Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement F: Laboratory Guidance

Appendix F5

Laboratory Biosafety Guidelines for Handling and Processing Specimens
Associated with SARS-CoV

Although routine clinical laboratories around the world have processed
an estimated several thousand diagnostic specimens from patients with
SARS, no cases of SARS-CoV disease among laboratory workers performing
diagnostic assays have been reported to date. However, there have been
two reported cases of SARS-CoV disease in workers in research
laboratories where SARS-CoV was being propagated. Until more information
about the transmission of SARS-CoV in the laboratory setting is known,
precautions should be taken in handling specimens (e.g., respiratory and
stool specimens, unfixed lung tissue, viral cultures) that might contain
large quantities of SARS-CoV.

Effective and timely communication between clinical and laboratory staff
is essential to minimize the risk incurred in handling specimens from
patients with possible SARS-CoV disease. Such specimens should be
labeled accordingly, and the laboratory should be alerted to ensure
proper specimen handling. Biosafety guidelines for handling SARS-CoV
specimens, by specimen type, are provided below. Guidelines on
implementing a medical surveillance system for laboratory workers are
provided in Appendix F6.

## A. Blood (blood, serum and plasma) and urine specimens

-   Handle these specimens using Universal Precautions, which includes
    use of gloves, gown, mask, and eye protection. For more information
    on Universal Precautions, see
    <http://www.osha.gov/SLTC/bloodbornepathogens/index.html#revised_standard>.

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-   Any procedure with the potential to generate fine-particulate
    aerosols (e.g., vortexing or sonication of specimens in an open
    tube) should be performed in a biological safety cabinet (BSC). Use
    sealed centrifuge rotors or sample cups, if available, for
    centrifugation. Ideally, rotors and cups should be loaded and
    unloaded in a BSC. Perform any procedures outside a BSC in a manner
    that minimizes the risk of exposure to an inadvertent sample
    release.

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-   After specimens are processed, decontaminate work surfaces and
    equipment. Use any EPA-registered hospital disinfectant. Follow
    manufacturer\'s recommendations for use-dilution (i.e.,
    concentration), contact time, and care in handling.

## B. Other specimens (e.g., respiratory secretions, stool, or tissue for procedures performed in microbiology or pathology laboratories)

-   The following activities may be performed in BSL-2 facilities with
    standard BSL-2 work practices:

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-   Pathologic examination and processing of formalin-fixed or otherwise
    inactivated tissues

-   Molecular analysis of extracted nucleic acid preparations

-   Electron microscopic studies with glutaraldehyde-fixed grids

-   Routine examination of bacterial and mycotic cultures

-   Routine staining and microscopic analysis of fixed smears

-   Final packaging of specimens for transport to diagnostic
    laboratories for additional testing. Specimens should already be in
    a sealed, decontaminated primary container.

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-   The following activities involving manipulation of untreated
    specimens should

> be performed in BSL-2 facilities and in a Class II BSC:

-   Aliquoting and/or diluting specimens

-   Inoculating bacterial or mycological culture media

-   Performing diagnostic tests that do not involve propagation of viral
    agents in vitro or in vivo

-   Nucleic acid extraction procedures involving untreated specimens

-   Preparation and chemical- or heat-fixing of smears for microscopic
    analysis

> Work surfaces should be decontaminated on completion of work with
> appropriate disinfectants. All disposable waste should be autoclaved.
>
> Laboratory workers should wear personal protective equipment (PPE),
> including disposable gloves and laboratory coats.

Any procedure or process that cannot be conducted in a BSC should be
performed while wearing gloves, gown, eye protection, and respiratory
protection, (see Supplement I, Section III.D.5).

> Acceptable methods of respiratory protection include: a properly
> fit-tested, NIOSH-approved filter respirator (N-95 or higher level) or
> a powered air-purifying respirator (PAPR) equipped with
> high-efficiency particulate air (HEPA) filters. Accurate fit-testing
> is a key component of effective respirator use.[^1] Personnel who
> cannot wear fitted respirators because of facial hair or other fit
> limitations should wear loose-fitting hooded or helmeted PAPRs.
>
> Appropriate physical containment devices (e.g., centrifuge safety
> cups; sealed rotors) should also be used. Ideally, rotors and cups
> should be loaded and unloaded in a BSC.

-   The following activities must be performed in a BSL-3 facility using
    BSL-3 work practices:

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-   SARS-CoV propagation in cell culture

-   Initial characterization of viral agents recovered in cultures of
    SARS specimens

> Any procedure or process that cannot be conducted in a BSC should be
> performed while wearing gloves, gown, eye protection, and respiratory
> protection (see Supplement I, Section III.D.5).
>
> Acceptable methods of respiratory protection include: a properly
> fit-tested, NIOSH-approved filter respirator (N-95 or higher level) or
> PAPR equipped with HEPA filters. Accurate fit-testing is a key
> component of effective respirator use.[^2] Personnel who cannot wear
> fitted respirators because of facial hair or other fit limitations
> should wear loose-fitting hooded or helmeted PAPRs.
>
> Centrifugation should be carried out using sealed centrifuge cups or
> rotors that are unloaded in a BSC.

-   The following activities must be performed in Animal BSL-3
    facilities using Animal BSL-3 work practices:

    -   Inoculation of animals for potential recovery of SARS-CoV from
        SARS samples

    -   Protocols involving animal inoculation for characterization of
        putative SARS agents

Consideration may also be given to referral of specimens to a suitably
equipped reference laboratory.

**Note**: Packaging, shipping, and transport of specimens from possible
and known cases of SARS-CoV disease must follow the current edition of
the International Air Transport Association (IATA) Dangerous Goods
Regulations at
([www.iata.org/dangerousgoods/index](http://www.iata.org/dangerousgoods/index))
and US DOT 49 CFR Parts 171-180
([hazmat.dot.gov/rules.htm](http://hazmat.dot.gov/rules.htm)).
Step-by-step instructions on appropriate packaging and labeling are
provided at:
<http://www.cdc.gov/ncidod/sars/pdf/packingspecimens-sars.pdf>

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)

[^1]: Respirators should be used in the context of a complete
    respiratory protection program, as required by the Occupational
    Safety and Health Administration (OSHA). This includes training,
    fit-testing, and fit-checking to ensure appropriate respiratory
    selection and use. To be effective, respirators must provide a
    proper sealing surface on the wearer's face. Detailed information on
    a respiratory protection program can be found at:
    [www.osha.gov/SLTC/etools/respiratory/](http://www.osha.gov/SLTC/etools/respiratory/).

[^2]: ^1^ Respirators should be used in the context of a complete
    respiratory protection program, as required by the Occupational
    Safety and Health Administration (OSHA). This includes training,
    fit-testing, and fit-checking to ensure appropriate respiratory
    selection and use. To be effective, respirators must provide a
    proper sealing surface on the wearer's face. Detailed information on
    a respiratory protection program can be found at:
    [www.osha.gov/SLTC/etools/respiratory/](http://www.osha.gov/SLTC/etools/respiratory/).