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RESEARCH SAFETY (BIOSAFETY) AND SECURITY MANUAL AND CHEMICAL HYGIENE
PLAN

Research Service Line

Michael E. DeBakey Veterans Affairs Medical Center

*Houston, TX*

June 27, 2007

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height="1.8743055555555554in"}

EMERGENCY PHONE NUMBERS

Fire 911

Chemical Spill/Smell 911

Police 911

Medical Emergency 911

MEDVAMC Safety Officer (Jeff Triebel) 7396

Pager 713-841-0933

Radiation Safety/Spill (Jeff Triebel) 7396

Pager 713-841-0933

Chemical Hygiene Officer (Jeff Triebel) 7396

Pager 713-841-0933

Biological Safety Officer (Richard Hamill, MD, Chair, SRS) 7384

Pager 713-841-1345

Research Safety Coordinator (Pamela Maseda) 7567

Director of Operations for Research (Joyce A. McDaniel) 7564

> Pager 713-841-5724

Associate Chief of Staff/Research (Holly H. Birdsall, MD, PhD) 7775

Cell 713-819-0020

*SUBCOMMITTEE ON RESEARCH SAFETY*

RESEARCH SAFETY (BIOSAFETY) AND SECURITY MANUAL

AND CHEMICAL HYGIENE PLAN

TABLE OF CONTENTS

## Page

CHAPTER 1 Emergency Response Guide 1

A Biological Spill 1

B Chemical Spill 2

C Fire 4

D Medical Emergency 4

E Radiation Spill 5

CHAPTER 2 Disaster Response Guide 7

A Community Emergency 7

B Civil Defense Disaster 7

C Civil Disturbance 7

D Bomb Threat 7

E Major Power, Utility, or Communication Disruptions 7

F Severe Weather Emergency 7

G Bioterrorism Readiness 8

CHAPTER 3 Unidentified Odor Policy 9

CHAPTER 4 First Aid 10

CHAPTER 5 Emergency Response Guidelines 11

A Cascade System for Emergency Calls 11

> B Evacuation of Personnel 11
>
> C Security System 11

CHAPTER 6 Evacuation of Personnel With Disabilities 12

A Procedures 12

CHAPTER 7 Vivarium Emergency 13

A Animal Emergency 13

B Security Breach Procedures 14

CHAPTER 8 Cyber Security 15

A Security Measures 15

B Cyber Security Incident 18

C Computer System Failure 19

CHAPTER 9 Chemical Hygiene Plan 20

A General 20

B Standard Laboratory Procedures 20

C Employee Exposure 23

D Employee Information and Training 23

E Medical Program 25

F Special Procedures/Provisions 26

G Hazard Identification 29

H Recordkeeping 30

I Reference Material 30

J Hazardous Chemicals by Category 31

K Chemical Procurement, Distribution, and Storage 40

L Environmental Monitoring 41

M Housekeeping 42

N Maintenance 42

O Inspections 43

P Personal Protective Apparel and Equipment Assessment 44

Q Disposal of Chemicals From Laboratories 45

R The Material Safety Data Sheet 48

S Incompatible Chemicals (Reactive Hazards) 50

CHAPTER 10 Occupational Health and Safety Program 51

A Medical/Occupational Health and Safety 51

B Occupational Health Program for Personnel Using Animals 54

CHAPTER 11 Biological Hazards 57

A Introduction 57

B General Principles 57

C Routes of Infection 57

D Precautionary Techniques 58

E Laboratory Biosafety Level Criteria 60

F Summary of Recommended BSLs for Infectious Agents 66

G Accidents and Spills (additional information) 67

H Disposal of Biological Waste 68

I Treatment/Disposal Techniques 69

J Biological Waste with Chemical Contamination 70

K Incineration 70

L Waste Segregation 71

CHAPTER 12 Equipment and Utility Management 72 A Utility Management 72

B Electrical Safety 76

APPENDIX A Bomb Threat Telephone Report A1

APPENDIX B Cascade for Emergency B1

CHAPTER 1 [EMERGENCY RESPONSE GUIDE]{.underline}

###  

### A. BIOLOGICAL SPILL

\(1\) Call 911

> \(a\) Alert people in immediate area of spill to evacuate.

\(b\) Soak paper towels in disinfectant and place over spill area.

> \(c\) Wear protection.

\(2\) Biological spills outside biological safety cabinets will generate
aerosols that can be dispersed in the air throughout the laboratory.
These spills are very serious if they involve microorganisms that
require Biosafety Level 3 (BSL-3) containment. Reduce the risk of
inhalation exposure by holding breath and leave the laboratory
immediately. The laboratory should not be reentered to decontaminate and
clean up the spill for at least one hour. (During this time, the aerosol
will be removed from the laboratory by the exhaust air ventilation
system.) Wear appropriate protective equipment.

### (a) Spill Involving a Microorganism Requiring BSL 1 Containment (Work involving agents of no known or of minimal potential hazard to laboratory personnel and the environment)

[1]{.underline} Wear disposable gloves.

> [2]{.underline} Soak paper towels in disinfectant and place over spill
> area.
>
> [3]{.underline} Place towels in plastic bag for disposal.

[4]{.underline} Clean spill area with fresh towels soaked in
disinfectant.

###  (b) Spill Involving a Microorganism Requiring BSL 2 Containment (Work involving agents of moderate potential hazards to personnel and the environment. Laboratory personnel must have specific training in handling pathogenic agents and access to the laboratory is limited when work is being conducted. Procedures in which infectious aerosols are created are conducted in biological safety cabinets or other physical containment equipment.)

[1]{.underline} Alert people in immediate area of spill.

[2]{.underline} Put on protective equipment.

[3]{.underline} Cover spill with paper towels or other absorbent
materials.

[4]{.underline} Carefully pour a freshly prepared 1 in 2 dilution of
household bleach around the edge of the spill and then into the spill.

> [5]{.underline} Avoid splashing and allow 20 minutes contact.

[6]{.underline} Use paper towels to wipe up the spill, working from the
edge to center.

> [7]{.underline} Clean spill area with fresh towels soaked in
> disinfectant.

[8]{.underline} Place towels in a plastic bag and dispose of as
infectious waste.

### (c) Spill Involving a Microorganism Requiring BSL 3 Containment (Work is done with indigenous or exotic agents that may cause serious or potentially lethal disease as a result of exposure by the inhalation route. Laboratory personnel have specific training in handling pathogenic and potentially lethal agents. Procedures are conducted within biological safety cabinets or other physical containment devices or by personnel wearing appropriate personal protective clothing and devices. When existing facilities do not have all the facility safeguards recommended for BSL 3 (e.g., access zone, sealed penetrations, and directional airflow, etc.), acceptable safety may be achieved for routine or repetitive operation (e.g., diagnostic procedures involving the propagation of an agent for identification, typing, and susceptibility testing).)

[1]{.underline} Alert people in immediate area of spill.

> [2]{.underline} Put on protective equipment.
>
> [3]{.underline} Cover spill with paper towels or other absorbent
> materials.

[4]{.underline} Carefully pour a freshly prepared 1 in 2 dilution of
household bleach around the edge of the spill and then into the spill.

> [5]{.underline} Avoid splashing and allow 20 minutes contact.

[6]{.underline} Use paper towels to wipe up the spill, working from the
edge to center.

> [7]{.underline} Clean spill area with fresh towels soaked in
> disinfectant.

[8]{.underline} Place towels in a plastic bag and dispose of as
infectious waste.

B. [CHEMICAL SPILL]{.underline}

\(1\) Call 911

> \(a\) If spilled material is flammable, turn off ignition and heat
> sources.
>
> \(b\) Alert people in the laboratory to evacuate area.
>
> \(c\) Use spill kits to confine spill.

The cleanup of a chemical spill can only be done by knowledgeable and
experienced personnel. Spill kits with instructions, absorbents,
reactants, and protective equipment are available in laboratories to
contain many minor spills.

\(2\) In the event of a [major chemical spill]{.underline},

\(a\) Attend to the injured or contaminated persons and remove them from
exposure.

> \(b\) Alert people in the laboratory to evacuate.
>
> \(c\) If spilled material is flammable, turn off ignition and heat
> sources.

\(d\) Close doors to affected area.

\(e\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

\(3\) In the event of a [minor chemical spill,]{.underline}

\(a\) Avoid breathing vapors from spill.

\(b\) Confine spill to small area.

\(c\) Use appropriate kit to contain, neutralize, and absorb inorganic
acids and bases. (Neutralize acid spills with sodium carbonate
neutralize alkali spills with boric acid.)

\(d\) Attend to injured or contaminated persons and remove them from
exposure.

\(e\) Alert people in the laboratory to evacuate.

\(f\) If spilled material is flammable, turn off ignition and heat
sources.

\(g\) Close doors to affected area.

\(h\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

### C. FIRE

\(1\) Call 911 or pull alarm device box. Give name and specific
location.

\(a\) Small fires can be extinguished without evacuation. However, our
fire plan requires evacuation upon hearing a fire alarm.

> \(b\) Never enter a room that contains visible smoke.

\(c\) Never enter a room containing visible fire without a back-up
person on site.

> \(d\) Never enter a room if the door is warm to the touch.

\(2\) [R.A.C.E.]{.underline}

\(a\) RESCUE - Alert people in the area to evacuate, assist anyone
unable to evacuate on their own.

> \(b\) ALARM - Pull nearest fire alarm and call 911.

\(c\) CONFINE - Close doors to confine fire.

> \(d\) EXTINGUISH -- Smother fire or use fire extinguisher.

\(3\) [PASS Fire Extinguisher Usage]{.underline}

> \(a\) Pull pin on extinguisher
>
> \(b\) Aim at base of fire
>
> \(c\) Squeeze handle

\(d\) Sweep extinguisher across base of fire

EVACUATE IMMEDIATELY IF FIRE CANNOT BE CONTROLLED!!!!

### D. MEDICAL EMERGENCY

\(1\) Call 911; give name and specific location.

> \(2\) Attend to injured or contaminated persons and evacuate if
> necessary.
>
> \(3\) Initiate lifesaving measures, and if required, WEAR PROTECTION.
>
> \(4\) Do not move injured person unless there is danger of further
> harm.

### E. RADIATION SPILL

\(1\) Call 911. Spreading of radiation beyond the spill area can easily
occur by the movement of personnel involved in the spill or clean-up
effort. Prevent spread by confining movement of personnel until they
have been monitored and found free of contamination. Place absorbent
paper towels over liquid spill. Place towels dampened with water over
spills of solid materials. WEAR PROTECTION.

###  (2) Major Radiation Spill -- Definition: greater than 100 microcuries

\(a\) Attend to injured persons and remove them from possible exposure.

> \(b\) Alert people in the laboratory to evacuate.

\(c\) Have potentially contaminated personnel stay in one area until
they have been monitored and shown to be free of contamination.

> \(d\) Call Radiation Spill Emergency Response number (911).
>
> \(e\) Close doors and prevent entrance into affected area.

\(f\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

\(3\) [Minor Radiation Spill]{.underline} -- Definition: less than 100
microcuries

> \(a\) Alert people in immediate area of spill.

\(b\) Notify Radiation Safety Officer at 713/794-7396 and indicate
identity of isotope, chemical carrier and activity.

\(c\) Wear protective equipment including safety goggles, gloves, shoe
covers and long-sleeve lab coat.

> \(d\) Place absorbent paper towels over liquid spill.
>
> \(e\) Place towels dampened with water over spills of solid materials.
>
> \(f\) Using forceps, place towels in plastic bag.
>
> \(g\) Dispose in radiation waste container.

\(h\) Monitor area, hands, and shoes for contamination with an
appropriate survey meter or method.

\(i\) Repeat clean up until contamination no longer detected.

[Additional Information]{.underline} -- Contaminated clothing should be
removed for evaluation by the Radiation Safety Officer. If the spill is
on the skin, flush thoroughly or shower, then wash with a mild soap and
lukewarm water.

CHAPTER 2 [DISASTER RESPONSE GUIDE]{.underline}

### A. COMMUNITY EMERGENCY

Such an emergency would include fire, explosion, plane crash, tornado,
hurricane, flood, and earthquake. Upon activation of the Community
Casualty Plan by the Medical Center Director, report, when notified, to
a designated area for instructions.

### B. CIVIL DEFENSE DISASTER

Such an event would include nuclear fallout from a bombing, accident, or
military casualties. As circumstances dictate, the Community Casualty
Plan will be effected. Report, when notified, to a designated area for
instructions.

### C. CIVIL DISTURBANCE

Such a disturbance would include a riot, acts of massive violence
causing casualties in the community, or individuals threatening
violence. Notify MEDVAMC Police at 911. If you are not at risk, gather
descriptive information about the offenders, names, places, etc. Report
all collected information to the MEDVAMC Police.

### D. BOMB THREAT

\(1\) When a bomb threat is received, the individual receiving the
threat shall ASK CALLER questions contained in Appendix A. Get as much
details as possible.

\(2\) When the call is terminated, call 911 and alert people in the area
to evacuate to a safe location.

\(3\) Take the completed "Bomb Threat Telephone Report" to the on-duty
MEDVAMC Police Officer.

### E. MAJOR POWER, UTILITY, OR COMMUNICATIONS DISRUPTIONS

\(1\) Notify MEDVAMC Police at 911 and Facilities Management Service at
713/791-1414, x-5884.

\(2\) Turn off gas valves and powered equipment.

\(3\) If animals are affected, contact the Research Administration
Office at 713/794-7566 to assist in moving animals to Baylor College of
Medicine.

### F. SEVERE WEATHER EMERGENCY

Await MEDVAMC Medical Center Director instructions via the Command
Center. If necessary, the Command Center will arrange sleeping/food. Do
not venture into an inclement environment without a clear understanding
of the potential hazards. In the event of a hurricane, the Veterinary
Medical Unit Hurricane Emergency Response Plan, briefly discussed in
Chapter 7, will be activated as pertains to the welfare of animals.

G. [BIOTERRORISM READINESS]{.underline}

The MEDVAMC and other healthcare facilities may be the initial sites of
recognition and response to bioterrorism events. If a bioterrorism event
is suspected, local emergency response systems will be activated.

Bioterrorism may occur as covert events, in which persons are
unknowingly exposed and an outbreak is suspected only upon recognition
of unusual disease clusters or symptoms. Bioterrorism may also occur as
announced events, in which persons are

warned that an exposure has occurred.

CHAPTER 3 [UNIDENTIFIED ODOR POLICY]{.underline}

[15-MINUTE POLICY ON UNIDENTIFIED ODORS]{.underline}

The 15-minute policy is necessary when odors are detected but the source
is unknown. In the first 5 minutes that an unidentified smell/odor is
detected, the individual should try to determine the origin. If the
odor/smell is associated with coughing, sneezing, shortness of breath,
eye tearing or any other adverse reactions, immediately call 911 and
report the circumstances. Individuals may ask others in the local area
for their assistance in locating the source of the odor. In any case, if
the source cannot be located, call 911 and report the order in 15
minutes or less. In some circumstances, the odor will be identified and
the individual has the responsibility to question risks of hazards. For
answers to questions about the hazards, call the Safety Manager at
713/794-7396.

CHAPTER 4 [FIRST AID]{.underline}

The following is not to be used as a substitute for professional medical
care, but is intended for emergency use until a doctor can see the
victim.

[Personal Injury]{.underline}

Emergency Response Procedures -- Call 911

[Clothing on Fire]{.underline}

Roll person around on floor to smother flame, or drench with water, if
safety shower is immediately available. Obtain medical attention.

[Biological Spill on Body]{.underline}

Remove contaminated clothing. Repeated washing of exposed area with soap
and water for five minutes. Report incident to supervisor. Obtain
medical attention.

[Radiation Spill on Body]{.underline}

Remove contaminated clothing. Rinse exposed area thoroughly with water.
Report incident to supervisor and Radiation Safety Officer,
713/794-7396. Obtain medical attention, if necessary.

[Hazardous Material Splashed in Eye]{.underline}

Immediately rinse eye with water continuously for 15 minutes. Forcibly
hold eye open to ensure effective wash behind eyelids. Report incident
to supervisor. Obtain medical attention.

[Chemical Spill on Body]{.underline}

Flood exposed area with running water shower for at least five minutes.
Remove contaminated clothing at once. Make sure chemical has not
accumulated in or on shoes. Report incident to supervisor and Chemical
Hygiene Officer at 713/794-7396. Obtain medical attention.

[Minor Cuts and Puncture Wounds]{.underline}

Repeated washing of injury with soap and water for several minutes.
Report incident to supervisor. Obtain medical attention.

[Additional Site Instructions]{.underline}

-   Know the location of the nearest safety shower.

-   Know the location of nearest eyewash fountain.

-   Do not move an accident victim except to prevent further injury.

-   If a person is unconscious, or in need of professional
    transportation, call 911. Be sure to give exact location. If
    necessary and you are trained, begin CPR.

CHAPTER 5 [EMERGENCY RESPONSE GUIDELINES]{.underline}

A. [THE CASCADE SYSTEM FOR EMERGENCY CALLS IS AT APPENDIX
B]{.underline}. Activation is by:

\(1\) An individual who has seen or heard something that would indicate
an impending or actual emergency situation.

\(2\) The Houston Fire Department

> \(3\) The Houston Police Department
>
> \(4\) Civil Defense Office

\(5\) Center for Comparative Medicine, Baylor College of Medicine

\(6\) MEDVAMC Police notification

\(7\) MEDVAMC Research Administration notification

Once the Emergency Preparedness and Incident Response Plan is activated,
primary notification to Research Service Line personnel will be via word
of mouth.

B. [EVACUATION OF PERSONNEL]{.underline}

\(1\) Horizontal: Moving persons laterally away from the site of danger
to the outside.

\(2\) Vertical: Moving persons down the closest/safest stairwell.

Elevators SHALL NOT BE USED during an evacuation.

C. [SECURITY SYSTEM]{.underline}

Buildings 109 and 110 are secured and access-controlled 24 hours a day,
7 days a week, including weekends and holidays. Employees in Buildings
109 and 110 needing an ambulance crew, firemen, or other emergency
response personnel are to pull the fire alarm device box -- even if
there is no fire. The fire alarm is the fastest and most reliable way to
inactivate all of the door locks simultaneously.

Immediately notify the Research Office at 713/794-7564 or 713/794-7566
of the nature of the emergency.

CHAPTER 6 [EVACUATION OF PERSONNEL WITH DISABILITIES]{.underline}

# 

# A. **PROCEDURES**

# 

#  (1) Each floor will have two designated evacuation stations with signs that are clearly marked and near a telephone. People with disabilities will be trained as to their location as well as this plan.

\(2\) There will be four employees and two alternate employees per floor
who are trained in the evacuation of disabled persons herein referred to
as evacuators.

\(3\) Designated staff for the service line components will be notified
by the person with disabilities of his or her destination within the
building. The designated staff will then be responsible for ensuring
that all persons with disabilities know the location of the evacuation
stations on the floor of their destination.

\(4\) The designated staff will then notify one of the four trained
evacuators that a person with disabilities will be on their floor and in
which room they will be waiting.

\(5\) When a fire alarm is sounded, the evacuators on the floor will go
to the location or workstation of the person with disabilities on their
floor.

\(a\) If the person with disabilities is found, he/she should be
evacuated immediately to a safe place outside.

\(b\) If the person with disabilities is not located there or in a
nearby area, the evacuators should go to their respective evacuation
stations (two evacuators to a station).

\(c\) After waiting a reasonable length of time (two minutes, if
possible) depending on the situation, the evacuators should leave the
area themselves, unless they are contacted by the designated staff and
are advised of that person's location and can get to him/her, conditions
permitting.

\(d\) Once the person with disabilities reaches the evacuation station,
one of the evacuators should call their staff designee and advise that
the person with disabilities is on his/her way to safety. When the
person with disabilities is accounted for, the staff designee will
contact any waiting evacuators so that they can proceed to a safe place.

\(6\) The evacuators should work with the person with disabilities to
determine the best method of transport for that individual. If the
person with disabilities is found unconscious, the evacuators should
appraise the situation and use whatever techniques they deem safest and
most expedient for the circumstances at that moment.

CHAPTER 7 [VIVARIUM EMERGENCY]{.underline}

A. **[ANIMAL EMERGENCY]{.underline}**

\(1\) Animal temperature emergency procedures: Temperature exceeds 85
degrees or is less than 60 degrees in hallway.

\(2\) During normal working hours, the Vivarium staff notifies
Facilities Management Service (713/791-1414, x-5884) that the
temperature is high or low and also notifies Research Administration
(713/794-7566).

\(3\) During off-hours, the MEDVAMC Police monitor the temperature. If
the temperature is noticed to exceed limits, Facilities Management
Service is called to assess the situation. If the problem is not
resolved, the Facilities Management Service Line Executive
(713/794-7474) is notified, as is the Director of Operations for
Research (713/794-7564) and/or the Associate Chief of Staff for Research
(713/794-7566).

\(4\) [Evacuation.]{.underline} In the event of immediate
life-threatening disaster, refer to the MEDVAMC Research and Development
Safety Manual. Do not evacuate animals. If there is no immediate
life-threatening disaster, but knowledge of an impending problem, i.e.,
toxic fumes, possibility of smoke, or other damage spreading to the
Vivarium in the near future, gain permission of the person in charge
(e.g., Fire Chief, MEDVAMC Police, etc.) to evacuate animals as follows:

\(a\) To laboratories already approved to use animals.

\(b\) Center for Comparative Medicine, Baylor College of Medicine

If the situation poses no threat to human life, remain with relocated
animals. Following the disaster, return the animals to the Vivarium or
move to location determined by the Veterinary Medical Unit Supervisor
and continue animal care.

\(5\) [Hurricane emergency response.]{.underline} Welfare of animals
housed in the Vivarium is the primary concern in the event of a weather
emergency. The MEDVAMC Veterinary Medical Unit Hurricane Emergency
Response Plan describes preparatory and ride-out policies and procedures
to ensure adequate animal care up to, during, and following the
emergency. Readiness levels include the following:

\(a\) [HURRICANE CONDITION IV -- Forecast landfall in \> 96
hours]{.underline}. Hurricane Condition IV is the normal state of
readiness maintained throughout the year. During this time, planning,
assessment, and review of Research Service Line and MEDVAMC plans
occurs.

\(b\) [HURRICANE CONDITION III -- Forecast landfall in 96 -- 72
hours.]{.underline} When Hurricane Condition III is set by the MEDVAMC
Director, there is a high probability that a severe weather condition
will pose a threat to the facility including the Veterinary Medical
Unit.

\(c\) [HURRICANE CONDITION II -- Forecast landfall in 72 -- 48
hours.]{.underline} When Hurricane Condition II is set by the MEDVAMC
Director, all protective measures must be completed to ensure that the
Veterinary Medical Unit is in a final state of readiness. Condition II
is completed when all non-essential personnel have been evacuated.

\(d\) [HURRICANE CONDITION I -- Forecast landfall in less than 48
hours.]{.underline} When Hurricane Condition I is set by the MEDVAMC
Director, all ride-out and post-storm activities shall be initiated. A
Hurricane Watch will occur at 24 -- 36 hours from the threat. A
Hurricane Warning will occur at less than 24 hours from the threat.

B. **[SECURITY BREACH PROCEDURES]{.underline}**

Alarm systems are monitored for breaches. The MEDVAMC Police will
investigate all breaches and notify the Director of Operations for
Research of any intrusions. The Houston Police is also notified as
specified in MEDVAMC Police Security and Law Enforcement Policy, when
necessary. If there is resultant damage to the facility, the Director of
Operations for Research and the Public Affairs Officer are notified in
addition to regular MEDVAMC Police notifications. All questions from the
press are referred either to the Public Affairs Officer or, if
unavailable, to the Director of Operations for Research. No other staff
is to discuss the event with the press.

CHAPTER 8 [CYBER SECURITY]{.underline}

A. [SECURITY MEASURES]{.underline}

For all employees who are involved with the management, use, or
operation of automated information systems in the Research Service Line,
the following necessary practices must be adhered to as assurance that
cyber security controls are in place to protect our information systems
from malicious intent. *NOTE: Computers connected to the Baylor College
of Medicine intranet must also adhere to relative Baylor College of
Medicine Information Technology Security policies.*

##### (1) Networks

\(a\) Establish a network infrastructure dedicated to the control of all
network elements.

\(b\) Ensure that all systems are authenticated and protected.

\(c\) Implement protection against denial of access.

#####  (2) Servers and clients

\(a\) Include the exclusive use of securable operating systems on all
servers and workstations.

\(b\) Ensure security hardened operating systems configurations.

\(c\) Establish "least privilege" based access permissions for users and
operators.

> \(d\) Establish auditing procedures

\(e\) Ensure secure centralized administration

#####  (3) Boundary protections

\(a\) A tightly constrained host configuration to stop dangerous
protocols

and unauthorized access.

\(b\) Elimination of all unprotected backside access within enclaves,
e.g., stand-alone/internal PC modems and dedicated, but otherwise
unprotected, site-to-site circuits.

##### (4) Intrusion detection devices

\(a\) Network-based monitoring for intrusion detection at enclave
boundaries.

\(b\) Host-based monitoring.

\(c\) Intrusion detection to counter compromise from the distant end.

\(d\) Centralized and automated intrusion monitoring and incident
reporting.

#####  (5) Online virus protection

\(a\) Centralized malicious code protection for email, web traffic, and
file transfers.

\(b\) Malicious code protection on all servers and workstations
(including mobile users and remote/home offices) that screens exchanges
of email, web traffic, and files

\(c\) Screening of all applications and files prior to each use, and
regular malicious code screening of locally stored files and
applications.

\(d\) Centralized and automated updating of virus scripts and anti-virus
software.

\(6\) [Software and Data Security.]{.underline}

\(a\) Establish safeguards to detect and minimize inadvertent or
malicious modification or destruction, or attempts to do so, of
application software, operating system software, and critical data
files.

\(b\) At a minimum, back up essential data and store in a location
physically separate from the automated information systems. Implement
appropriate physical and environmental controls to ensure viability of
such back-ups.

\(7\) [Hardware Security.]{.underline} Ensure security measures are
taken to protect against theft and unauthorized use of automated
information systems peripheral and communications devices,
microcomputers, laptops, and related items such as printers, floppy
disks, and software.

\(8\) [Physical Security]{.underline}. Controlled and restricted areas
are to be protected by physical security as appropriate for the
sensitivity or criticality of the system. The following rules apply to
all VA owned Government Furnished Equipment and non-VA owned other
equipment used to transmit, transport, access, process or store VA data:

\(a\) Equipment, information, or software must not be taken off-site
without express authorization by the employee's supervisor.

\(b\) Equipment must be housed and protected to reduce the risks from
environmental threats and hazards, and the opportunities for
unauthorized access, use, or removal.

\(c\) Portable computers that have VA Protected Information on their
storage device(s) or have software that provides access to VA private
networks must be secured under lock and key when not in the immediate
vicinity of the responsible employee. This includes external hard drives
and other storage devices. If such devices are maintained in a hotel
room or residence, they must be stored out of sight and the door(s) to
the room or residence must be locked when the employee is not physically
present.

\(d\) Employees must use physical locks to secure portable computers to
immovable objects when the computers must be left in a meeting room, or
other semi-public area to which individuals other than the authorized
employee have access.

\(e\) When in an uncontrolled environment, employees must follow "clear
desk" practices for media to reduce the risk of unauthorized access to,
loss of, and damage to VAPI. No VAPI may be left on desks.

\(f\) When in an uncontrolled environment, employees must guard against
disclosure of VAPI information through eavesdropping, overhearing or
overlooking (shoulder surfing) by unauthorized persons. When traveling,
employees must keep portable computers or storage devices in their
possession, and may not check them as baggage.

\(g\) Data and system backups that include VA information have the same
confidentiality classification as the originals. Therefore, these
materials must be protected with the same or equally effective physical
security as that provided to the source computer, its media, and
information contained therein.

\(h\) Backups must be stored where they are physically secured yet
accessible within a reasonable timeframe when they are needed in
accordance with applicable VA policy.

\(i\) Limit access to controlled areas to those individuals having an
official need to be in the area.

\(j\) Contract maintenance personnel, and others, not authorized
unrestricted access, will be escorted by an authorized person at all
times when they are within the controlled area.

\(k\) Media used to record and store sensitive software or data is to be
externally identified, protected, controlled, and secured when not in
actual use.

B. [CYBER SECURITY INCIDENT.]{.underline}

A cyber security incident is any event, suspected event, or
vulnerability that could pose a threat to the integrity, availability,
or confidentiality of information systems' applications or data. In the
event of suspicious activity or cyber attack including loss or theft of
a computer, disk, or files with sensitive VA research data:

\(1\) Immediately report the incident to the following:

\(a\) MEDVAMC Police, 713/794-7106, if at MEDVAMC

\(b\) TMC Security, 713/795-0000, if at McGovern Campus

\(c\) Baylor College of Medicine Security, 713/798-3000, if at Baylor.

Note: If at another institution, contact security for that institution
as well as policy in the jurisdiction where event occurred. Obtain the
case number and the name and badge number of the investigating
officer(s). If possible, obtain a copy of the case report.

\(2\) Within one hour of the incident, call or e-mail (preferably both):

\(a\) Your supervisor

\(b\) Research Office -- Holly H. Birdsall, MD, PhD

[**BIRDSALL.HOLLYH@va.gov**](mailto:BIRDSALL.HOLLYH@va.gov)

Office 713/794-7775

Cell 713/819-0020

or

Joyce A. McDaniel

[**JoyceA.McDaniel@va.gov**](mailto:JoyceA.McDaniel@va.gov)

Office 713/794-7564

Pager 713/841-5724

\(c\) Privacy Officer Marta Gifford

[**Marta.Gifford@va.gov**](mailto:Marta.Gifford@va.gov)

Office 713/791-1414, ext. 5529

Pager 713/841-0101

\(d\) Information Security Kevin Cox

Officer [**Roy.Cox@va.gov**](mailto:Roy.Cox@va.gov)

Office 713/794-7915

Pager 713/841-8700

\(e\) If event occurred at Laura Petersen, MD, MPH

HSR&D COE [**laura.petersen@va.gov**](mailto:laura.petersen@va.gov)

Office 713/794-8623

or

Alex Chau

[**alex.chau@va.gov**](mailto:alex.chau@va.gov)

Office 713/794-8645

\(3\) Disable nonessential ports and services

> \(4\) Perform preliminary investigation of all affected systems
>
> \(5\) Raise awareness within the cyber environment

\(6\) Increase monitoring efforts

C. [COMPUTER SYSTEM FAILURE]{.underline}

Should the computer systems fail, staff shall manually document staff
presence for payroll purposes. All correspondence and documents (that
would otherwise be prepared using computer software) shall be prepared
manually. The Research Information Technology Specialist will coordinate
data retrieval efforts with the MEDVAMC Information Security Officer and
Information Management Service Line, as appropriate.

CHAPTER 9 [CHEMICAL HYGIENE PLAN]{.underline}

A. [GENERAL]{.underline}

\(1\) This section of the policy describes the chemical hygiene plan for
Research and Development Service as required by OSHA's Occupational
Exposure to Hazardous Chemicals in Laboratories Standard, 29 CFR
1910.1450.

\(2\) In order to comply with this standard, Research Service has
established a plan to ensure that employees are protected from health
hazards associated with hazardous chemicals in the laboratory, and
capable of keeping exposures below the permissible exposure limits
specified in 29 CFR part 1910. subpart 2. Questions regarding this plan
should be directed to facility Safety Manager/Chemical Hygiene Officer,
via pager 713-841-0933.

\(a\) This plan shall be available through employee's supervisor and the
Research and Development Service Safety Subcommittee representatives.

\(b\) A review and evaluation of the Chemical Hygiene Plan will be
conducted annually by the Medical Center Safety Manager.

\(c\) The person responsible for implementation of this plan is the
Chief, Research and Development Service.

B. [STANDARD OPERATING PROCEDURES]{.underline}

\(1\) Research Service laboratory work, which involves the use of
hazardous chemicals, standard operating procedures have been addressed
in order to reduce potential safety and/or health hazards caused by such
use. The procedures include use of appropriate personal protective
equipment and engineering control measures such as room air
changes/hour, negative air work environment, biological, ionization and
fume hoods, and maintenance procedures for these engineering control
measures including testing of proper function of the maintenance of such
equipment.

\(2\) These specific procedures that Research Service has implemented
are:

\(a\) *General Rules for Safe Practices in Laboratories*

[1]{.underline} *Accidents and spills:* Eye contact: Promptly flush eyes
with water for a prolonged period (15 minutes) and seek medical
attention from the Employee Health Clinic.

-   Ingestion: Encourage the victim to drink large amounts of water.

-   Skin Contact: Promptly flush the affected area with water and remove
    any contaminated clothing. If symptoms persist after washing. Seek
    medical attention from the Employee Health Clinic.

-   Spills: Call 911.

[2]{.underline} *Avoidance of "routine" exposure:* Develop and encourage
safe habits; avoid unnecessary exposure to chemicals by any route.

-   Do not smell or taste chemicals. Vent apparatus that may discharge
    toxic chemicals (vacuum pumps, distillation columns, etc.) into
    local exhaust hoods.

-   Inspect gloves and test glove boxes before use.

-   Do not allow release of toxic substances in cold rooms and warm
    rooms, since these have self-contained recirculated atmospheres.

[3]{.underline} *Choice of chemicals:* Use only those chemicals for
which the quality of the available ventilation system is appropriate.

[4]{.underline} *Eating, smoking, etc.:* Don't eat, drink, smoke, chew
gum, or apply cosmetics in areas where laboratory chemicals are present;
wash hands before conducting these activities.

-   Do not store, handle or consume food, ice, or beverages in storage
    areas, refrigerators, glassware or utensils that are also used for
    laboratory operations.

[5]{.underline} *Equipment and glassware:* Handle and store laboratory
glassware with care to avoid damage; do not use damaged glassware. Use
extra care with Dewar flasks and other evacuated glass apparatus; shield
or wrap them to contain chemicals and fragments should implosion occur.
Use equipment only for its [designed]{.underline} purpose.

[6]{.underline} *Exiting:* Wash areas of exposed skin well before
leaving the laboratory.

[7]{.underline} *Horseplay:* Avoid practical jokes or other behavior,
which might confuse, startle or distract another worker.

[8]{.underline} *Mouth suction:* Do not use mouth suction for pipeting
or starting a siphon.

[9]{.underline} *Personal apparel:* Confine long hair and loose
clothing. Wear closed toe shoes at all times in the laboratory but do
not wear sandals, perforated shoes, sneakers, or shorts.

[10]{.underline} *Personal housekeeping:* Keep the work area clean and
uncluttered with chemicals and equipment being properly labeled and
stored; clean up the area on completion of an operation or at the end of
each day.

[11]{.underline} *Person protection:* Assure that appropriate eye
protection is worn where a splash may occur by all persons, including
visitors, where chemicals are stored or handled.

-   Wear appropriate gloves per Safety Manager guidance when the
    potential for contact with toxic materials exists; inspect the
    gloves before each use, wash them before removal, and replace them
    periodically.

-   Use appropriate respiratory equipment per Safety Manager guidance
    when air contaminant concentrations are not sufficiently restricted
    by engineering controls. Inspect the respirator before use.

-   Use any other protective and emergency apparel and equipment as
    directed by Safety Manager.

-   Do not use contact lenses in the laboratory.

-   Remove laboratory coats when contaminated.

[12]{.underline} *Planning:* Seek information and advice about hazards
per Safety Manager guidance, plan appropriate protection procedures, and
plan positioning of equipment before beginning any new operation.

[13]{.underline} *Unattended operations:* Notify Safety Manager during
administrative hours, via pager 0730, of any unattended laboratory
operations; then leave lights on, place and appropriate sign on the
door, and provide for containment of toxic substances in the event of
failure of a utility service (such as cooling water) to an unattended
operation.

[14]{.underline} *Use of hoods:* Use the hood for operations which
[might result]{.underline} in release of toxic chemical vapors or dust.

-   As a rule of thumb, use a hood or other local ventilation device
    when working with any appreciable volatile substance with a TLV of
    100 ppm or less.

-   Confirm adequate hood performance before use; keep hood closed at
    all times except when work within the hood is conducted; keep
    material in hoods to an absolute minimum and do not allow material
    to block vents or air flow.

-   Leave the hood "on" when it is not in active use if toxic substances
    are stored in it or if it is uncertain whether adequate general
    laboratory ventilation will be maintained when it is "off".

[15]{.underline} *Vigilance:* Be alert to unsafe conditions and see that
they are reported to Principal Investigator when detected.

[16]{.underline} *Waste disposal:* The plan for each laboratory
operation includes procedures and training for waste disposal:

-   Deposit chemical waste per Safety Manager guidance in appropriately
    labeled receptacles and follow all other waste disposal procedures
    per Safety Manager guidance.

-   Do not discharge to the sewer concentrated acids or bases; highly
    toxic, malodorous, or lachrymatory substances; or any substances
    which might interfere with the biological activity of waste water
    treatment plants, create fire or explosion hazards, cause structural
    damage or obstruct flow.

[17]{.underline} *Working alone:* Do not work alone in a building; do
not work alone in a laboratory if the procedures being conducted could
result in employee injury or illness.

In addition laboratory personnel will utilize NFPA 491M, Hazardous
Chemical Reactions to correctly identify and avoid preventable hazardous
chemical reactions. Call pager 713-841-0933 for assistance.

C. [EMPLOYEE EXPOSURE]{.underline}

\(1\) The facility Safety Manager provides an initial determination of
employee's exposure during annual Walk Through inspection and/or upon
request from the supervisor for any substance regulated by a standard
(29 CFR 1910.001 through 29 CFR 1910.1101) which requires monitoring if
there is reason to believe that exposure levels for that substance
routinely exceed the action level or in the absence of an action level,
the permissible exposure level or PEL. If this initial monitoring
discloses employee exposure over the action level or PEL, exposure
monitoring is done in accordance with the relevant standard. This
monitoring may be terminated in accordance with the relevant standard
when permissible.

\(2\) Where the use of respirators is determined to be necessary to
maintain exposure below permissible limits, appropriate respiratory
protection per Safety Manager evaluation will be provided at no cost to
employees. Respirators are selected and used in accordance with the
requirements of 29 CFR 1910.134.

\(3\) The Safety Manager will notify the effected employee of these
monitoring results in writing via Service Chief or by posting at
worksite within 15 working days after the receipt of any test results.

D. [EMPLOYEE INFORMATION AND TRAINING]{.underline}

\(1\) Research Service supervisor/principal investigators will provide
employees with initial and annual refresher information and training on
hazardous chemicals used in their work area at the time of initial
assignment, and prior to assignments involving new laboratory procedures
or new exposure.

\(2\) The following information is conveyed to employees:

\(a\) The contents of the Occupational Exposure to Hazardous Chemicals
in Laboratories Standard 29 CFR 1910.1450 its appendices and Hazardous
Communication Standard 29 CFR 1910.1200.

\(b\) The location and availability of Service Chemical Hygiene Plan.

\(c\) The permissible exposure limits for OSHA regulated substances or
recommended exposure limits for other hazardous chemicals where there is
no available OSHA standard.

\(d\) The signs and symptoms associated with exposure to hazardous
chemicals used in the laboratory and,

\(e\) The location and availability of known reference material on the
hazards, safe handling, storage and disposal of hazardous chemicals
found in the laboratory including but not limited to Material Safety
Data Sheets received from the chemical supplier. - See paragraph IX of
this section.

\(3\) In addition to the above information, employees are trained on the
following:

\(a\) Methods and observations that may be used to detect the presence
or release of a hazardous chemical in the work area.

\(b\) The physical and health hazards of chemicals in the work area.

\(c\) The measures employees can take to protect themselves from these
hazards, including specific procedures that have been implemented to
protect employees from exposure to hazardous chemicals, such as
appropriate work practices, emergency procedures, and personal
protective equipment to be used, and

\(4\) After attending the class, each employee will sign a form
(appendix A) given by the supervisor/lead technician stating that they
reviewed the training outlined above and had the opportunity to ask
questions about any uncertainty remaining. This documentation is then
forwarded to the Program Support Assistant, located in Bldg. 110, Room
318, where it will be entered into the hospital computer as training
completed and filed in a three ring binder to be kept for review.

E. [MEDICAL PROGRAM]{.underline}

\(1\) MEDVAMC provides all employees who work with hazardous chemicals
the right to receive medical attention, including any follow-up
examination, which the examining physician determines to be necessary,
for the following circumstances:

\(a\) Whenever an employee develops signs or symptoms associated with a
hazardous chemical to which the employee may have been exposed in the
laboratory, the employee is provided an opportunity to receive an
appropriate medical examination.

\(b\) Where exposure monitoring reveals an exposure routinely above the
action level (or in the absence of an action level, the PEL) for an OSHA
regulated substance for which there are exposure monitoring and medical
surveillance requirements, medical surveillance is established for the
effected employee as prescribed by the particular standard.

\(c\) Whenever an event takes place in the work area such as a spill,
leak, explosion, or occurrence resulting in the likelihood of a
hazardous exposure, the affected employee is provided an opportunity for
a medical consultation. This consultation is for the purpose of
determining the need for a medical examination. Employee Health
Physician as necessary will provide an appropriate medical examination.

\(2\) Medical examinations and consultations are performed by or under
direct supervision of a licensed physician, are provided at no cost to
employees without loss of pay, and at a reasonable time and place. The
examining physician is provided:

\(a\) The identity of hazardous chemical(s) to which employee may have
been exposed to;

\(b\) A description of conditions under which the exposure occurred
including quantitative exposure data, if available; and

\(c\) A description of the signs and symptoms of exposure that the
employee is experiencing if any.

\(3\) A written report from the examining physician based on an
examination or consultation is provided to the employee. This report
includes:

\(a\) Any recommendation of further medical follow-up;

\(b\) The results of the medical examination and any associated tests;

\(c\) Any medical condition that may be revealed in the course of the
examination which may place the employee at increased risk as a result
of exposure to a hazardous chemical found in; the workplace; and

\(d\) A statement that the employee has been informed by the physician
of the results of the consultation or medical examination and any
medical condition that may require further examination or treatment.

This written opinion will not include any specific findings of diagnoses
that are unrelated to occupation exposure.

F. [SPECIAL PROCEDURES/PROVISIONS]{.underline}

\(1\) Research Service has certain procedures or activities that require
prior approval from facility Radiation Safety Officer, Safety Manager,
Chairperson Laser Safety Committee, Chairperson Biohazard Subcommittee,
or Chairperson Infection Control Committee before implementation. These
procedures are as follows:

\(2\) Work with Nuclear Regulatory Commission, Environmental Protection
agency, Occupation Safety and Health Administration, Texas Department of
Health or Texas Water Commission regulated substances/ material and
those work procedures included in Communicable Disease Center prudent
practice recommendations.

\(3\) There are special provisions for additional employee protection
for work with particularly hazardous substances used. These substances
include "select" carcinogens", reproductive toxins, and substances which
have a high degree of acute toxicity.

\(4\) Specific considerations for these particular hazardous
substance(s) classified as potentially carcinogenic by the International
Agency for Research on Cancer, the National Toxicology Program, the
National Institute for Occupational Safety and Health, the Occupational
Safety and Health Administration or the American Conference of
Governmental Industrial Hygienists include use, storage and disposed in
accordance with the Chemsyn Science Laboratory handbook entitled
"Handling Chemical Carcinogens, a Safety Guide for the Laboratory".

\(a\) *[Working with Allergens and Embryotoxins]{.underline}*

[1]{.underline} *Allergens:* (examples: diazomethane, isocyanates,
bichromates): Wear suitable gloves to prevent hand contact with
allergens or substances of unknown allergenic activity.

[2]{.underline} *Embryotoxins:* (examples: organomercurials, lead
compounds, formamide): If you are a woman of childbearing age, handle
these substances only in a hood whose satisfactory performance has been
confirmed, using appropriate protective apparel (especially gloves) to
prevent skin contact.

-   Review each use of these materials with the research supervisor and
    review continuing uses annually or whenever a procedural change is
    made.

-   Store these substances, properly labeled, in an adequately
    ventilated area. In and unbreakable secondary container.

-   Notify supervisor of all incidents of exposure or spills and consult
    Employee Health Physician.

\(b\) *[Working with Chemicals of Moderate Chronic or High Acute
Toxicity]{.underline}*

(Examples: disopropyiflurophosphate, hydrofluoric acid, hydrogen
cyanide.)

Supplemental rules to be followed in addition to those mentioned above:

[1]{.underline} *Aim:* To minimize exposure to these toxic substances by
any route using all reasonable precautions.

[2]{.underline} *Applicability:* These precautions are appropriate for
substances with moderate chronic or high acute toxicity.

[3]{.underline} *Location:* Use and store these substances only in areas
of restricted access with special warning signs. (Always use a hood
(previously evaluated) to confirm adequate performance.)

[4]{.underline} *Personal protection:* Always avoid skin contact by use
of gloves and long sleeves (and other protective apparel as appropriate
per Safety Manager guidance). Always wash hands and arms immediately
after working with these materials.

[5]{.underline} *Records:* Supervisors maintain records for employee
health of the amounts of materials on hand, amounts used, and the names
of the workers involved.

[6]{.underline} *Prevention of spills and accidents:* Be prepared for
accidents and spills.

-   Assure that at least 2 people are present at all times if a compound
    in use is highly toxic or of unknown toxicity.

-   Store breakable containers of these substances in chemically
    resistant trays; also work and mount apparatus above such trays or
    cover work and storage surfaces with removable, absorbent, plastic
    backed paper.

[7]{.underline} *Waste:* Contact Safety Manager via pager 713-841-0933
for moderate, high, or chronic toxicity waste pick up.

-   Store contaminated waste in closed, suitably labeled, impervious
    containers (for liquids, in glass or plastic bottles half-filled
    with vermiculite).

\(c\) *[Working with Chemicals of High Chronic Toxicity]{.underline}*

(Examples: dimethyimercury and nickel carbonyl, benzo-a-pyrene,
N-nitrosodiethylamine, other human carcinogens or substances with high
carcinogenic potency in animals.)

Further supplemental rules to be followed in addition to all these
mentioned above, for work with substances of known high chronic
toxicity.

[1]{.underline} *Access:* Conduct all transfers and work with these
substances to a "controlled area": a restricted hood, glove box, or
portion of a lab, designated for ruse of highly toxic substances, for
which all people with access are aware of the substances being used and
necessary precautions.

[2]{.underline} *Approvals:* Prepare a written plan for use and disposal
of these materials and obtain the approval of the Safety Manager.

[3]{.underline} *Non-contamination/Decontamination:* Protect vacuum
pumps against contamination by scrubbers or HEPA filters and vent them
into the hood. Decontaminate vacuum pumps or other contaminated
equipment. Including glassware in the hood before removing them from the
controlled area.

-   Decontaminate the controlled area per manufacturer instructions
    before normal work is resumed there.

[4]{.underline} *Exiting:* On leaving a controlled area, remove any
protective apparel (placing it in an appropriate, labeled container) and
thoroughly wash hands, forearms, face, and neck.

[5]{.underline} *Housekeeping:* Laboratory personnel will use a wet mop
or a vacuum cleaner equipped with a HEPA filter instead of dry sweeping
if the toxic substance was a dry powder.

[6]{.underline} *Records:* Supervisors maintain records for employee
health of the amounts of materials on hand, amounts used, and the names
of the workers involved.

[7]{.underline} *Signs and labels:* Assure that the controlled area is
conspicuously marked with warning and restricted access signs and that
all containers of these substances are appropriately labeled with
identity and warning labels.

[8]{.underline} *Spills:* Call 911.

[9]{.underline} *Storage:* Store containers of these chemicals only in a
ventilated limited access area. In appropriately labeled unbreakable,
chemically resistant, secondary containers.

[10]{.underline} *Glove boxes:* Trap the exit gases or filter them
through a HEPA filter and then release them through a HEPA filter and
then release them into the hood.

[11]{.underline} *Waste:* Contact Safety Manager via pager 713-841-0933
for moderate, high or chronic toxicity wastes pick up.

-   Store contaminated waste in closed, suitably labeled, impervious
    containers (for liquids, in glass or plastic bottles half-filled
    with vermiculite).

\(d\) *[Animal Work with Chemicals of High Chronic
Toxicity]{.underline}*

[1]{.underline} *Access:* For large scale studies, special facilities
with restricted assess are preferable.

[2]{.underline} *Administration of the toxic substances:* When possible,
administer the substance by injection or gavage instead of in the diet,
use a caging system under negative pressure or under laminar air flow
directed toward HEPA filters.

[3]{.underline} *Aerosol suppression:* Devise procedures which minimize
formation and disposal of contaminated aerosols, including those from
food, urine, and feces (e.g., use HEPA filtered vacuum equipment for
cleaning, moisten contaminated bedding before removal from the cage, mix
diets in closed containers in a hood).

[4]{.underline} *Personal protection:* When working in the animal room,
wear plastic or rubber gloves, fully buttoned laboratory coat or
jumpsuit and, if needed because of incomplete suppression of aerosols,
other apparel and equipment (shoe and head coverings, respirator).

[5]{.underline} *Waste:* Contact Safety Manager via pager 713-841-0933
for moderate, high or chronic toxicity wastes pick up.

-   Store contaminated waste in closed, suitably labeled, impervious
    containers (for liquids, in glass or plastic bottles half-filled
    with vermiculite).

G. [HAZARD IDENTIFICATION]{.underline}

\(1\) Research Service will assure labels on incoming containers of
hazardous chemicals are not removed or defaced; and material safety data
sheets that are received with incoming shipments of hazardous chemicals
are maintained and readily accessible to laboratory employees.

\(2\) For chemical substances developed in the laboratory, the following
procedures have been implemented:

\(a\) For known composition for chemicals substances produced
exclusively for the laboratory use, which are determined by the
supervisor to be hazardous, the appropriate training and labeling will
be provided;

\(b\) No unknown composition of chemicals produced as a by product, is
permitted and;

\(c\) For chemical substances produced for another user outside of the
laboratory, Research Service complies with the Hazard Communication
Standard 29 CFR 1910.1200, including the requirements of preparation of
material safety data sheets and labeling.

H. [RECORDKEEPING]{.underline}

MEDVAMC establishes and maintains for each employee an accurate record
of any measurements taken to monitor employee exposure and any medical
consultation and examinations including tests or written opinions as
required by the Standard. These records are kept, transferred, and made
available in accordance with 29 CFR 1910.20, Access to Employee and
Medical Records. Contact facility Safety Manager; via pager 713-841-0933
or Employee Health Physician, extension 7003 for employee access
information.

I. [REFERENCE MATERIAL]{.underline}

\(1\) The below listed reference material, identified in this Chemical
Hygiene Plan may be obtained from facility Safety Manager, via pager
713-841-0933.

\(a\) NFPA 491M, Manual of Hazardous Chemical Reactions. Handling
Chemical Carcinogens: a Safety Guide for the Laboratory.

\(b\) Prudent Practices for Handling Hazardous Chemicals in
Laboratories.

\(c\) OSHA 1910.1450, Occupational Exposure to Hazardous Chemicals in
Laboratories.

\(d\) OSHA 1910.20, Access to Employee Exposure and Medical Records.

\(e\) OSHA 1910.1200, Hazard Communication Standard.

J. **[HAZARDOUS CHEMICALS BY CATEGORY]{.underline}**

[Introduction]{.underline}

As a group, chemical substances constitute the most numerous and varied
hazards found in research laboratories. In addition to the inherent
toxic properties of many chemical agents, laboratory workers must also
guard against accidents caused by improper use of equipment employed in
carrying out chemical procedures. Laboratory procedures should be
designed with safety in mind.

KNOW: Location of emergency equipment:

> Fire extinguishers
>
> Showers
>
> Eye washes

Fume hoods must be used in handling dangerous chemicals and they should
have sufficiently. Explosion-proof exhaust fans to remove toxic,
explosive, or flammable vapors effectively and safely, even when the
sash is raised.

\(1\) ***[Corrosive Chemicals]{.underline}***

\(a\) **Solids** - A corrosive solid injury depends on solubility in
body moisture. Some corrosive solids include caustic alkalis such as
NaOH, KOH, Na2S, Ba(OH)2 and Ca(OH)2; alkali metals (Na & K);
phosphorus, antimony salts, chromium salts, Na3P04, and phenol.

[Special Considerations]{.underline}:

Once absorbed, the corrosive spreads rapidly; many cause delayed
injuries. Corrosive solid dust can gain entrance by inhalation, and
dissolve organics by absorbing moisture from the air.

\(b\) **Gases** - Corrosive gases are readily absorbed and represent the
most serious corrosive chemical hazard, possibly damaging the lung and
dissolving in the blood with transfer to all body tissues. Common
hazardous corrosive gases are NH3, 03, HCI, C12, S02FN02, HCHO, and HBr.
Burns of the skin and eyes, respiratory, edema, nausea, unconsciousness
and death are possible effects of prolonged exposure.

[Special Considerations]{.underline}: The greatest hazard from corrosive
gases in the laboratory comes from the use of compressed gas cylinders.
Evacuation is essential when an accident involving corrosive gases
occurs.

\(c\) **Liquids** - Common acidic liquids are formic, acetic, sulfuric,
nitric, hydrofluoric and hydrochloric acids. Basic solutions are KOH,
NaOH, and NH4OH. Other corrosive liquids are phenol, acid chlorides,
acid anhydrides, and chlorinated hydrocarbons. Examples of corrosives:
Strong acids, strong alkalis, phenol, bromine, fluorine, phosphorus, and
sodium.

[Special Considerations]{.underline}: Acids precipitate protein on
contact with body tissue; a sensation of pain is usually immediate.
Bases may not produce an immediate sensation of pain so the \'burn\'
from base may be more extensive because of longer exposure. Therefore,
chemical antidotes and neutralization are not recommended. Wash with
water for at least 15 minutes. If the chemical is splashed in the face
while wearing safety goggles, wash the face thoroughly before removing
the goggles. It may be necessary to remove clothing to stop exposure to
corrosive liquids.

\(2\) ***[Contact Hazard Chemicals, Irritants and
Allergens]{.underline}***

Contact hazard chemicals cause an allergic reaction when they come in
contact with living tissue. Examples of compounds commonly causing
allergic reactions include diazomethane, chromium, nickel, biochromates,
formaldehyde, isocyanates, phenols and epoxides.

\(a\) [Contact irritants and allergens]{.underline}: Pollens, molds,
antibiotics, horse serum, poison ivy toxin, histamine, serotonin,
bradykinin, formalin, iodides, picryl chloride, isocyanates,
dinitrochlorobenzene.

\(b\) [Respiratory irritants]{.underline}: Ammonia, carbon dioxide,
carbon monoxide, tetrachloride, benzene, chlorine, fluorine,
hydrofluoric acid, concentrated acetic acid, acetic anhydride, peracetic
acid, acetyl chloride, hydroiodic acid, sulfur dioxide, ether,
bromoform, chloroform, pyridine, methyl tribromide.

\(c\) [Narcotics and poisons]{.underline}: Barbiturates, morphine,
venoms, toxins, cyanides, fluorides, iodoacetic acid, mercurials,
organo-phosphates, vitamin and amino acid analogs, coumarin, digitalis,
pilocarpine, strychnine, and many other therapeutic agents if ingested
in large amounts.

[Special Considerations]{.underline}: Contact can occur either on skin
or in the lungs from inhaling an aerosol. An allergic reaction can
result after repeated exposure, which can cause hypersensitivity in some
people. Allergic responses can vary widely from one person to the next.
Swelling, rashes, itching (contact dermatitis), and asthma are examples
of possible reactions. Exposure should be limited by using appropriate
protective equipment such as fume hood, gloves, goggles, laboratory
coats, etc.

\(3\) ***[Toxic Chemicals (Poisons)]{.underline}***

Toxic chemicals commonly known as poisons can cause damage if relatively
small amounts are inhaled, ingested or come in contact with exposed
skin.

[Special Considerations]{.underline}: It is necessary to use protective
equipment to handle these substances. Whenever toxic substances have a
vapor pressure that exceeds that of air, the chemical must be used in a
fully operational fume hood or similar device that can restrict exposure
to the chemical. Gloves, masks, goggles, respirators, laboratory coats,
should be used when indicated by the Material Safety Data Sheet.

\(4\) ***[Volatile and Explosive Chemicals]{.underline}***

Volatile and explosive chemicals easily ignite, burn and serve as fuel
for a fire. Flammability is determined by flash point, the lowest
temperature at which one spark can cause the chemical to ignite.
Examples are ethers, acetone, and other solvents (many alcohols),
freons, perchlorates, sodium, ammonium nitrate, hydrogen and oxygen.

[Special Considerations]{.underline}: More than bench top quantities of
fire-hazard chemicals must be stored in flammable storage cabinets,
refrigerators and freezers for flammable materials. Never store
flammable liquids and gases in domestic freezers and refrigerators.
These refrigerators have various sparking devices (temperature control,
defrost control, light, light switch, heater, and solenoid).

In addition, the motor overload switch, fan, and compressor are external
and can ignite vapors from containers that are not sealed, have loose
caps, cotton stoppers, or are in cracked bottles. The temperature
control arcs every time the refrigerator system is started or stopped
(several times an hour) and could ignite the vapor-air mixture.

Some other points to keep in mind about flammables:

-   It's not the liquid that burns; it\'s the vapor.

-   Flammable vapors may be heavier than air, settle to the floor and
    move to an ignition source.

-   The \"flash point\" is the temperature at which a liquid will give
    off enough vapors to \"flash\" into flame if ignited.

-   Liquids with high flash points (above room temperature) are called
    combustibles.

These include fuel oil, phenol, and paint.

-   Liquids with low flash points (below 100°F) are called
    \"flammables." Gasoline (flash point 45°F) and ether (flash point
    49°F) are common flammables; ether is the more dangerous of the two,
    however, because of its relatively low boiling temperature (95°F).

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-   Keep a minimum amount of flammables on hand and return containers of
    flammables to an approved flammable storage cabinet when they are
    not being used.

-   Ventilate lab area to keep vapors below the flammable limit and to
    avoid health hazards; use fume hoods whenever possible.

-   Remove sources of ignition from the presence of flammables.

-   In a flammable liquids fire, pull the alarm then use dry chemical
    fire extinguishers.

\(5\) ***[Cumulatively Toxic Metals]{.underline}***

Cumulatively toxic metals are metals that over time accumulate in the
body. Examples are lead, cadmium, strontium, mercury, zinc, copper,
nickel.

[Special Considerations]{.underline}: Metals enter the body in the forms
of dust and fumes by inhalation, ingestion and absorption. Metal
compounds are more dangerous than elemental metals because compounds
tend to be more readily absorbed. Reduce risks by using good
ventilation/exhaust. Do not sweep or vacuum metal dust. Wash hands well
and remove work clothing and shower if necessary before leaving the
laboratory.

\(6\) ***[Carcinogens, Teratogens and Mutagens]{.underline}***

Carcinogens (chemicals which possess carcinogenic properties) pose a
particularly insidious risk; their effect may not become evident until
years later. For this and other reasons chemicals labeled as \"known\"
or \"suspect\" carcinogens should always be handled with extreme care.
Examples include: Alfatoxins, benzene, benzidines, nitrobenzenes,
napthylamines, nitrosylamines, benzanthracenes, methylcholanthrene,
cadmium compounds, carbon tetrachloride, diphenylamines, diethyl
stilbesterol (DES), 14-dioxane, estrogens, betapropriolactone
ethyfeneimine, asbestos fibers, ethane sulfonate, and triphenylmethane
dyes, actinomycin D, thalidomides, chloroform, ether, formaldehyde,
purine and pyrimidine analogs.

[Special Considerations:]{.underline} Treat known or suspected
carcinogens as you would either biohazardous or radioactive materials.
Signs must be posted to alert personnel that potential carcinogens are
in use. Restrict traffic in area. Personnel in laboratories using
carcinogens must be fully informed of the risks by the Principal
Investigator and specifically trained in the proper procedures for
handling and disposal of carcinogenic agents. Wear impervious gloves (if
solutions are organic may need nitrile), laboratory coats or disposable
gowns, and safety goggles. Protect hands, eyes, and clothing from
contamination. This is mandatory. Use trays or absorbent coverings on
bench tops. Transport materials in sealed, airtight, protective
containers. Centrifuge only in sealed non-Ieakable tubes. Use fume or
HEPA-filtered hoods when opening containers, transferring materials or
mixing. Protect vacuum lines and water aspirators with HEPA filters.
Follow hazardous material waste disposal procedures as specified in
Material Safety Data Sheet and by the MEDVAMC Safety Manager for the
specific chemical you are using.

\(7\) ***[Prohibited Carcinogens]{.underline}***

**THESE ARE NOT TO BE USED IN ANY RESEARCH LABORATORY ANY
CIRCUMSTANCES.**

[Chemicals or mixture containing 1% or more by weight of such
chemicals]{.underline}:

2-Acetylaminofluorene; 3,3\'-Dichtorobenzidine; and its salts

4-Dimethylami noazobenzene; Ethyleneimine;

4,4\'-Methylene (bis 2-chloroaniline); alpha-Naphthytamine;

N-Nitrosodimethylamine; beta-Propiolactone;

[Chemicals or mixture containing 0.1% or more by weight of such
chemi]{.underline}cals:

4-Aminodiphenyl; Benzidine; and its salts

bis-Chloromethyl ether; Methyl chloromethyl ether;

beta-Naphthylamine; 4-N itrobiphenyl;

[Other chemicals]{.underline}:

1.2-nitronapthylamine; N-phenyI-beta-napthylamine

Note that both of these chemicals metabolize to the known carcinogen
beta-napthylamine in humans.

\(8\) **[Other Chemical Notes]{.underline}**:

\(a\) [Chloroform]{.underline}: Is a common laboratory solvent and may
be used in extraction and purification. It is not flammable.

\(b\) [Azide:]{.underline} Extremely explosive compounds are formed when
waste azide is disposed of in copper, brass or lead sinks, lines or
fittings (copper azide, for example, is considered too sensitive to use
in ammunition). Even 0.1 % azide is concentrated enough to cause a
plumbing problem if the volume is large enough. Label and drain lines
from laboratory devices typically involving azide. These include a
Sorvall automatic cell washer, Coulter counter, gel permeation columns,
and other devices in which azide may be used to prevent bacterial
contamination. If your laboratory has a device (e.g., water bath) which
has had azide solutions in contact with copper, notify the MEDVAMC
Safety Manager.

\(c\) [Benzene:]{.underline} Is a common laboratory solvent that should
be used only in a hood and kept off your skin. Benzene is a carcinogen
and can cause leukemia. When possible, substitutes should be found.

\(d\) [Cyanogen Bromide (CNBr):]{.underline} Is a reagent widely used in
protein chemistry to cleave proteins at methionine residues. It is
non-combustible but in water it is highly toxic by inhalation and
ingestion and is a strong irritant to skin and eyes. It may be fatal if
swallowed. Impure material decomposes and tends to explode. Always store
CNBr in a protective dispenser container at 0-5°C, away from acids and
water. CNBr should be disposed of cautiously behind a shield in a fume
hood, by stirring it into a large volume of excess alkaline solution of
sodium or calcium hypochlorite.

\(e\) [Ethylene Glycol]{.underline}: Toxic symptoms of diethylene glycol
include vomiting, drowsiness, coma, respiratory failure, convulsions,
and renal damage, and may proceed to anuria, uremia, and death. Lethal
dosage is 1.4ml/kg or about 100ml/person.

\(f\) [Mercury]{.underline}: As a poison (mainly via inhalation of the
vapor), mercury can cause colitis, nephritis, nephrosis and brain
damage.

\(g\) [Picric Acid]{.underline}: A biological stain and a pH indicator
that becomes explosive as it ages. A yellow solid, picric acid
(trinitrophenol) is closely related to TNT, and must contain at least
10% water to reduce the explosion hazard. Picric acid is readily
absorbed through the skin and has toxic effects including headache,
fever, and irritation of eyes, nose and throat. Picric acid usage is
generally banned by VA and requires permission of the MEDVAMC Safety
Manager to begin or continue usage. The same rules apply to perchloric
acid.

\(9\) **[Other Components of the Chemical Hygiene Plan]{.underline}**

\(a\) Safety in research laboratories is a top priority. To ensure
safety, the following procedures are recommended:

-   Training is conducted as part of orientation at the MEDVAMC for both
    paid and unpaid employees

-   Employees are expected to follow the procedures outlined in this
    guide.

-   Material Safety Data Sheets are kept in using areas and regular
    inventories of hazardous chemicals are maintained.

\(b\) Safety in medical research laboratories must be a prime concern of
everyone involved in the administration and conduct of research. Failure
to implement safe operating procedures can cause injury to personnel and
damage to laboratory facilities. Most accidents are preventable, but
require meticulous attention to practices that will insure safe handling
of hazardous materials, reactions and procedures.

\(c\) As pointed out above, accidents don\'t just happen. In the
laboratory environment there are many potential hazards. If we do not
recognize them or do not exercise proper caution in dealing with them,
serious injury may occur. The investigator in charge of each project in
our research laboratories has the responsibility to train staff in
appropriate safety practices, but each of us has the responsibility to
act in conformity with those guidelines, and also to recognize and
correct any hazardous situations that may arise.

> \(d\) [Developing a Constructive Safety Attitude]{.underline}

[1]{.underline} [Think Defensively]{.underline}: Just as in defensive
driving, the anticipation that an accident can happen leads to conduct
which acts to prevent it. In addition to acting in a safe manner
yourself - DON\'T FORGET - be alert to the actions of co-workers to
avoid becoming a victim of their carelessness.

[2]{.underline} [Consequences:]{.underline} The principal investigator
in charge of the laboratory has the primary responsibility for providing
safe laboratory conditions, informing and training laboratory personnel
in the safe use of hazardous materials (\"The Right to Know Law\"), and
for assuring compliance with the continuous practice of proper safety
procedures. Each of us still has the responsibility of performing
assigned duties in a safe manner. A dangerous situation must be
CORRECTED PROMPTLY, and not ignored to become a hazard for someone else.
.

[3]{.underline} [Slower is Safer]{.underline}: The research laboratory
is a place where speed can cost you. Undue haste or working under
pressure frequently results in failed experiments and is a leading
contributor to many laboratory accidents. Don\'t save time at the
expense of safety. Safety equipment which is appropriate for the job
must be used in laboratory. Failure to use required safety equipment
increases the chances of serious accidents.

> \(e\) [Risk Behaviors]{.underline}

-   Lifting or moving heavy equipment alone.

-   Stretching to reach heavy or bulky supplies or dangerous chemicals
    from high shelves without using a firm ladder or step stool.

-   Working at cramped or cluttered workbenches.

-   Storing any chemicals in mislabeled containers.

-   Storing incompatible chemicals together.

-   Working with electrical equipment when a floor or workbench is wet.

-   Failing to use safety equipment or hoods when working with dangerous
    chemicals or biohazards.

-   Leaving burner flames or hot plates "ON" when not in use.

-   Blocking the exit from the room, or blocking eyewash stations.

-   Using toxic or volatile solvents in poorly ventilated rooms.

-   Storing improperly labeled infectious specimens in cold rooms and
    freezers.

-   Storing dangerous chemicals on open shelves, on tops of
    refrigerators, or on tops of wall cabinets.

-   Storing volatile solvents in refrigerators. (There is no such thing
    as a completely explosion-proof refrigerator.)

-   Eating food in a laboratory, or storing food in laboratory
    refrigerators.

-   Smoking (Note: No smoking is permitted in buildings at the MEDVAMC.)

-   Transporting through public areas large bottles of corrosive
    flammable or toxic materials by hand to or from the laboratory.

-   Transporting or storing compressed gas cylinders without caps or
    without using cylinder carts and safety harnesses.

-   Failing to use safety pipetting devices when handling radioisotopes,
    toxic chemicals, or infectious materials.

-   Failing to decontaminate glassware before discarding in glass
    disposal.

-   Failing to label isotopes, toxins, infectious materials, or
    dangerous chemicals properly, or failing to store them in a safe and
    clearly marked secluded area.

-   Failing to limit the traffic of unauthorized persons or visitors in
    areas where dangerous materials are being used.

\(10\) [Material Safety Data Sheets]{.underline}. Material Safety Data
Sheets are documents provided by manufacturers that describe the
physical and chemical properties of products, their physical and health
hazards, and precautions for safe handling and use. Every laboratory
must have a MSDS for each hazardous chemical that is used.

\(11\) [Standard Laboratory Procedures]{.underline}

> \(a\) Basic Rules and Procedures

[1]{.underline} Approval: Use of hazardous chemicals must be reviewed by
the Subcommittee on Research Safety.

[2]{.underline} Eye Protection: Wear when appropriate and always if
contact lenses are worn in the laboratory. Be advised that contact
lenses may absorb chemicals (liquid spills or gaseous} and keep the
chemical in contact with the eye.

[3]{.underline} Washing: Flush skin well if exposed to a chemical. Wash
skin well with soap before leaving laboratory.

> [4]{.underline} Avoid inhalation: Do not sniff to test chemicals.
>
> [5]{.underline} Never mouth pipette.

[6]{.underline} Dilution: Add reagents slowly and always add acid to
water never water to acid. Transfer acid slowly and mix slowly by gentle
rotation. A hood is recommended for chemical mixing procedures.

[7]{.underline} Exothermic reactions should be done very slowly to allow
for cooling.

[8]{.underline} No eating or drinking: Do not bring or eat food or
beverages or apply cosmetics in the laboratory. Food may not be stored
in laboratory refrigerators or other areas of potential biological or
chemical hazard. Food containers may not be used as storage vessels for
laboratory materiaIs. Laboratory glassware should not be used for food
preparation or consumption. Coffeepots are not permitted in research
laboratories.

[9]{.underline} Gloves: Wear gloves when working with body fluids,
chemical, biological or radioactive hazards. Remove gloves and wash
hands before touching anything outside of the area or when leaving area.
Reglove with new gloves before continuing.

[10]{.underline} Personal hygiene: Secure long hair and do not put
objects such as pens or your fingers in your mouth.

[11]{.underline} Clothing: Wear laboratory coats at all times. Avoid
loose clothes and dangling neckties. Shorts are prohibited. Shoes should
cover the entire foot. Sandals and open-toed shoes are strongly
discouraged.

[12]{.underline} Work areas are to be kept clean and free from
obstruction. Hallways cannot be used as storage areas. Never block
access to exits, emergency equipment, electrical panels, showers or
eyewash. Keep all compressed gas cylinders secured and tied down.

[13]{.underline} Damaged or cracked glassware should be discarded in the
glass waste boxes provided.

[14]{.underline} Clean up following the completion of any procedure and
at the end of the day. All containers must be labeled. Chemical waste
must be reported to the Chemical Hygiene Officer (x-7396). Infectious
waste should be placed in infectious waste containers. Radioactive waste
should be labeled and disposed of with the assistance of the Radiation
Safety Officer (x-7396).

[15]{.underline} Spilled chemicals should be cleaned up immediately and
disposed of properly. Spill kits are available in each laboratory.

[16]{.underline} Follow specialized instructions for specific chemical
categories and consult the MSDS and be sure you have been properly
trained before performing new procedures.

[17]{.underline} No smoking in any buildings. The MEDVAMC is smoke free.

K. **[CHEMICAL PROCUREMENT, DISTRIBUTION AND STORAGE]{.underline}**

\(1\) [Purchasing Rules]{.underline}:

\(a\) Order chemicals only in minimal quantities. Flammables form
explosive peroxides when stored for extended amounts of time so buy
flammables appropriate for a months need.

\(b\) Order liquid chemicals in plastic-coated safety bottles whenever
available. The added cost of such containers over unprotected glass
bottles is usually small, yet the added margin of safety may be
significant.

\(c\) Chemicals are purchased from manufacturers only through proper
channels.

\(d\) A MSDS must be on file in the using laboratory or the purchase
request must indicate \"MSDS to be shipped with order\".

\(2\) [Transfer:]{.underline} Chemicals entering this facility are for
use only in this facility. Chemicals may not leave or enter the facility
without being. authorized by the MEDVAMC Safety Manager and then only in
approved transport containers. The practice of walking outside with
hazardous chemicals will not be tolerated and will result in revocation
of research privileges.

\(3\) [Storage:]{.underline} Chemicals are stored by category. Care must
be taken to be certain that all chemicals are compatible with the
material of the containers (do not store corrosives in metal
containers). In general, isolate the following types of chemicals from
each other and from other materials:

\(4\) [Corrosives:]{.underline} Store caustic and corrosive materials
near the floor to minimize danger of bottles falling. Acids and bases
should be segregated from each other. Organic Acids (acetic acid and
acetic anhydride) should be stored separately from strong oxidizing
agents (sulfuric, nitric or perchloric) to prevent interaction of fumes
and corrosion of storage cabinets.

\(5\) [Flammables:]{.underline} Small working quantities (1 liter) may
be stored in work areas. Larger quantities must be stored in an approved
flammable storage cabinet. Do not store flammables in areas exposed to
direct sunlight or near other sources of heat or combustion. Flammable
solvents should be stored in an approved solvent storage cabinet. Avoid
storing solvents above eye level in the work area.

\(6\) [Reactive chemicals]{.underline}: Which could react exothermically
with each other should be segregated when storing. Mixing reactive
chemicals is only to be done after appropriate training has been
received and with proper precautions. Reactivity information is given on
MSDSs and on labels.

\(7\) [Oxidizing materials]{.underline}: Such as nitrates and chlorates,
should be stored in a dry area apart from organic material.

\(8\) [Keep Separated:]{.underline}

> Strong acids
>
> Strong bases/oxidizers
>
> Flammables/Combustibles/Organic liquids
>
> Poisons/Carcinogens
>
> Water-Reactives (Keep desiccated)

\(9\) [Chemical Inventories]{.underline}: Each laboratory is required to
maintain an inventory list of their chemicals. This list MUST be
maintained in the laboratory, and copies forwarded through the Research
Administration Office to the Environmental Management Office. The list
must be updated semi-annually.

\(10\) [Labeling:]{.underline} All storage containers must be plainly
and permanently marked, including receipt dates and expiration dates
using the manufacturer's or an equivalent label.

\(11\) [Secondary containers]{.underline}: Into which chemicals are
transferred for storage should be labeled with the same identification
and hazard information as the original container. When opening bottles
that may be under pressure, always cover the top with paper towels to
divert any chemical spray.

**Use safety carriers when transporting glass bottles containing
hazardous chemicals e.g., acids, corrosives, flammable liquids.**

L. **[ENVIRONMENTAL MONITORING]{.underline}**

\(1\) Environmental monitoring is conducted to monitor possible employee
exposure. Environmental monitoring is frequently conducted for chemicals
and substances that have specific OSHA designated limits for exposure.
Consult the MSDS and MEDVAMC Safety Manager for information on the
recommended limits or OSHA mandated limit as guidelines for exposure.
Typical limits are the threshold limit values (TLV) and permissible
exposure limits (PEL).

\(2\) The environmental monitoring for Research laboratories will
include the following:

\(a\) Hazardous Chemicals - formaldehyde, xylene, antineoplastic,
cytotoxic drugs, other miscellaneous gases, dusts, fumes, aerosols.

\(b\) Occupational Health and Environmental Control Monitoring -includes
fume hood and biological safety hood monitoring.

\(c\) Environmental Health workplace surveys are performed to identify
potential exposure risks and will be evaluated to establish workplace
profiles of exposure.

\(3\) Monitoring records for individual personnel are maintained as per
OSHA 1910.20.

M. **[HOUSEKEEPING]{.underline}**

\(1\) There is a correlation between orderliness and level of safety in
the laboratory. A disorderly laboratory can hinder or endanger emergency
response personnel. Use the following guidelines. to maintain an orderly
laboratory:

\(a\) Environmental Management Service is responsible for routinely
cleaning all floors within the Research Service. They are responsible
for trash removal as well.

\(b\) All research laboratory personnel are responsible for daily
cleaning of all bench tops and other work areas such as fume hoods and
laminar flow hoods.

\(c\) Do not block exits, emergency equipment or controls or use
hallways and stairways as storage areas.

> \(d\) Properly label and store all chemicals.
>
> \(e\) Secure all gas cylinders to walls or benches.

N. **[MAINTENANCE]{.underline}**

\(1\) The Biomedical Engineering Section, Facilities Management Service,
is responsible for routine maintenance of research equipment unless
covered by contract.

\(2\) All laminar flow hoods will be inspected, and certified on a
yearly basis. Staff will not use hoods lacking certification or where
certification has expired.

\(3\) Fume hoods will be certified and necessary maintenance performed
by Engineering Service on an annual basis.

\(4\) Eyewash fountains.

\(a\) Engineering Service will inspect all eye wash fountains at 6-month
intervals.

\(b\) Eyewash fountains will be inspected by research personnel during
regular monthly laboratory inspections. Any problems will be recorded on
the inspection report when it is submitted to the Research Office so
that Engineering Service can be notified to take corrective action.

\(5\) Emergency drench-type showers. Engineering Service will inspect
all emergency showers at 6-month intervals.

\(6\) Fire extinguishers. MEDVAMC Safety Office/Fire Inspector will
inspect all Research Service fire extinguishers once a month.

\(7\) Fume Hoods and Biological Safety Cabinets: Regular inspections of
the proper functioning of fume hoods and biological safety cabinets will
be conducted by an approved contractor and linear feet per minute rates
will be posted on each hood.

O. **[INSPECTIONS]{.underline}**

\(1\) Monthly inspections of research areas will be carried out by
research laboratory personnel.

\(2\) The Subcommittee on Research Safety will annually inspect areas
where biohazards are in use. (This does not include radioisotopes since
areas using radioisotopes are routinely inspected by the Radiation
Safety Office.)

[Flammable Liquid Storage/Acid Storage]{.underline}: Special storage
cabinets are available in laboratories to store chemicals.

[Respirators]{.underline}: Laboratory workers will wear a respirator
suitable for protection against a suspected chemical if the vapor in the
air shows (or it is suspected) that the recommended limit is exceeded.
The Chemical Hygiene Officer will first determine the need for a
respirator (upon request) and fit-test the employee before a respirator
is worn.

[Ventilation]{.underline}: Regular checks of air exchanges (recommended
at 8 air exchanges per hour) will be conducted. Employees will be
notified of areas significantly lower than the recommended air exchange
rate and will be given additional precautions if recommended by the
MEDVAMC Safety Manager or the Subcommittee on Research Safety.

[Inspection Schedule]{.underline} [Timing]{.underline}

Chemical Hygiene Quarterly

Eyewash Quarterly

Respirators for routine use Regularly

Safety Showers 3 -- 6 months regularly

Other equipment Regularly

P. **[PERSONAL PROTECTIVE APPAREL AND EQUIPMENT
ASSESSMENT]{.underline}**

*[Check the MSDS for Special Personal Protective Equipment
instructions.]{.underline}*

\(1\) [Gloves]{.underline} - Gloves should be worn when working with
body fluids, chemical, biological or radiological hazards, or when
handling very hot, cold, or sharp objects or when handling animals.
Check gloves closely for holes and use only gloves impermeable to the
substance being used. Wash gloves after using, then discard if
disposable. Wash hands after removing gloves. Do not wear gloves outside
the laboratory except for their intended purpose. Select glove
composition appropriate to the material or task at hand.

\(a\) [Latex Rubber]{.underline} - Suitable for handling infectious
fluids, most aqueous and organic chemicals, radiochemicals. A good
substitute for latex is nitrile, which is impervious to most organic
solvents including acetone and alcohols.

\(b\) [Vinyl Plastic]{.underline} - Good substitute for latex in
general. Do not use with organic solvents such as chloroform,
dichloroethane, and ethers.

\(c\) [Neoprene Rubber]{.underline} - (heavy duty) - Resistant to most
chemicals including corrosive materials.

\(d\) [Thermal Gloves]{.underline} - Suitable for handling extreme hot
or cold objects (avoid use of older asbestos gloves).

\(e\) [Leather/Fabric]{.underline} - Use when working with sharps
(including razor blades) and animals. Wash gloves after using, then
discard if disposable. Wash hands after removing gloves.

*Do not wear gloves outside the laboratory except for their intended
purpose*.

\(2\) [Gowns]{.underline} - Laboratory coats should be used whenever
possible and gowns are available for use in specific experiments when
necessary.

\(3\) [Lab Coats -]{.underline} Wear a lab coat for general protection
of the skin and clothing from chemicals, or from contamination by
infectious materials or radioactive materials. Keep the lab coat
buttoned in front. Do not wear the lab coat outside the lab.

\(4\) [Masks]{.underline} - Masks should be worn when airborne droplets
or other release into the room is likely. Wear a mask as (only) minimal
protection against inhaling aerosols, or of hazardous materials that are
especially dusty in nature.

\(5\) [Respirators]{.underline} - When greater protection is required,
respirators are fitted by the MEDVAMC Safety Manager. Respirators may be
needed for complete protection against certain volatile or toxic
substances.

\(6\) [Goggles]{.underline} - Safety goggles should be worn when heating
liquids in a test tube, pouring and handling caustic and corrosive
materials, toxic or hazardous reagent preparation, handling reactive
chemicals or volatile solvents. Always use goggles or full face shield
whenever there is a risk of splashing. chemicals or flying particles.
High risk procedures should be conducted behind a stationary shield,
such as a fume hood. ALWAYS USE GOGGLES WHEN USING LlQUID NITROGEN
SAMPLES!

Avoid wearing contact lenses when working with, or in the vicinity, of
volatile hazardous materials. Contact lenses not only do not provide eye
protection, but they may absorb or TRAP chemicals, and may actually
aggravate chemical damage to the eye following exposure.

Always protect eyes from direct exposure to ultraviolet radiation.
Regular eyeglasses provide some protection, but they do not protect
against side-angle exposure.

BETTER: Use wrap around dark lens safety goggles.

Q. **[DISPOSAL OF CHEMICALS FROM LABORATORIES]{.underline}**

Laboratory personnel are the generators of waste, have the best general
knowledge of the hazard characteristics of their waste and are in the
best position to identify any of their chemicals that might pose unusual
hazards. Laboratory personnel are responsible for putting waste in the
proper containers, labeling and calling the Industrial Hygienist for
pick-up at x-7396.

\(1\) [Reduction of Volume of Waste]{.underline}. Make every attempt to
reduce the volume of waste generated in the laboratory.

\(2\) [Planning Experiments]{.underline}: The planning of every
experiment should include consideration of the disposal of leftover
starting materials and of the products and by-products that will be
generated.

Questions to be considered in such planning include the following:

-   Can any material be recovered for reuse?

-   Will the experiment generate any chemical that should be destroyed
    by a laboratory procedure? What procedure?

-   Can any unusual disposal problem be anticipated?

-   Are chemicals being acquired in minimal quantities?

-   Is there a possibility of replacing a hazardous reagent or solvent
    with one that is less hazardous?

\(3\) [Labeling - Older Chemicals]{.underline}:

Deterioration of labels is a common occurrence on old reagent
containers. If the reagent or container has not deteriorated, the
container should be relabeled if its identity is certain.

Laboratory glassware used for storing chemicals should be labeled with
the chemical composition, the date of placement, the name of the
laboratory worker responsible, and a notebook reference. This procedure
can provide the information necessary to guide the disposal of the
mixture.

\(4\) [Segregation/Labeling]{.underline}

Classes of waste must be properly segregated for temporary accumulation
and storage as well as for transportation and disposal. Accordingly, all
wastes must be properly labeled before being called in for pick up. The
label should contain sufficient information to assure safe handling and
disposal:

-   initial date of accumulation

-   chemical names of the principal components

-   chemical names of the major ingredient plus any minor components
    that could be hazardous

-   whether the waste is toxic, reactive, corrosive to skin or metal,
    flammable, an inhalation hazard, or a lachrymator

\(5\) [Disposal of Waste in Sewer System]{.underline}

Limited quantities of some wastes can be disposed of in the sewer
systems, which will destroy the wastes if it is connected directly to a
water-treatment plant. Only a few years ago it was common practice to
dispose of most laboratory wastes down the laboratory drain. The
indiscriminate drain disposal of laboratory chemicals, without regard to
quantity or chemical type, is not acceptable. Laboratory drains are
connected to sanitary sewer systems, and effluent will eventually go to
the sewage treatment plant. Some chemicals can interfere with the proper
functioning of sewage treatment facilities. In the laboratory drain
system itself, some chemicals can create hazards of fire, explosion, or
local air pollution; others can corrode the drain system.

The quantities of chemicals disposed of in the drain must be limited
generally to not more than a few hundred grams or milliliters. The
disposal should be performed by flushing with at least 100-fold excess
water at the sink, so that the chemicals become highly diluted in the
wastewater effluent from the laboratory and even more so by the time the
effluent reaches the treatment plant.

\(6\) [Disposal of Organic Compounds]{.underline}

Only those organic compounds that are reasonably soluble in water are
suitable for drain disposal:

-   A compound is considered water soluble if it dissolves to the extent
    of at least 3%, judged by whether 0.2 ml or 0.1g dissolves in 3 ml
    of water in a test tube.

-   Substances that boil below 50°C, even though adequately water
    soluble, should not be poured down the drain because they can cause
    unacceptable concentrations of vapor in the user\'s or another
    laboratory or in the sewer system

-   Diethyl ether, which can create a hazard of fire or explosion, is
    not to be disposed of in this manner.

-   Formaldehyde (b.p. - 21°C) is an exception because it is so hydrated
    in water that very little of it vaporizes from dilute aqueous
    solution.

-   Highly malodorous substances should not be put down the drain.

-   Substances that meet the solubility criterion, but contain another
    material that does not, should not be poured down the drain.
    However, if the water-insoluble material comprises less than about
    2% of the mixture, drain disposal is usually acceptable because the
    small quantity of water-insoluble material will be well dispersed in
    the aqueous effluent. Common examples are acetone that has been used
    to rinse glassware and ethanol that contains a hydrocarbon
    denaturant.

-   Some organometallic compounds such as Grignard reagents and
    alkyllithiums or aryllithiums can be decomposed by water into
    innocuous solutions that are suitable for drain disposal. This
    decomposition should always be performed in the laboratory before
    drain disposal.

-   Hydrocarbons, halogenated hydrocarbons, nitro compounds, mercaptans,
    and most oxygenated compounds that contain more than five carbon
    atoms should not be disposed of down the drain.

-   Other exclusions are explosives, such as azides and peroxides, and
    water-soluble polymers that could form intractable gels in the sewer
    system.

\(7\) [Disposal of Inorganic Compounds and Chemicals]{.underline}

Drain disposal is permissible for dilute solutions of inorganic salts
within certain cation and anion designations. Mineral acids and alkalis
are preferably neutralized before drain disposal.

R. **[THE MATERIAL SAFETY DATA SHEET]{.underline}**

A Material Safety Data Sheet (MSDS) is a document that provides
important safety information for specific hazardous materials or
chemicals. All persons working in an area where hazards are used should
understand what information is contained in the MSDS. A copy of the MSDS
for each material must be kept for ready accessibility in the laboratory
.

\(1\) [A MSDS is divided into ten (10) sections]{.underline}:

-   Product Identification: Chemical and trade names, synonyms,

> manufacturer, and product codes.

-   Hazardous Ingredients: Chemical ingredients and toxicity data such
    as

> permissible exposure limits (PEL).

-   Physical Data: Physical properties, such as vapor density,

vapor pressure, boiling point, appearance,

odor.

-   Fire and Explosion Hazard Data: Flash point, extinguishing media,
    description of

> and explosion potential.

-   Health Hazard: Provides threshold limit values (TLV), health

> hazard(s), emergency first aid procedures.

-   Reactivity data: Stability, incompatibility; consequence of

> reaction and decomposition.

-   Spill Disposal: Steps to contain and neutralize a spill; waste

> disposal methods.

-   Protection Information: Equipment and protective clothing

> recommended when handling material.

-   Handling/Storage Precautions: Provides information about storage

> procedures.

-   Miscellaneous Information: Any other pertinent information regarding

> storage and handling precautions.

\(2\) **[MSDS/Labeling]{.underline}**

\(a\) Labeling is closely tied to information on the MSDS. Every
chemical in a container more than 8 hours must have a label. Every label
must contain the following:

-   Chemical Name (common name and chemical name)

-   Hazard Determination (NFPA/NIOSH Coding)

-   Manufacturer tri-color diamond label with numbers that indicate
    hazard level for each category.

\(b\) Labels may not be removed or defaced. Labels are available in the
Research Office for chemicals transferred out of original containers.
Additional information on the label includes:

-   Safety Precautions

-   Date Created/Placed into Container

-   Contact for emergencies.

\(3\) [Signs.]{.underline} Signs shall be posted in each laboratory that
identifies emergency phone numbers, eyewash stations, safety showers,
fire extinguishers, exits. Other safety equipment must be properly
identified with signs. Warning signs should be posted for special or
unusual hazards such as a volatile or extremely toxic reagents used
routinely.

\(4\) [Specific Management Approval of all Laboratory
Operations]{.underline}. All research involving hazardous chemicals must
be approved by the Subcommittee on Research Safety before materials can
be purchased for work to begin. Investigators are required to certify
that their laboratory contains necessary equipment to safely execute the
proposed experiments and that all personnel involved have been
appropriately trained in safe work practices for the specific materials
they will be using.

## S. **PARTIAL LIST OF INCOMPATIBLE CHEMICALS (REACTIVE HAZARDS)**

Substances in the left hand column should be stored and handled so that
they cannot accidentally contact corresponding substances in the right
hand column under uncontrolled conditions.

+------------------------+---------------------------------------------+
| ######### Acetic Acids | Chromic acid, nitric acid, hydroxyl         |
|                        | containing compounds, ethylene glycol,      |
|                        | perchloric acid, peroxides, and             |
|                        | permanganates.                              |
+------------------------+---------------------------------------------+
| Acetone                | Concentrated sulfuric and nitric acid       |
|                        | mixtures                                    |
+------------------------+---------------------------------------------+
| Acetylene              | Copper (tubing), fluorine, bromine,         |
|                        | chlorine, iodine, silver, mercury and their |
|                        | compounds.                                  |
+------------------------+---------------------------------------------+
| Alkali metals (calcium | Water, carbon dioxide, potassium, sodium,   |
|                        | carbon tetrachloride and other chlorinated  |
|                        | hydrocarbons                                |
+------------------------+---------------------------------------------+
| Ammonia (anhydrous)    | Mercury, halogens, calcium, hypochlorite,   |
|                        | fluoride                                    |
+------------------------+---------------------------------------------+
| Ammonium nitrate       | Acids, metal powders, flammable liquids,    |
|                        | chlorates, nitrates, sulfur, and finely     |
|                        | divided organics or combustibles            |
+------------------------+---------------------------------------------+
| Bromine                | Ammonia, acetylene, butadiene, butane,      |
|                        | hydrogen, sodium carbide, turpentine, and   |
|                        | finely divided metals                       |
+------------------------+---------------------------------------------+
| Chlorates              | Ammonium salts, acids, metal powders,       |
|                        | sulfur, finely divided organics or          |
|                        | combustibles, carbon                        |
+------------------------+---------------------------------------------+
| Chromic acid           | Acetic acid, naphthalene, camphor, alcohol, |
|                        | glycerin,turpentine, and other flammables.  |
+------------------------+---------------------------------------------+
| Chlorine               | Ammonia, acetylene, butadiene, benzene, and |
|                        | other petroleum fractions, sodium divided   |
|                        | powdered metals                             |
+------------------------+---------------------------------------------+
| Cyanides               | Acids                                       |
+------------------------+---------------------------------------------+
| Hydrogen peroxide      | Nitric acid, oxidizing gases                |
+------------------------+---------------------------------------------+
| Iodine                 | Acetylene, ammonia                          |
+------------------------+---------------------------------------------+
| Mercury                | Acetylene, ammonia                          |
+------------------------+---------------------------------------------+
| Nitric Acid            | Acetic, chromic, and hydrocyanic acids,     |
|                        | aniline, carbon, hydrogen sulfide,          |
|                        | flammables, readily nitrated substances.    |
+------------------------+---------------------------------------------+
| Oxygen                 | Oils, grease, hydrogen, flammables          |
+------------------------+---------------------------------------------+
| Perchloric acid        | Acetic anhydride, bismuth and its alloys,   |
|                        | alcohol, paper, wood and other organic      |
|                        | materials                                   |
+------------------------+---------------------------------------------+
| Phosphorous pentoxide  | Water                                       |
+------------------------+---------------------------------------------+
| #########              | Glycerin, ethylene glycol, benzaldehyde and |
| Potassium permanganate | sulfuric acid                               |
+------------------------+---------------------------------------------+
| Sodium                 | Any oxidizable substances, i.e., methanol,  |
|                        | glacial acetic acid, carbon disulfide,      |
|                        | benzaldehyde, ethylene                      |
+------------------------+---------------------------------------------+
| Sulfuric acid          | Chlorates, perchlorates, permanganates      |
+------------------------+---------------------------------------------+

CHAPTER 10 [OCCUPATIONAL HEALTH AND SAFETY PROGRAM]{.underline}

### A. MEDICAL/OCCUPATIONAL HEALTH AND SAFETY

Personal safety is of utmost concern; employees are the first lines of
defense against health problems. Life Support/Emergency Room is
available around the clock to handle emergencies and first aid
treatment.

[MEDICAL PROGRAM]{.underline}

\(1\) [Routine Surveillance]{.underline}

\(a\) Employee Health administers the surveillance program, as outlined
by OSHA regulations, for all VA employees who handle or are exposed to
hazardous materials.

\(b\) MEDVAMC Employee Health/Safety Manager monitors the following on
an as-needed basis.

-   Formaldehyde

-   Asbestos

-   Anticholinesterases/insecticides

-   Chemotherapeutic agents

-   Ethylene oxide

-   Nitrous oxide

-   Noise

-   Ionizing radiation

-   Blood-borne disease agents

\(2\) [Emergency First Aid Procedures]{.underline}

\(a\) Eye

[1]{.underline} In the event of a chemical splash to the eyes, ask
co-workers to help you wash the eyes thoroughly. Lift eyelids to avoid
pooling of chemicals under eyelids. Flush with water for 15 minutes.

[2]{.underline} Consult Employee Health immediately.

[3]{.underline} Report accident to immediate supervisor.

[4]{.underline} Follow procedures outlined below under "Employee
Incident Reporting".

\(b\) Cuts, punctures and needlesticks

[1]{.underline} If the injures are clean cuts, punctures, and
needlesticks, clean the affected area immediately with surgical soap,
then flood or soak affected area in antiseptic fluid. Bandage to prevent
infection. Consult Employee Health.

[2]{.underline} If the injuries are dirty cuts, punctures, or
needlesticks, e.g. those contaminated with patient blood or body fluids
or bacterial agents, proceed as above as long as no object which caused
the wound is left in the wound. Consult Employee Health.

[3]{.underline} If the object causing the injury is not easily removed,
do not attempt to cleanse the area. Doing so may cause further damage.
Consult Employee Health immediately.

[4]{.underline} If the object, which causes the injury, is contaminated
with patient's specimens, identify the specimen with the patient's name
for further evaluation and investigation. Thoroughly cleanse wound.
Consult Employee Health at once.

[5]{.underline} Follow procedures outlined below under "Employee
Incident Reporting".

\(3\) [Employee Incident Reporting]{.underline}

The MEDVAMC will promptly investigate all employee‑reported incidents in
which there is even a remote possibility of employee overexposure to a
toxic substance. A laboratory employee may have been overexposed if:

-   a hazardous chemical was spilled, leaked or was released in an
    uncontrolled manner.

-   a laboratory employee had direct skin or eye contact with a
    hazardous chemical.

-   a laboratory employee has symptoms of headache, rash, nausea,
    coughing; tearing, irritation or redness of eyes; irritation of nose
    or throat, and some or all of the symptoms disappear when the
    employee leaves an exposure area, and the symptoms reappear soon
    after returning to the exposure area.

-   two or more laboratory employees in the same work area have similar
    complaints of symptoms.

\(a\) Each employee is required to immediately report the following
accidents and injuries and situations to their supervisor and the
Subcommittee on Research Safety.

\(b\) In the event of a serious injury, an employee may report to the
Employee Health Office for first aid treatment before notifying his or
her supervisor. Take a copy of the MSDS.

> \(4\) [Accident Records]{.underline}

Each accident occurring as a result of a chemical exposure should be
recorded on VA Form 2162, Report of Accident, Injury, Occupational
Illness or Fire. This form allows for a detailed analysis of the
accident. Following any accident an investigation will include:

> \(a\) The chemical agent responsible for the accident
>
> \(b\) A record of any measurements made to monitor exposures

\(c\) Medical consultation information, including any written reports,
if applicable.

> \(d\) The most likely cause of the accident
>
> \(e\) A review to determine if proper procedures were followed
>
> \(f\) Recommendations to prevent reoccurrence.

\(5\) [Tracking of Problems]{.underline}

Records of personnel exposed to chemical hazards will be maintained in
the Medical Record of the individual in the Employee Health Office.
Accidents are reported to the facility Safety Manager who reviews the
original accident analysis, conducts trend analysis of accidents, and
reports the finding back to the using areas, including any
recommendations for action.

## (6) Health Records

Each employee will have a Health and Safety Record kept on file in
Employee Health. This record is confidential and may be reviewed by
appointment.

## (7) Training

Employees are instructed on safe work practices before beginning work
and on an annual basis while employed. This will include, but not be
limited to, training information on:

\(a\) Safe work habits

\(b\) Chemical Hygiene

\(c\) Emergency Response

\(d\) Biosafety

\(e\) Safe use of Radioactivity if applicable

\(f\) Use of employee health clinic for reporting injuries and illnesses

B. [OCCUPATIONAL HEALTH PROGRAM FOR PERSONNEL USING ANIMALS]{.underline}

The Employee Health Physician is responsible for monitoring the health
program and maintains a file on each employee, which contains the
pre-employment health assessment reports and subsequent evaluations,
immunization schedules and bite wound records. The Employee Health
Physician establishes and coordinates the appropriate follow-up,
referral or treatment for each employee.

Each employee or student who works with animals must participate in the
Occupational Health Program. Participation is documented by individual
signature.

Each principal investigator is responsible for ensuring that all persons
involved in the projects under his/her direction shall comply with the
program. Any principal investigator who fails to carry out this
responsibility will be denied the use of animals until full compliance
has been established.

\(1\) [Pre-employment]{.underline}

Before a VA employee is hired, a physical is conducted. The following
information is gathered depending on the type of work.

\(2\) [General Research]{.underline}

General Exam-The Pre-employment work and health history examines risk
factors for various types of research work.

Blood Sample

RPR-Syphillis Titer

Profile #3 (Chem 20)

CBC-Platelets and Differential

Urinalysis with micro

PPD Tuberculosis skin test

Tetanus/Diphtheria status determination

Optional: Hepatitis B Vaccine

\(3\) [Animal Research - Level 1]{.underline} - Rodents and Rabbits from
Regulated Sources

General Exam - This pre-employment work and health history examines risk
factors for various animal exposures related syndromes

Blood Sample

RPR-Syphillis Titer

Profile #3 (Chem 20)

CBC-Platelets and Differential

Urinalysis with micro

PPD tuberculosis skin test

Tetanus/Diphtheria status determination

Optional: Hepatitis B Vaccine

\(4\) [Animal Research - Level 2]{.underline} - Random Source Animals
(cats, dogs and rodents not from approved sources).

General Exam-The pre-employment work and health history examines risk
factors for various animal exposure related syndromes.

Blood Sample

RPR-Syphillis Titer

Profile #3 (Chem 20)

CBC-Platelets and Differential

Urinalysis with micro

Toxoplasmosis Titer

PPD tuberculosis skin test

Tetanus/Diphtheria status determination

Optional:

Pre-exposure rabies prophylaxis (human diploid cell vaccine)

Rabies booster (human diploid cell vaccine)

Hepatitis B Vaccine

Annual physical

Post employment physical exam upon employee's request.

\(5\) [Animal Research - Level 3]{.underline} (non human primates-not in
effect)

\(6\) [During Employment]{.underline}

After employment begins, the following are part of the ongoing
occupational health program:

\(7\) [Periodic Health Appraisals]{.underline}

As noted in the animal levels, periodic (annual) health assessments are
conducted while one is employed. This may also be done for employees
working with hazardous environments including:

\(a\) Infectious diseases

\(b\) Highly toxic chemicals

\(c\) Other health hazards

Employees who return to work after an injury may also be provided a
health assessment

\(8\) [Post Employment]{.underline}

Employees may have an exit interview and exit physical exam upon leaving
employment.

\(a\) [Aspects Relating to Hazardous Agents.]{.underline} Users of
radioisotopes, including animal technicians, wear film badges. The
Hospital Infection Control Committee reviews policies relating to
occupational health and infections in personnel and advises the Employee
Health Physician on appropriate procedures. Animal Component of Research
Protocol forms must include information regarding safe handling of
animals/tissue exposed to hazardous agents.

\(b\) [Protective Equipment/Clothing Provided.]{.underline} Gowns,
gloves, masks or respirators, head covers or goggles are required by all
personnel working with potentially hazardous microbiological, chemical
and radiological agents. Animals harboring potentially infectious agents
are housed in negative pressure rooms and/or isolators.

\(c\) [Experimentation Involving Hazardous Agents]{.underline}. Studies
involving hazardous agents and animals must be reviewed by all
appropriate subcommittees for the Research and Development Committee
before final approval. These subcommittees include the Radiation Safety
Committee, Institutional Animal Care and Use Committee, and Subcommittee
on Research Safety. These committees review the qualifications of
personnel, assess dangers associated with such hazardous agents and
approve appropriate safeguards. Instruction is given to personnel
related to other chemicals, microbiological or physical hazards during
staff training sessions. As a supplement, full protective disposable
clothing is available. Ear protectors are also available for work in the
dog rooms and face masks are required when disposing of dirty bedding.

## CHAPTER 11 BIOLOGICAL HAZARDS

A. [INTRODUCTION]{.underline}

Biohazards are living agents that may be hazardous to the health and
certain non‑living agents that may also present a health risk including
bacteria, viral agents, fungi, protozoan and parasites. In recent years,
HIV and HBV have become predominant concerns. Risk to laboratory workers
from these agents stems from being invisible to the naked eye and that
their presence may be unsuspected. Another risk is their infectious
nature, allowing them to spread, and an infection acquired in the
laboratory may be disseminated to people and places far from the
original sources.

Several types of precaution systems are used to protect employees
including [Universal Precautions]{.underline} and [NIH Biosafety level
classifications.]{.underline}

B. [GENERAL PRINCIPLES]{.underline}

The guiding principles for working with biohazards are isolation and
containment. This means that special sanitized hoods, centrifuges, and
storage facilities may have to be reserved for the use of particular
projects.

Special precautions are required for research projects involving the use
of any of the following biohazards:

-   Research involving pathogens/etiologic agents.

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-   Research involving recombinant DNA molecules.

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-   Research involving HIV.

C. [ROUTES OF INFECTION]{.underline}

\(1\) Infections may be acquired by several routes. The actual
occurrence of an infection depends on both the virulence of the
infecting agent, the size of the dose, the route of entry, and the
susceptibility of the host.

-   Airborne droplets and aerosols: formed by removing caps or cotton
    plugs or swabs from tubes; spills; heating liquids on loops too
    rapidly; syringe and needles use; blending; breakage in centrifuges;
    and laboratory accidents; etc.

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-   Ingestion: occurs through mouth pipetting, handling of cigarettes
    and food in the laboratory, etc.

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-   Direct inoculation: scratches, needles, broken glass or animal
    bites.

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-   Skin contact: entry through small cuts or scratches, or through
    conjunctivas of the eye.

> \(2\) [Sources of Infection and Universal Precautions]{.underline}:
>
> Specimens: Laboratories in which studies are being conducted on
> specimens from potentially infected patients. [Because some diseases
> may be transmitted by persons who do not exhibit the symptoms of the
> infection, all specimens from patients. (e.g., blood, saliva, urine,
> feces, exudates, tissue, and tissue cultures) should be handled with
> the same precautions as if they were known to be
> infected.]{.underline} This is called \"Universal Precautions\".

Some infectious agents may survive and be transported for long distances
in air currents or dust. Consequently, it is necessary that any spills
within the laboratory be promptly and effectively disinfected.
Furthermore, avoid any procedure that would result in the formation of
infectious aerosols.

\(3\) [Animals]{.underline}: Laboratory animals are a potential source
of infection. Although strict precautions are taken in the Vivarium to
minimize this danger by purchasing animals from certified suppliers and
through quarantine, it cannot be assumed that risks are completely
absent. If even a "healthy" animal bites someone, it can cause severe
and painful infection.

\(4\) [Sharps:]{.underline} Hypodermic and surgical needles and surgical
blades are frequent causes of injuries and may transmit infections to
those using them and also to housekeeping personnel who encounter them
in trash containers. These objects should never be disposed of in common
waste receptacles. Medical Center regulations specify that they must be
placed in sharps containers.

### 

### D. PRECAUTIONARY TECHNIQUES

\(1\) Hand washing should be performed frequently during the day, before
and after contact with patient\'s specimens and before eating and
drinking.

\(2\) Safety devices, including masks, goggles, protective clothing and
safety pipettors must be used.

\(3\) Disinfectants should routinely be used to sanitize working areas
and equipment before and after use, as well as to decontaminate any
accidental spills that may occur. 70% alcohol, phenolic cleaner or
laundry bleach can be used depending upon agents to be destroyed.

\(4\) Benches should be disinfected in the morning before work is begun
and in the afternoon after work is finished, or at any time the
technician feels it has become contaminated.

\(5\) Laboratory garments should never be worn home or in public places
such as the library, auditorium, or cafeteria.

\(6\) Restrict traffic in biohazardous areas. Post signs (Biohazard) to
alert personnel of potential biohazards.

\(7\) Be aware of people who have to enter laboratories where infectious
materials are present such as clerical, administrative, or maintenance
personnel, as well as those who handle papers, glassware, or supplies
coming from those laboratories who also come under risk of exposure.

\(8\) Infectious materials should not be stored in common use
refrigerators, cold rooms, or freezers.

\(9\) Avoid using needles and surgical blades, unless it is necessary.
Do not recap needles, or intentionally bend, break, or remove needles
from disposable syringes. These objects or supplies should be disposed
in specially provided red plastic sharps containers in accordance with
Medical Center regulations.

\(10\) Any project that involves the use of biohazards will be reviewed
by the Subcommittee on Research Safety, which will determine if the
available or proposed facilities, equipment, and personnel are adequate
to carry out the project in full safety.

\(11\) Personnel in laboratories specializing in infectious disease
studies must be fully informed of risks, and specifically trained in the
proper procedures to handle the disease agent safely.

## (12) Glassware

\(a\) Contaminated glassware that is to be reused is disinfected and
thoroughly washed prior to returning it to the working area.

\(b\) Sharps and glassware that are/is to be discarded should be
disposed of in proper red plastic sharps containers.

\(c\) All glassware, pipettes, slides, etc., used in the examination or
testing of biologic materials must be autoclaved or chemically
disinfected before being discarded or prepared for reuse. Single use
bottles, tubes, vials, and other biological specimen containers should
not be placed in wastebaskets customarily emptied by the housekeeping
staff.

\(d\) All glassware that comes in contact with human specimens must be
considered potentially infectious and placed in closed containers, and
autoclaved before being discarded or sent to the washroom.

\(e\) The contents of pipettes and syringes should be expelled slowly to
avoid formation of aerosols.

##  (13) Centrifuges

\(a\) No open specimens are to be placed in centrifuges. Tubes must be
stopped with a rubber stopper or plastic caps, bags.

\(b\) Special attention should be given to the selection of glassware or
plastic ware used for centrifugation of specimens or cultures. They must
be sealed and able to withstand the centrifugal forces without breaking.

> \(c\) Centrifuge rotors must [NOT]{.underline} be run above their
> rated speed.

\(14\) [Specimen Handling]{.underline}: All cultures are potential
pathogens - Use careful techniques at all times.

\(a\) Large numbers of plates should be handled in baskets. Test tube
racks or trays are required for tube cultures. (Do not place tubes in
glasses or paper cups.)

\(b\) Tuberculosis and fungus specimens and cultures should be handled
and processed in the biologic safety cabinet. Additionally, refer to the
CDC publication \"Classification of Etiologic Agents on the Basis of
Hazard\" for other agents that must be handled in biologic safety
cabinets.

\(c\) Needles and loops should be flamed frequently and when the
procedure is over.

\(d\) Treat blood and other body fluids from all persons as though they
were infectious.

\(e\) Because some diseases may be transmitted by persons who do not
exhibit the symptoms of the infection, all specimens from patients
(e.g., blood, exudates, tissues, and tissue cultures) or other body
fluids with visible blood should be handled with the same precautions
that would be taken if they were known to be infected. Universal
Precautions Apply.

### E. LABORATORY BIOSAFETY LEVEL CRITERIA

\(1\) *[Biosafety Level 1]{.underline}*

Work involving agents of no known or of minimal potential hazard to
laboratory personnel and the environment.

> \(a\) [Standard Microbiological Practices]{.underline}

-   Access to the laboratory is limited or restricted.

-   Work surfaces are decontaminated once a day and after any spill

-   All contaminated liquid or solid wastes are decontaminated before
    disposal.

-   Mechanical pipetting devices are used; mouth pipetting is
    prohibited.

-   All procedures are performed carefully to minimize the creation of
    aerosols.

-   Laboratory coats or gowns are worn to prevent contamination or
    soiling of street clothes.

\(2\) *[Biosafety Level 2]{.underline}*

Work involving agents of moderate potential hazards to personnel and the
environment. Laboratory personnel must have specific training in
handling pathogenic agents and access to the laboratory is limited when
work is being conducted. Procedures in which infectious aerosols are
created are conducted in biological safety cabinets or other physical
containment equipment.

> \(a\) [Standard Microbiological Practices]{.underline}

-   Access to the laboratory is limited or restricted when work with
    infectious

> agents are in progress.

-   Work surfaces are decontaminated once a day and after any spill.

-   All contaminated liquid or solid wastes are decontaminated before
    disposal.

-   Mechanical pipetting devices are used; mouth pipetting is
    prohibited.

-   All procedures are performed carefully to minimize the creation of
    aerosols.

> \(b\) [Special Practices]{.underline}

[1]{.underline} Laboratory limits access. In general, persons who are at
increased risk of acquiring infection or for whom infection may be
unusually hazardous are not allowed in the laboratory or animals rooms.

[2]{.underline} Only persons who have been advised of the potential
hazard and meet any specific entry requirements (e.g., immunization) can
enter the laboratory or animal rooms.

[3]{.underline} A hazard warning sign incorporating the universal
biohazard symbol is posted on work area. The hazard warning sign
identifies the infectious agent, lists the name and telephone number of
the laboratory director or other responsible person(s), and indicates
the special requirement(s) for entering the laboratory.

[4]{.underline} Animals not involved in the work being performed are not
permitted in the laboratory.

[5]{.underline} All waste from laboratories and animal rooms are
appropriately decontaminated before disposal.

[6]{.underline} Spills and accidents which result in overt exposures to
infectious materials are immediately reported to the laboratory
supervisor/ principal investigator.

\(c\) [Containment Equipment]{.underline}

Biological safety cabinets (Class I or II) or other appropriate personal
protective or physical containment devices are used whenever:

[1]{.underline} Procedures with a high potential for creating infectious
aerosols are conducted. These may include centrifuging, grinding,
blending, vigorous shaking or mixing, sonic disruption, opening
containers of infectious materials whose internal pressures may be
different from ambient pressures, inoculating animals intranasally, and
harvesting infected tissues from animal eggs.

2 High concentrations or large volumes of infectious agents are used.
Such materials may be centrifuged in the open laboratories if sealed
heads or centrifuges/safety cups are used.

\(d\) [Laboratory Facilities]{.underline}

[1]{.underline} An autoclave for decontaminating infectious laboratory
waste is available.

2 Spore killing once a month should check efficiency of sterilization
for that autoclave.

\(3\) *[Biosafety Level 3]{.underline}*

Work is done with indigenous or exotic agents that may cause serious or
potentially lethal disease as a result of exposure by the inhalation
route. Laboratory personnel have specific training in handling
pathogenic and potentially lethal agents. Procedures are conducted
within biological safety cabinets or other physical containment devices
or by personnel wearing appropriate personal protective clothing and
devices. When existing facilities do not have all the facility
safeguards recommended for Biosafety Level 3 (e.g., access zone, sealed
penetrations, and directional airflow, etc.), acceptable safety may be
achieved for routine or repetitive operation (e.g., diagnostic
procedures involving the propagation of an agent for identification,
typing, and susceptibility testing).

\(a\) [Standard Microbiological Practices]{.underline}

-   Work surfaces are decontaminated at least once a day and after any
    spill of viable material.

-   All infectious liquid or solid wastes are decontaminated before
    disposal.

-   Mechanical pipetting devices are used; mouth pipetting is
    prohibited.

-   All procedures are performed carefully to minimize the creation of
    aerosols.

> \(b\) [Special Practices]{.underline}

[1]{.underline} Laboratory doors are kept closed when experiments are in
progress.

2 Access is restricted to persons whose presence is required for program
or support purposes. Persons who are at increased risk of acquiring
infection or for whom infection may be unusually hazardous are not
allowed in the laboratory or animal rooms.

[3]{.underline} Only persons who have been advised of the potential
biohazard, who meet any specific entry requirements (e.g.,
immunization), and who comply with all entry and exit procedures may
enter the laboratory or animal rooms.

[4]{.underline} When infectious materials or infected animals are
present in the laboratory or containment module, a hazard warning sign,
incorporating the universal biohazard symbol, is posted on all
laboratory and animal room access doors. The hazard warning sign
identifies the agent, lists the name and telephone number of the
laboratory director or other responsible person(s), and indicates any
special requirements for entering the laboratory, such as the need for
immunizations.

[5]{.underline} All activities involving infectious materials are
conducted in biological safety cabinets or other physical containment
devices within the containment module. No work in open vessels is
conducted on the bench.

[6]{.underline} The work surfaces of biological safety cabinets and
other containment equipment are decontaminated when work with infectious
materials is finished. Plastic backed paper toweling used on
nonperforated work surfaces within biological safety cabinets
facilitates clean up.

[7]{.underline} Laboratory clothing that protects street clothing (e.g.,
solid front or wrap‑around gowns, scrub suits, coveralls) is worn in the
laboratory. Laboratory clothing is not worn outside the laboratory, and
it is decontaminated before being laundered.

[8]{.underline} Molded surgical masks or respirators are worn in rooms
containing infected animals.

[9]{.underline} Animals not related to the work being conducted are not
permitted in the laboratory.

[10]{.underline} All waste from laboratories and animal rooms are
appropriately decontaminated before disposal.

[11]{.underline} Vacuum lines are protected with high efficiency
particulate (HEPA) filters and liquid disinfectant traps.

[12]{.underline} Spills and accidents, which result in overt or
potential exposures to infectious materials, are immediately reported to
the laboratory.

[13]{.underline} Baseline serum samples for all laboratories and other
at‑risk personnel should be collected and stored. Additional serum
specimens may be collected periodically, depending on the agents handled
or the function of the laboratory.

> \(c\) [Containment Equipment]{.underline}

Appropriate combinations of personal protective and physical containment
devices (special protective clothing, masks, gloves, respirators,
centrifuge safety cups, sealed centrifuge rotors, and containment caging
for animals) are used for all activities with infectious materials which
pose a threat of aerosol exposure. These include manipulation of
cultures and of those clinical or environmental materials which may be a
source of infectious aerosols; the aerosol challenge of experimental
animals; harvesting of tissues or fluids from infected animals and
embryonated eggs, and necropsy of infected animals.

> \(d\) [Laboratory Facilities]{.underline}

[1]{.underline} The laboratory is separated from areas that are open to
unrestricted traffic flow. Passage through two sets of doors is the
basic requirement for entry into the laboratory from access corridors or
other contiguous areas. Physical separation of the high containment
laboratories from access corridors or other laboratories or activities
may also be provided by a double‑doored clothes change room (showers may
be included), air lock, or other access facility which requires passage
through two sets of doors before entering the laboratory.

[2]{.underline} Windows in the laboratory are closed and sealed.

[3]{.underline} Access doors to the laboratory or containment module are
self-closing.

[4]{.underline} An autoclave for decontaminating laboratory waste is
available, preferably within the laboratory.

[5]{.underline} A ducted exhaust air ventilation system is provided.
This system creates directional airflow that draws air into the
laboratory through the entry areas. The exhaust air is not recirculated
to any other area of the building, is discharged to the outside, and is
dispersed away from occupied areas and air intakes. Hoods must be
checked to verify that the direction of the airflow (into the
laboratory) is proper. The exhaust air from the laboratory room can be
discharged to the outside without being filtered or otherwise treated.

[6]{.underline} The HEPA‑filtered exhaust air from Class I or Class II
biological safety cabinets is discharged directly to the outside or
through the building exhaust system. Exhaust air from Class I or II
biological safety cabinets may be recirculated within the laboratory if
the cabinet is tested and certified at least every twelve months. If the
HEPA‑filtered exhaust air from Class I or II biological safety cabinets
is to be discharged to the outside through the building exhaust air
system, it is connected to this system in a manner (e.g., thimble unit
connection) that avoids any interference with the air balance of the
cabinets or building exhaust system.

\(e\) [Highest levels of biocontainment]{.underline} ‑ cells containing
viruses or bacterial ETIOLOGIC agents (class 2 or higher); oncogenic
viruses of moderate or high risk unknown isolates from malignant tissue.

\(f\) [Lowest levels of biocontainment]{.underline} ‑ Unpassaged primary
peripheral lymphocytes; primary fibroblast explants before first
passage.

-   Cells from herpes or Epstein‑Barr (EB) virus transformed cultures
    are considered to pose a moderate risk.

-   All permanently cultured human lymphocytes should be assumed to
    harbor the EB virus.

-   No investigator should ever handle lymphoid cell lines which are
    self‑derived or derived from a close relative.

F. [SUMMARY OF RECOMMENDED BIOSAFETY LEVELS FOR INFECTIOUS
AGENTS]{.underline}

+---+---------------------+-----------------+------------+------------+
| B | Agents              | Practices and   | Safety     | Facilities |
| S |                     | techniques      | equipment  |            |
| L |                     |                 |            |            |
+---+---------------------+-----------------+------------+------------+
| 1 | Not known to        | Standard        | None       | Open bench |
|   | consistently cause  | microbiological | required.  | top sink   |
|   | disease in healthy  | practices.      |            | required.  |
|   | adults *(e.g., B.   |                 |            |            |
|   | subtilis)*.         |                 |            |            |
+---+---------------------+-----------------+------------+------------+
| 2 | Associated with     | BSL-1 practices | Primary    | BSL-1      |
|   | human disease.      | plus:           | barriers = | plus:      |
|   | Hazard:             |                 | Class I or |            |
|   | percutaneous        | -   Limited     | II         | -          |
|   | injury; ingestion;  |     access.     | Biosafety  |  Autoclave |
|   | mucous membrane     |                 | Cabinet    |            |
|   | exposure *(e.g.,    | -   Biohazard   | (BSC)s or  | available. |
|   | Salmonella* spp*).* |     warning     | other      |            |
|   |                     |     signs.      | physical   |            |
|   |                     |                 | c          |            |
|   |                     | -   "Sharp"     | ontainment |            |
|   |                     |                 | devices    |            |
|   |                     |    precautions. | used for   |            |
|   |                     |                 | all        |            |
|   |                     | -   Biosafety   | man        |            |
|   |                     |     manual      | ipulations |            |
|   |                     |     defining    | of agents  |            |
|   |                     |     any needed  | that cause |            |
|   |                     |     waste       | splashes   |            |
|   |                     |                 | or         |            |
|   |                     | decontamination | aerosols   |            |
|   |                     |     or medical  | of         |            |
|   |                     |                 | infectious |            |
|   |                     |    surveillance | materials; |            |
|   |                     |     policies.   | Personal   |            |
|   |                     |                 | Protective |            |
|   |                     |                 | Equipment  |            |
|   |                     |                 | (PPE)s:    |            |
|   |                     |                 | laboratory |            |
|   |                     |                 | coats;     |            |
|   |                     |                 | gloves;    |            |
|   |                     |                 | face       |            |
|   |                     |                 | protection |            |
|   |                     |                 | as needed. |            |
+---+---------------------+-----------------+------------+------------+
| 3 | Indigenous or       | BSL-2 practices | Primary    | BSL-2      |
|   | exotic agents with  | plus:           | barriers = | plus:      |
|   | potential for       |                 | Class I or |            |
|   | aerosol             | -   Controlled  | II BSCs or | -          |
|   | transmission;       |     access.     | other      |   Physical |
|   | disease may have    |                 | physical   |            |
|   | serious or lethal   | -               | c          | separation |
|   | consequences        | Decontamination | ontainment |     from   |
|   | *(e.g., M.          |     of all      | devices    |     access |
|   | tuberculosis and    |     waste.      | used for   |            |
|   | Francisella).*      |                 | all open   | corridors. |
|   |                     | -               | man        |            |
|   |                     | Decontamination | ipulations | -   Sel    |
|   |                     |     of lab      | of agents; | f-closing, |
|   |                     |     clothing    | PPEs:      |     d      |
|   |                     |     before      | protective | ouble-door |
|   |                     |     laundering. | lab        |            |
|   |                     |                 | clothing;  |    access. |
|   |                     | -   Baseline    | gloves;    |            |
|   |                     |     serum.      | r          | -          |
|   |                     |                 | espiratory |  Exhausted |
|   |                     |                 | protection |     air    |
|   |                     |                 | as needed. |     not    |
|   |                     |                 |            |     rec    |
|   |                     |                 |            | irculated. |
|   |                     |                 |            |            |
|   |                     |                 |            | Negative   |
|   |                     |                 |            | airflow    |
|   |                     |                 |            | into       |
|   |                     |                 |            | l          |
|   |                     |                 |            | aboratory. |
+---+---------------------+-----------------+------------+------------+
| 4 | Dangerous and/or    | BSL-3 practices | Primary    | BSL-3      |
|   | exotic agents which | plus:           | barriers = | plus:      |
|   | pose high risk of   |                 | All        |            |
|   | life-threatening    | -   Clothing    | procedures | -          |
|   | disease;            |     change      | conducted  |   Separate |
|   | aerosol-transmitted |     before      | in Class   |            |
|   | lab infections; or  |     entering.   | III BSCs   |   building |
|   | related agents with |                 | or Class I |     or     |
|   | unknown risk of     | -   Shower on   | or II BSCs |            |
|   | transmission        |     exit.       | in         |   isolated |
|   | (*e.g., Ebola       |                 | c          |     zone.  |
|   | virus*).            | -   All         | ombination |            |
|   |                     |     material    | with       | Dedicated  |
|   |                     |                 | full-body, | supply and |
|   |                     |  decontaminated | air        | exhaust,   |
|   |                     |     on exit     | -supplied, | vacuum,    |
|   |                     |     from        | positiv    | and        |
|   |                     |     facility.   | e-pressure | decon      |
|   |                     |                 | personnel  | tamination |
|   |                     |                 | suit.      | systems.   |
+---+---------------------+-----------------+------------+------------+

As a general rule, laboratories should have in writing procedures for
waste management, accidents, and spills with infectious agents and more
over, should ensure that laboratory workers are familiar with these
guidelines. Potentially infectious waste should be separated immediately
at the time of production and should be disposed of in sturdy bags
marked with biohazard logos. Puncture-resistant, leak-proof containers
should be used when disposing of any kind of sharp object. Furthermore,
tuberculocidal disinfectants should be used for regular decontamination
of work surfaces and equipment, and antibacterial soaps or alcoholic
hand rubs should be used for hand disinfection.

G. [ACCIDENTS AND SPILLS (ADDITIONAL INFORMATION]{.underline})

\(1\) [Immediate actions]{.underline}:

-   Call 911; clear the area at once.

-   Shut down air conditioning and/or ventilation to area if possible.

-   Notify the supervisor and laboratory director.

-   Assess the type of spill and degree of hazard involved.

-   Determine most effective and least hazardous approach to clean up
    and decontamination.

[NOTE]{.underline}: Laboratories handling highly virulent infectious
agents must have specific plans for handling accidents. Procedures for
such circumstances are beyond the scope of this manual. The reader is
referred to other sources such as DHEW publication CDC 75‑8118
\"Laboratory Safety at the Center for Disease Control,\" Centers for
Disease Control, Atlanta, Georgia.

\(2\) [\"Dry\" spills (overturned or broken culture plate) with no
significant aerosol formation]{.underline}.

-   Evacuation of room probably not indicated.

-   Flood area with disinfectant solution.

> Soak up the disinfectant and contaminated material with an absorbent
> material (polysorb spill pillows) and dispose of in a plastic bag or
> sealed container.

-   Wear gloves for spill clean up.

-   Autoclave the contaminated material.

\(3\) [Liquid spills on bench or floor:]{.underline}

-   If significant aerosols were formed the area should be evacuated and
    not reentered for at least an hour.

-   Cover the spills with an absorbent (polysorb spill pillows).

-   Dispose of the absorbent and contaminated material in plastic bags
    or a sealed container and autoclave.

-   The spill area should be thoroughly washed after clean up.

\(4\) [Centrifuge spills]{.underline}:

-   Shut off instrument, evacuate, and shut down ventilation to area.

-   Do not re‑enter for at least one hour until aerosols have settled.

-   The person entering the area to clean up should wear protective
    clothing, gloves, and mask.

-   If liquids are present, soak up in an absorbent material and handle
    as above. If not, clean the instrument and clean the room thoroughly
    before resuming work.

\(5\) [Spills in incubators, autoclaves, or other closed
areas:]{.underline}

-   Soak up liquids with an absorbent material and dispose as outlined
    above if possible.

-   If routine clean-up is not possible, the unit may have to be
    decontaminated by means of a sterilizing gas such as formaldehyde or
    glutarldehyde left overnight.

-   The unit should be thoroughly washed (if possible) after
    decontamination.

-   Some infectious agents may survive and be transported for long
    distances in air currents or by dust. Consequently, it is necessary
    that any spills within the laboratory be promptly and effectively
    decontaminated with an appropriate disinfectant. (e.g., 100% bleach,
    Roccal).

-   Any breakage in bags or leakage of contaminated material should be
    reported to the laboratory supervisor at once.

H. [DISPOSAL OF BIOLOGICAL WASTE]{.underline}

Research laboratories generate waste that may be solid or liquid and
includes such materials as carcasses, tissues, animal bedding and
excrement, plant material, and microorganism cultures. Any of these may
be contaminated with hazardous chemicals, depending on the laboratory
activity. The microorganisms (e.g., bacteria, fungi, and viruses) may be
hazardous pathogens.

\(1\) [Defining the Waste]{.underline}

The first step in managing any waste is to characterize it: identifying
types and sources of the waste; determining its rate of generation; and
describing its physical, chemical, and biological properties are
required. Types of waste:

-   dead animals and animal tissues

-   animal bedding and excrement

-   cell cultures, and body fluids

Chemical contamination usually comes from administering chemicals to
determine their effects on life systems or application of chemicals for
a germicidal or disinfecting purpose. An animal challenged with a
suspected carcinogen might contain only micrograms or milli­grams of the
challenge material.

Heat‑resistant spores, animal carcasses, or some biological toxins
(e.g., aflatoxin) may not be effectively treated through the use of
autoclaving.

Disinfectants that contain active chlorine or iodine are useful for
killing bacteria, bacterial spores, viruses, rickettsiae, and fungi on
large pieces of equipment subject to surface contamination or in
heat‑sensitive materials whose subsequent use or effectiveness might be
compromised if autoclaved.

Before a treatment or disposal the following questions should be
answered:

-   What is the chemical contaminant, and how much was added to the
    biological material?

-   What is the fate of the contaminant within the biological system?

-   How much chemical is metabolized or otherwise altered, and how much
    remains unchanged?

-   Are more hazardous reaction products formed?

-   What are the known toxic properties of the chemical contaminants or
    reaction products?

-   Are the chemicals or reaction products easily volatilized, oxidized,
    or otherwise affected by the input of some form of energy?

-   Does the waste contain radioactive material? Disposal of such waste
    is strictly regulated.

#### 

#### I. **TREATMENT/DISPOSAL TECHNIQUES**

Viable organisms in biological materials must be killed before they
leave the laboratory. This is true even if their destination is an
incinerator, for they may contaminate the ash or be carried off in the
gases if incineration is not rapid and complete. It applies particularly
to certain viruses and spore‑forming organisms.

For animal tissue and excrement containing their normal microbial
population, direct incineration is usually acceptable. If the material
may contain disease‑causing organisms, autoclaving or other treatment
should precede incineration. With proper selection of temperature,
pressure, and time, autoclaving is often highly efficient.

\(1\) [Treatment approaches]{.underline}*:*

\(a\) Heat/pressure, such as autoclaving, wet heat, dry heat.

\(b\) Chemicals (wet/gaseous), such as chlorine, iodine, phenols,
acidified alcohols, ethylene oxide, ozone, formaldehyde, or various
quaternary ammonium salts.

Ultimate disposal, following treatment, is usually to the sewer system
for certain liquids or to a sanitary landfill for solids.

Treatment products can include autoclaved tissue culture fluids, ash and
residue from a pathological waste incinerator, and pipettes that have
been soaked in a chemical disinfectant such as an iodine solution.

J. [BIOLOGICAL WASTE WITH CHEMICAL CONTAMINATION]{.underline}

If the biological waste contains a chemical contaminant, the selection
of a treatment/disposal strategy becomes more complicated. Autoclaving a
cell culture contaminated with a highly volatile carcinogen could lead
to a dangerous release of the carcinogen. In incineration, a common
treatment for dead animals, the volatilization of the chemical
contaminant may be beneficial, particularly if the chemical itself is
oxidized to harmless end products. However, if the contaminant contains
a volatile metal, such as mercury or lead, or is an organic compound
that is difficult to destroy by combustion, such as
tetrachlorodibenzodioxin, incineration may actually serve to disperse a
toxic substance into the air. For chemical decontamination of pathogenic
materials that contain added chemicals, an assessment of the interaction
between the chemical species is helpful in anticipating potentially
harmful end products (e.g., chlorination yielding chloramines) and in
assuring that the amount of disinfecting the chemical is adequate to
destroy the pathogens.

K. [INCINERATION]{.underline}

Incineration is a clean, efficient method of disposing of animal
carcasses, animal organs, animal excrement and the paper or other
bedding on which it is collected, and wood or cardboard containers in
which animals have been shipped. Incineration is more important for
animal material containing hazardous chemicals than for chemical free
animal material. Wet animal waste, such as carcasses and excrement,
should be placed in bags of plastic, such as polyethylene. The bags
should be tied or taped shut. If Glass and metal should be excluded from
bags going to a hearth‑type incinerator because of the possibility of
explosion of closed bottles or cans and increased incinerator
maintenance due to fused glass or excessive ash. Appropriate labels
should be attached, such as \"Animal Carcasses\" and \"Caution\--Cancer
Suspect Agent.\"

L. [WASTE SEGREGATION]{.underline}

-   Regular trash - Uncontaminated paper, soft plastics, etc.

-   Round cardboard barrels - Uncontaminated glass, hard plastics
    (pipettes, tips, anything that could shatter and puncture a bag.

-   Red Biohazard bags - Contaminated paper, soft plastics, gloves, etc.

-   Red Plastic Biohazard Sharp's Buckets - Contaminated glass, sharps,
    hard plastics.

CHAPTER 12 [EQUIPMENT AND UTILITY MANAGEMENT]{.underline}

# A. **UTILITY MANAGEMENT**

Other types of hazards in the laboratory which can cause injury to the
unwary or uninformed laboratory worker include microwave, ultra-sonic
and ultra‑violet wavelengths, lasers, and even cryogenic equipment and
associated materials. While these hazards may not be common to most
laboratories, everyone should be cognizant of the dangers they present.

\(1\) [Centrifuges]{.underline}

\(a\) If a tabletop model is used, make certain it is securely anchored.
Locate the centrifuge where vibration will not cause bottles or
equipment to fall off shelves.

\(b\) Always close the lid when operating the centrifuge. If noise or
vibration begins, the instrument should be turned off immediately
because the rotor is not balanced, the shaft is bent, or the bearings
are worn, presenting considerable hazard when high speeds are reached.
Swinging buckets must be symmetrically arranged and correctly supported,
and maximum rotor speed must not be exceeded.

\(c\) Always take proper precautions when centrifuging radioactive or
infectious materials to avoid filling the air with finely divided
aerosols. Flammables should not be centrifuged without positive exhaust
ventilation.

\(2\) [Cold Rooms]{.underline}

\(a\) Cold rooms are not suitable for flammable liquids. The sparking
devices in the room can set off an explosion. Sodium azide solution,
even with NaOH present, has an appreciable vapor pressure of hydrazoic
acid over its surface. Such solutions must not be stored in
refrigerators with exposed copper parts, since in the presence of azide
and moisture copper is capable of forming copper azides, which are
sensitive explosives. Various other volatile liquids can condense on the
cold coils.

\(b\) Certain acids (HCl, Acetic acid), even when stored in a \"closed\"
container, can transfer to the refrigerating coils, switches, and other
electrical devices and cause eventual corrosive damage.

## (3) Microwave Devices

\(a\) Radiation from microwave devices can cause deep and serious burns
in unprotected tissues. Remember: These devices can also interfere with
apparatus that depends on the transmission of electronic signals (e.g.,
pacemakers, oscilloscopes).

\(b\) To avoid these problems, microwave emitters should be shielded
both electrically and thermally, and operated only as recommended by the
manufacturer.

\(c\) All microwave devices require inspection annually for leakage and
functionality (call Radiation Safety to arrange for inspection).

\(4\) [Ultrasonic Cleaning Devices/Cell Disintegrators]{.underline}

\(a\) One or both of these devices are commonly present in research
laboratories.

\(b\) Improperly tuned devices can cause hearing damage.

\(c\) Even when working properly they may emit an irritating sound that
can disturb mental concentration, which itself poses a safety hazard.

\(d\) These devices should be used in areas where few people are apt to
enter.

\(e\) The devices should be acoustically shielded whenever possible.

\(5\) [Ultra‑Violet Radiation]{.underline}

Radiation is used in chemical synthesis and analysis, medical diagnosis
and treatment, photoelectric scanning, electrostatic processes, as well
as in fluorescent lamps, instrument panel lights, et cetera. Continued
exposure to UV radiation speeds skin aging and can even cause skin
cancer, conjunctivitis, and other conditions. Persons with fair skin
should always avoid prolonged exposure. Barrier creams and lotions give
some protection, but protective clothing, gloves, and face shields
should be used for all exposures.

\(a\) Exposure to excessive amounts of this type of radiation can result
in eye injuries, serious skin burns, and may even incite malignant skin
lesions.

\(b\) In the laboratory, the common sources include leakage from UV
light sources in microscopes, spectrophotometers, column monitors and
from UV (short/long wavelength) mineral lamps used for examining paper
chromatograms or electrophoresis gels, and from \"Sterilamps\" used in
biological safety hoods or sterile rooms.

\(c\) Protect against leakage hazards by sealing light leaks in
equipment.

\(d\) Fluorescent microscopes should be fitted with a plastic shield
that protects the user\'s eyes from stray radiation.

\(e\) Ventilation is not needed to protect the worker\'s eyes or skin
from UV radiation, but to remove toxic gases that may be created by the
interaction of the radiation with air and atmospheric contaminants.

\(6\) [Cryogenic Equipment]{.underline}

\(a\) Extremely cold surfaces and liquid nitrogen will cause the
condensation and local enrichment of oxygen from the atmosphere.
Therefore, keep sources of ignition at a distance.

\(b\) Store open containers of liquid nitrogen or dry ice in
well-ventilated areas. Condensation may critically deplete the
surrounding air of oxygen.

\(c\) Discard liquid nitrogen which has been exposed to the atmosphere
for a prolonged period of time, or which appears to have a blue tint
(oxygen contamination). This is a potential explosion hazard.

\(7\) [Autoclaves]{.underline}

Personnel should not operate autoclaves until the Vivarium Supervisor
has checked them out in the proper operation. Do not open until both
temperature and pressure is back to normal. Do not stand in front of
door when opening. Use heat resistant gloves when putting items into or
removing items from the autoclave. The sides and door may be hot in
addition to the material being autoclaved. NOTE: Beware of steam that
will permeate heat‑resistant gloves. Loosen caps of any containers to
allow equalization of pressures inside containers. This prevents
explosion, boil‑overs, and implosions.

\(8\) [Gas Cylinders:]{.underline}

Compressed gases constitute several hazards. Any gas cylinder with a
broken valve head becomes a missile capable of penetrating walls.
Specific gases may be toxic or flammable. Heating of cylinders may
result in explosion.

> \(a\) Handling:

[1]{.underline} Cylinder contents must be properly identified - do not
rely on color codes for identification, and do not destroy
identification tags or labels. Likewise, cylinders must be protected. Do
not accept any cylinder without valve protective caps. Check that caps
are screwed on fully before attempting to move cylinder. Leave caps in
place until ready to use gas, and after use replace the caps and screw
on tightly.

[2]{.underline} Store empties apart from full cylinders and mark them
appropriately, never completely empty a cylinder (this may lead to
\"suck back\" contamination which can result in an explosive mixture).

[3]{.underline} The valve safety covers must be left on the cylinders
until they are secured to walls, benches, or stable pieces of equipment,
or until nontip bases are attached. Valve safety covers are removed only
when pressure regulators are attached.

> [4]{.underline} Secure all tanks properly.

[5]{.underline} Never drop cylinders or permit them to strike each other
violently.

[6]{.underline} No part of a cylinder should be subjected to a
temperature higher than 125° F.

\(9\) [Pickup and Disposal]{.underline}

\(a\) Large gas cylinders are ordered through the Research Office and
are delivered to the gas cylinder room near the loading dock. All labs
are responsible for picking up their own cylinders. These labs should
plan sufficiently in advance for gas use so that orders for delivery may
be processed in time.

\(b\) Liquid Nitrogen: Well‑ventilated storage and working space should
be provided when using liquid nitrogen. Because serious burns can result
from careless handling of liquid nitrogen, personnel should keep the
following precautions in mind:

\(c\) Wear goggles or face shields, gloves large enough to allow quick
removal, and rubber aprons when pouring liquid nitrogen from one
container to another. The receiving container should be cooled gradually
to prevent thermal shock. The liquid should be poured slowly to avoid
spattering. The receiving vessel should always be vented to the
atmosphere.

\(d\) Only carts, hand trucks, or dollies must transfer cylinders. They
must not be rolled or dragged. The valve safety covers must be in place
and the cylinders secured to the carts during transport.

\(e\) The use of oil, grease or lubricants on valves, regulators, or
fittings is prohibited. An explosion may result.

\(f\) Do not attempt to repair damaged cylinders or use force to free
frozen cylinder valves.

\(10\) [Regulators and Connections]{.underline}

\(a\) Connections and regulators are designed specifically for different
families of gases. Do not interchange. Use only the properly designated
fittings.

\(b\) Threads and surfaces must be cleaned and tightly fitted. Do not
lubricate with grease or oil.

\(c\) Tighten regulators and fittings firmly with the proper sized
wrench. (Do not use adjustable wrenches or pliers. Do not force fittings
that \"stick\". Stand back from the regulator when opening the main
cylinder value. High tank pressure could cause the gauge to fail.

\(d\) Check for leaks at connections. Leaks are usually due to damaged
connections or improper fittings. Do not attempt to force an improper
fit. (It may only damage a previously undamaged connection and compound
the problem.)

> \(e\) Valve handlers must be left attached to the cylinders.

\(f\) The maximum rate of flow should be set by the high pressure gauge
on the cylinder. Fine-tuning of flow should be regulated by the needle
valve or low pressure gauge.

Shut off the main cylinder valve when a tank is not in use.

B. [ELECTRICAL SAFETY]{.underline}

Electricity can \"kill\". Every live electrical outlet, every worn wire
connection, every overloaded circuit, and every piece of equipment that
requires electricity represents a potential hazard to the laboratory
worker. Thus, any circumstance that permits a connection to be made
between you and a live source of electricity will result in a shock that
could have serious, even fatal consequences.

\(1\) [Electrical Safety Precautions]{.underline}

> \(a\) Never use water to extinguish an electrical fire.

\(b\) Be alert for old, frayed wiring, brittle insulation, situations
where wires can be rubbed or pinched and damaged. Submit work orders to
the Research Office to have these repaired

> \(c\) All fitting plugs and receptacles should be repaired
> immediately.

\(d\) All electrical equipment should be fitted with grounded
(three-prong) safety plugs. Two‑prong plugs, and plugs with paper
retainers, should be replaced promptly (submit work orders to the
Research Office).

\(e\) Avoid using extension cords. Use only grounded approved
extensions. Multiple outlet extensions power strips must be grounded and
must have integral circuit breakers.

\(f\) It is not necessary to touch a live wire directly to be shocked.
Even a thin film of water on the floor or on a bench top can complete
the circuit and result in a severe shock.

\(2\) [Electrical Equipment]{.underline}

> \(a\) Insure that all electrical equipment is properly grounded.

\(b\) Unplug equipment before dismantling or performing repair work.
Never work on live equipment. If necessary to do so, enlist the
assistance of a competent electrician.

\(c\) Electrical equipment must be checked out and certified as safe by
MEDVAMC Biomedical Engineering.

\(d\) Do not work with electrical equipment when hands are wet, or that
is near standing water.

\(e\) Motors or other pieces of equipment that have become wet should be
promptly disconnected, and thoroughly dried. Have equipment certified as
safe (see Biomedical Engineering) before reuse.

\(f\) Some types of electrical equipment contain certain components
which transform ordinary live voltages to much higher voltages (e.g.,
electrophoresis power supply). Such equipment can be extremely dangerous
if shock hazards are not properly eliminated. Never tamper with safety
systems built into such equipment. Do not use defective or
malfunctioning equipment.

\(g\) High voltage equipment should be identified with a warning sign.
It should never be left running unattended, and should be disconnected
when not in use.

\(h\) Know and observe equipment limitations. Never exceed manufacturer
operating instructions (or installation).

\(i\) Electric motors that spark or give off the odor of ozone could be
potential explosive hazards. Have them inspected promptly.

APPENDIX A

[BOMB THREAT TELEPHONE REPORT]{.underline}

Complete this questionnaire after receiving a bomb threat.

Date: Time: Call Received: Call Ended:

Exact words of Caller:[\
]{.underline}

Questions to ask:

-   When will it explode?

-   Where is it located? Building Floor Area Room

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-   What kind of bomb is it?

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-   What will make it explode?

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-   When is it going to explode?

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-   How do you detonate it?

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-   What does it look like?

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-   Why kill or injure innocent people?[\
    ]{.underline}

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-   Why was it put there?

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-   What is your name?

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```
-   Address?

Description of Voice:

Male Female Calm Nervous

Young Middle Age Old

Speech: Rough Refined Accent

Speech Impediment (describe)

Unusual phrases

Recognize voice? If so, who do you think it was?

Background Noise:

Music Running Motor (type) Traffic Whistles

Bells Horns Aircraft Tape Recorder

Machinery Other

Did the caller indicate knowledge of the facility?

If so, how?

Remarks:

DELIVER BOMB THREAT REPORT TO MEDVAMC POLICE IMMEDIATELY\
(Building 100, Room 1A-741)

APPENDIX B

###### CASCADE FOR EMERGENCY

The cascade list for emergency calls, which includes office as well as
home telephone numbers, is maintained by the Research Administration
Office and will be updated as often as necessary to keep all critical
data current.

An emergency notification system is used to summon assistance during
administrative and non-duty hours. The Associate Chief of Staff for
Research will notify key staff (or their designated alternates) as
outlined in the current cascade roster. Key staff, in turn, will notify
remaining staff as outlined in the current cascade roster.