, culture tubes, flasks,
bottles, dilution tubes, etc. are preferable to glass, to reduce the risks of aerosol generation due to
breakage and also to minimize the risk of cuts and accidental inoculation
Where feasible and depending on the risk of the material, avoid pouring off the supernatant fluid
after centrifugation, cell washes, etc., even inside a biological safety cabinet, because this leads to
contamination of the outside rim of the tube and to aerosol production (that will contaminate the
surrounding area)
o the use of pipettes to transfer fluids is preferable
Pouring may be necessary, particularly if large volumes are involved:
o disinfectant soaked absorbents can be used to wipe the rims of tubes
o infected material can be poured through a funnel, the end of which is below the surface of
disinfectant in the discard container (the top of the funnel should be slightly larger than
the discard container so it rests securely and disinfectant should be poured through the
funnel after use)
Those using Vacuum and Aspirator Equipment must comply with the Queens University
Standard Operating Procedure, SOP-Biosafety-01
In particular, note the requirement for a HEPA filter in the line leading into the vacuum line:
cartridge-type in-line filters provide an effective barrier to escape of aerosols into vacuum
systems, and are commercially available for this purpose (discard used filters as biomedical
waste)
Water baths
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APPENDIX II
CBSG Operational Practice Requirements for Containment Level 2 in vitro and in vivo
The tables below present the containment level 2 operational practice requirements as stated in Chapter 4 of Part I, the Standards, in the Canadian
Biosafety Standards and Guidelines (CBSG) 1st Edition, 2013.
For all PHAC (HPTA) or CFIA designated:
 CL2 laboratories
 CL2-SA (rooms with small animals in primary containment caging e.g. Micro isolator lids, or HEPA filtered vented
racks under negative pressure)
 CL2-Ag (large animal rooms where the room provides the primary means of containment i.e. animals are not in
primary containment caging)
Note that this table is provided here in isolation from the CBSG for convenience. However, it is strongly recommended that when first
reading an item in the Standards, or if you have any doubt about its intention, you also read the Transition Index for that item for
clarification. If still in doubt, consult the University Biosafety Officer.
Numbers in the left column are those used in the CBSG for each item of the Standards.
Definitions of terms can be found in the CBSG Glossary (Chapter 21).
Table 1 contains the requirements for CL2 laboratories. These are also required for CL2-SA and CL2-Ag facilities.
Table 2 contains additional requirements for CL2-SA facilities.
Table 3 contains requirements for CL2-Ag. Note that these requirements are in addition to those in the first two tables.
These tables do not present the operational requirements that are exclusively for prion work (for those look for P in the CBSG
matrices).
4.1.1
4.1.2
4.1.3
A biosafety program management system to be in place to oversee safety and containment practices.
Contact information to be provided to the relevant federal regulatory agency (or agencies), and kept up to date.
Program intent to be submitted to the relevant federal regulatory agency (or agencies) in accordance with importation and/or
certification/recertification requirements.
An overarching risk assessment to be conducted and documented to identify the hazards and appropriate mitigation management
4.1.4
4.1.5
4.1.6
4.1.7
4.1.8
monitoring of biological material that enters, is held within, or leaves the containment zone;
A Biosafety Manual to be developed, implemented, kept up to date, made available to personnel inside and outside of containment zone, and contain
institutional biosafety policies, programs, and plans, based on a documented overarching risk assessment and/or LRAs; the Biosafety Manual to include:
program intent;
biosafety program;
brief description of the physical operation and design of the containment zone and systems;
SOPs for safe work practices for handling infectious material, toxins, and/or infected animals, including:
o
PPE requirements;
biosecurity plan;
training program;
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4.1.9
4.1.10
4.1.11
4.1.12
facility and equipment maintenance program for components of the containment zone.
The Biosafety Manual to be supplemented and updated with SOPs specific to the nature of the work being conducted in the
containment zone and to each project or activity, as applicable.
A biosecurity risk assessment to be conducted.
A Biosecurity Plan, based on a biosecurity risk assessment, to be implemented, evaluated and improved as necessary, and kept up to
date.
Inventory of infectious material and toxins handled or stored in the containment zone to be maintained, and kept up to date. Infectious
material or toxins stored outside the CL2 zones to be included in the inventory.
4.1.13
Records pertaining to importation requirements to be kept for 2 years following the date of disposal, complete transfer or inactivation of the imported
infectious material or toxin, and made available upon request.
4.2
4.2.1
A medical surveillance program, based on an overarching risk assessment and LRAs, to be developed, implemented, and kept up to
date.
Containment zone personnel to immediately notify their supervisor of any illness caused by, or that may have been caused by, the
infectious material or toxin(s) being handled or stored.
4.2.3
4.3
4.3.1
4.3.2
4.3.3
4.3.4
4.3.5
4.3.6
4.3.7
4.3.8
4.3.9
4.3.10
Personnel to be trained on the relevant physical operation and design of the containment zone and systems.
Personnel to be trained on the correct use and operation of laboratory equipment, including primary containment devices.
Personnel working with animals to be trained in restraint and handling techniques.
Visitors, maintenance/janitorial staff, contractors, and others who require temporary access to the containment zone to be trained
and/or accompanied in accordance with their anticipated activities in the containment zone.
Personnel to demonstrate knowledge of and proficiency in the SOPs on which they were trained.
Trainees to be supervised by authorized personnel when engaging in activities with infectious material and toxins until they have fulfilled the training
requirements.
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4.3.13
Review of training needs assessment to be conducted, at minimum, annually. Additional or refresher training to be provided as determined by the review
process or when warranted by a change in the biosafety program.
Training and refresher training to be documented; records to be kept on file.
4.4
4.4.1
Appropriate dedicated PPE specific to each containment zone, to be donned in accordance with entry procedures and to be exclusively worn and stored in
the containment zone.
4.4.2
4.4.3
4.4.4
Face protection to be worn where there is a risk of exposure to splashes or flying objects.
Personnel working in animal rooms, cubicles, or PM rooms to wear dedicated protective footwear and/or additional protective
footwear.
Gloves to be worn when handling infectious material, toxins or infected animals.
4.5
4.5.1
4.5.2
4.5.4
4.5.6
4.5.7
4.5.10
4.5.11
Personnel to wash hands after handling infectious materials or toxins, and when exiting the containment zone, animal room/cubicle, or PM room.
4.6
Work Practices
4.3.11
General
4.6.1
4.6.2
4.6.3
4.6.5
4.6.6
4.6.7
4.6.8
4.6.9
4.6.10
Contact of the face or mucous membranes with items contaminated or potentially contaminated with infectious material or toxins to be prohibited.
Hair that may become contaminated with working in the containment zone to be restrained or covered.
Type of footwear worn to be selected to prevent injuries and incidents, in accordance with containment zone function.
Bending, shearing, re-capping, or removing needles from syringes to be avoided, and, when necessary, performed in accordance with
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4.6.11
4.6.14
4.6.15
SOPs.
Work surfaces to be cleaned and decontaminated with a disinfectant effective against the infectious material in use, or a neutralizing
chemical effective against the toxins in use at a frequency to minimize the potential of exposure to infectious material or toxins.
Verification of the integrity of primary containment devices to be performed routinely in accordance with SOPs.
BSCs, where present, to be certified upon initial installation, annually, and after any repairs or relocation. Certification to include verification of correct
operation by in situ testing in accordance with NSF International (NSF)/ANSI 49, or, where not applicable, with manufacturer specifications.
4.6.20
Containers of infectious material or toxins stored outside the containment zone to be labelled, leakproof, impact resistant, and kept either in locked storage
equipment or within an area with limited access.
A certified BSC to be used for procedures that:
4.6.23
4.6.25
4.6.26
4.6.28
4.6.29
4.6.30
4.6.31
4.6.32
may produce infectious aerosols or aerosolized toxins, when aerosol generation cannot be contained through other methods;
Containment zone (including floors) to be kept clean, free from obstructions, and free from materials that are in excess, not required,
or that cannot be easily decontaminated.
An effective rodent and insect control program to be maintained.
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4.6.38
Personnel to conduct periodic visual inspections of the containment zone to identify faults and/or deterioration; when found,
corrective actions to be taken.
4.6.39
4.6.40
Records of regular inspections of the containment zone and corrective actions to be kept on file.
Records of building and equipment maintenance, repair, inspection, testing or certification, in accordance with containment zone function, to be kept on
file.
4.8
4.8.1
4.8.2
Gross contamination to be removed prior to decontamination of surfaces and equipment, and disposed of in accordance with SOPs.
4.8.3
4.8.4
4.8.5
4.8.7
4.8.8
Disinfectants effective against the infectious material in use and neutralizing chemicals effective against the toxins in use to be available and used in the
containment zone.
Sharps to be discarded in containers that are leakproof, puncture-resistant, fitted with lids, and specifically designed for sharps waste.
Primary containment devices to be decontaminated prior to maintenance.
All clothing and PPE to be decontaminated when a known or suspected exposure has occurred.
Contaminated liquids to be decontaminated prior to release into the sanitary sewer.
Contaminated materials and equipment to be decontaminated and, in accordance with SOPs, labelled prior to cleaning, disposal, or
removal from the containment zone, animal rooms/cubicles, or PM rooms.
4.8.10
Decontamination equipment and processes to be validated (in accordance with SOPs) using representative loads, and routinely verified using applicationspecific biological indicators, chemical integrators, and/or parametric monitoring devices (e.g., temperature, pressure, concentration) consistent with the
technology/method used.
4.8.11
Efficacy monitoring of decontamination equipment and processes to be performed routinely, based on an LRA, and records of these
actions to be kept on file.
4.8.13
Contaminated bedding to be removed at a ventilated cage changing station or within a certified BSC prior to decontamination, or to be decontaminated
within containment cages.
4.8.14
Animal cubicles, PM rooms, and the dirty corridor, when present, to be decontaminated when grossly contaminated and at the end of
an experiment.
4.9
4.9.1
An ERP, based on an overarching risk assessment and LRAs, to be developed, implemented, and kept up to date. The ERP is to
describe emergency procedures applicable to the containment zone for:
 Accidents/incidents;
 medical emergencies;
 fires
 chemical/biological spills (small and large; inside/outside BSC and centrifuge);
 power failure;
 animal escape (if applicable);
 failure of primary containment devices;
 loss of containment;
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4.9.2
4.9.5
4.9.6
4.9.7
 emergency egress;
 notification of key personnel and relevant federal regulatory agency (or agencies)
 natural disasters; and
 incident follow-up and recommendations to mitigate future risks.
ERP to include procedures for any infectious material or toxins stored outside the containment zone.
Incidents involving infectious material, toxins, or infected animals, or involving failure of containment systems to be reported
immediately to appropriate personnel.
Incident investigation to be conducted and documented for any incident involving infectious material, toxins, infected animals, or
failure of containment systems, in order to determine root cause(s).
Records of incidents involving infectious materials, toxins, infected animals, or losses of containment to be kept on file.
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4.5.8
Personal belongings not required for work to be left outside the containment zone or in change areas outside the containment barrier.
4.6
Work Practices
General
4.6.13
Verification of inward directional airflow to be performed routinely and in accordance with SOPs.
Routine cleaning, in accordance with SOPs, to be carried out by containment zone personnel or other staff trained specifically for this task.
4.7
4.7.1
4.7.2
4.7.3
4.7.4
4.7.6
Proper methods of restraint to be used to minimize scratches, bites, kicks, crushing injuries, and accidental self-inoculation.
4.7.7
4.7.8
Inoculation, surgical, and necropsy procedures to be designed and carried out to prevent injuries to personnel and minimize the
creation of aerosols.
Inoculation, surgical, and necropsy procedures with animals in SA zones to be carried out in a certified BSC or other appropriate
containment devices. (does not apply to CL2-Ag)
Animals to be disinfected and/or cleaned at site of injection or exposure following inoculation or aerosol challenge with infectious
material or toxins, where possible based on work.
4.8
4.8.13
Contaminated bedding to be removed at a ventilated cage changing station or within a certified BSC prior to decontamination, or to be decontaminated
within containment cages.
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4.4.5
4.4.8
Full body coverage dedicated protective clothing to be worn inside the containment barrier where human or zoonotic pathogens are handled.
Respirators to be worn where there is a risk of exposure to infectious aerosols that can be transmitted through the inhalation route or to aerosolized toxins,
as determined by an LRA.
4.5
4.5.5
Personnel to verify correct reading of monitoring device(s) that visually demonstrate inward directional airflow, prior to entry into area where inward
directional airflow is provided.
Personnel to doff dedicated PPE (or additional layer of PPE, when worn) when exiting animal cubicles or PM rooms, except when exiting to the dirty
corridor.
4.5.12
4.7
4.7.5
Animal carcasses to be removed from cubicles/PM rooms via the dirty corridor or divided into smaller portions and placed into labelled, leakproof, and
impact resistant transport containers.
4.8
4.8.6
PPE to be decontaminated prior to disposal or laundering unless laundering facilities are located within the containment zone and have been proven to be
effective in decontamination.
Animal cubicles, PM rooms, and the dirty corridor, when present, to be decontaminated when grossly contaminated and at the end of an experiment.
4.8.14
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APPENDIX III
Canadian Biosafety Standards and Guidelines (CBSG), 1st Edition, 2013 will form the basis of regulations under the Human Pathogens
and Toxins Act.
o The CBSG describes the best practices for work with all human or terrestrial animal pathogens and, under Canadian law,
must be followed for Risk Group 2 pathogens and above.
o Updates and harmonizes three previous Canadian biosafety standards and guidelines for the design, construction and operation of
facilities in which pathogens or toxins are handled or stored:
 Human pathogens and toxins: Laboratory Biosafety Guidelines, 3rd Edition, 2014 (PHAC)
 Terrestrial animal pathogens: Containment Standards for Veterinary Facilities, 1st Edition , 1996 (CFIA)
 Prions: Containment Standards for Laboratories, Animal Facilities and Post Mortem Rooms handling Prion Disease Agents,
1st Edition, 2005 (CFIA)
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Several provincial and municipal laws and regulations also affect the use or disposal of biohazards and associated material at the University.
- Ontario Guideline C-4 defines biomedical waste and outlines its proper treatment and handling.
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Memorandum of Understanding. Roles and Responsibilities in the Management of Federal Grants and Awards. An agreement between
Queens University and the Federal Granting Agencies
o Institution to monitor research involving biohazards and to adhere to the PHAC and the CFIA Standards and Guidelines, including but
not limited to:
o Establish an Institutional Biosafety Committee and appoint a Biosafety Officer
 Provide appropriate training, as prescribed, prior to beginning the work, for all persons whose research may involve
biohazards
 Maintain a safe working environment by regularly inspecting and maintaining all equipment and facilities used specifically for
research, storage, or disposal of biological hazards
 Comply with all applicable federal and provincial laws
o Release funds to researchers only if the Institutional Biosafety Committee or Biosafety Officer has approved the project
procedures and has provided a certificate to the laboratory
o Process to ensure Institutional Biosafety Committee or Biosafety Officer is notified promptly by the researchers if the research
changes to involve the use of biohazards of a different level of risk
o Suspend funding due to a serious contravention of the Canadian Biosafety Standards and Guidelines; an applicable federal or
provincial law; or any condition of approval imposed by the Institutional Biosafety Committee or Biosafety Officer
o Advise the Agencies in writing of any situation that results in a suspension of funds to a research project
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