2. Goal Safety: 385,000 percutaneous injuries/yr in hospitals 1990 OSHA estimate: 9,000 bloodborne infections/yr, 200 deaths Laboratory acquired infections - Sulkin and Pike: 3,921 cumulative cases, including brucellosis, typhoid, tularemia, tuberculosis, hepatitis, and venezuelan equine encephalitis Less than 20% associated with known accident Lab environment more hazardous than nature due to culturing, propagation of infectious agents Recent events at U Chicago, Texas A&M Compliance with Safety Regulations: Cal-OSHA BBP Standard, 1992 Education, prevention

3. Lab acquired vaccinia infection, Virginia 2008 Worked in cancer research lab Handled mice infected with vaccinia virus Not vaccinated

4. What are Bloodborne Pathogens? microorganisms ( such as viruses or bacteria) that are carried in blood and can cause disease in people malaria, syphilis, Hepatitis B Virus(HBV), Hepatitis C Virus, Human Immunodeficiency Virus (HIV)

5. Am I at risk? Work with blood or OPIM OPIM - semen, vaginal secretions, saliva in dental procedures, CSF, or other internal body fluids Organs, unfixed human tissue HBV, HCV, HIV tissue cultures Human cell lines

6. Human Cell Lines Cell lines may be infected or become infected/contaminated in subsequent handling/passaging LCMV- Researchers infected working with nude mice (infected tumor cell line) “We recommend that all human cell lines be accorded the same level of biosafety consideration as a line known to carry HIV… Thus, it is best to use caution when handling any human cell line” Universal Precaution

7. Low Risk Materials Urine, feces, vomit, tears, sweat, sputum, nasal secretions Unless visibly contaminated with blood

8. Routes Of Transmission Sexual contact Sharing needles Blood Transfusion (very rarely in countries where blood is screened) Birth: Expose through amniotic fluid, blood during the birthing process, and (less likely) through breast milk Accidental puncture from contaminated needles, glass or other sharps Contact between broken or damaged skin and infected body fluids Contact between mucous membranes and infected body fluids

9. Common procedures where exposure may occur Handling containers of blood, fluid, tissue, or cultures Phlebotomy Pipetting, mixing, or handling blood, fluid, or tissue Cleaning blood/body fluid spills Handling contaminated sharps or other contaminated waste Puncture from improperly disposed needle Injections/inoculations ~89% occupationally acquired HIV

10. Determinants of Disease Transmission Individual receiving the dose Virulence / type of pathogen Size of delivered dose (concentration) Route of exposure Type of bodily fluid Whether post exposure prophylaxis was administered

11. Diseases caused by BBP Hepatitis B Hepatitis C AIDS(HIV)

12. Hepatitis B Inflammation of the liver Risk of HBV infection after a single positive needle stick is 30% Durable virus (7 days outside body) Acute or chronic More than 350 million people are chronic carriers of HBV worldwide (CDC) 800,000–1.4 million persons in the United States have chronic HBV infection Annual number of unreported infections may be 10 times greater than the number of reported (many HBV infections are either asymptomatic or never reported) rate of new HBV infections has declined ~80% since 1991

13. Hepatitis B Symptoms (weeks-~6months) – Fever, Jaundice, fatigue, abdominal pain, loss of appetite, nausea, vomiting, joint pain, dark urine Complications - Cirrhosis (scarring) of the liver, liver cancer, liver failure, and death Prevention - Hepatitis B Vaccine, PEP (Plasma fractionation of Hep B Antibody ), Universal Precautions http://phil.cdc.gov/phil/home.a sp

14. HEP B Vaccine Sometimes employers offer the vaccines to employees FREE OF CHARGE Series of 3 inoculations (shots) and Titer check After vaccination cellular immunity persists (despite low antibody levels)

15. Hepatitis C After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is approximately 1.8% 75-80% chronic 3.2 million persons in the U.S.- chronic HCV infection Vaccine? No PEP? No

16. Hepatitis C Virus Of every 100 persons infected with HCV, approximately 75–85 will go on to develop chronic infection 60–70 will go on to develop chronic liver disease 5–20 will go on to develop cirrhosis over a period of 20– 30 years 1–5 will die from the consequences of chronic infection (liver cancer or cirrhosis) 8,000–10,000 deaths each year in the United States (chronic)

17. Hepatitis C Symptoms - Jaundice, fatigue, abdominal pain, loss of appetite, nausea, dark urine Complications – Chronic liver disease, death Transmission: Occurs when blood or body fluids from an infected person enters the body of a person who is not infected Prevention – Universal precautions

18. HIV Attacks Immune System Infects/Kills T-Helper Cells (CD4) Final Stage of HIV Infection: AIDS – Acquired Immunodeficiency Syndrome Opportunistic infections – Kaposi’s sarcoma, CMV Workers have been infected with HIV after being stuck with needles containing HIV-infected blood or after infected blood gets into a worker’s open cut or a mucous membrane Electron microscope image of HIV, seen as small spheres on the surface of white blood cells. http://www.biologyimagelibrary.com/imagelibrary/ima ges/12646_1_PHIL_1843_lores_BIL260805.JPG

19. HIV Fragile retrovirus Risk of transmission after percutaneous exposure to HIV infected blood is approximately.3% ROT after splash to eye/mouth/nose ~.1% 57 healthcare workers with documented occupationally acquired HIV infection CDC ~56,300 new HIV infections in the US in 2006 http://www.agen.ufl.edu/~chyn/age2062/lect/lect_14/Lect_14.htm

20. Healthcare Personnel with Documented and Possible Occupationally Acquired AIDS/HIV Infection, by Occupation, 1981-2006 OccupationDocumentedPossible Nurse2435 Clinical Laboratory Worker 1617 Nonsurgical Physician 612 Non-Clinical Laboratory Technician 3- Housekeeping or Maintenance 213 Dentist or Dental Worker -6 U.S. Infect Control Hosp Epidemiol 2003;24:8 6-96.

21. What is risk with lentiviral vectors? Potential for generation of replication-competent lentivirus (RCL) Potential for insertional mutagenesis/oncogenesis Host range Mitigated by the nature of the vector system (and its safety features) or exacerbated by the nature of the transgene insert encoded by the vector.

23. Universal Precaution Treat all blood and body fluids as if infectious For labs: Biosafety Level 2 (BSL2) containment Defined by CDC/NIH Combination of laboratory practices and techniques, safety equipment, and laboratory facilities Many BSL2 safety procedures extend to non-lab settings

24. BSL2: Standard Microbiological Practices Access to lab limited during experiments Washing hands after handling viable materials, after removing gloves, and before leaving lab No eating, drinking, smoking, handling contacts, or applying cosmetics Safe handling of sharps, plastic substituted for glass Minimize splash/aerosols Decontaminate work surfaces daily and after spills Proper disposal of contaminated items as biohazardous waste

25. Biohazard Waste Disposal Gauze Plastic serological pipettes Plastic pipette tips Petri dishes Culture vials/plates Counter top covers Contaminated PPE

26. Sharps Contaminated broken glassware Scalpels, blades, capillary tubes Slides & cover slips Glass pipettes Glass capillary tubes Needles and syringes

27. Liquid Waste Decon. tissue and media with 10% bleach solution~ 15 minute contact May then be poured down drain USC does not have a permit to autoclave medical waste!

28. BSL2: Special Practices Only those who have been advised of potential hazards may enter lab Biohazard sign when agent in use, include relevant contact information, info on agent, what to do if exposed, PPE PI ensures all are appropriately trained on potential hazards of work involved, how to prevent exposure, offered appropriate immunizations Training on hazards, exposure prevention, SOP’s Sharps precautions, engineered sharps, handling broken glassware Infectious agents placed in container with cover that prevents leakage during collection, handling, processing, storage, transport, shipping Decontamination of equipment/work surfaces Report exposures to PI, seek treatment

29. Safety engineered sharps 2001 Needlestick Prevention Act

30. Labeling International biohazard symbol Biohazardous waste Door signs Incubators Freezers Refrigerators Shipping boxes

31. Decontamination Work surfaces, tools, and equipment 1:10 bleach solution Lysol or other EPA registered disinfectant 15 minute minimum decontamination time

32. Handling, storage, transport procedures Specimens must be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping (use secondary container), container must be labeled with biohazard symbol

33. BSL2: Safety Equipment Requires the use of a BSC for large volumes or potential aerosol generation Use of centrifuge safety cups/sealed rotors for aerosol containment Face protection for anticipated splashes or sprays when outside BSC Lab coats, leave before leaving lab Gloves whenever potential contact with hazardous agents

34. Biosafety Cabinets

35. Sweeping motions of arms Disinfect surfaces before and after use Front intake UV Bunsen burners alternatives (i.e. sterile loops, touch- plate microburners) Substitute plasticware for glassware or other sharp instruments whenever possible (i.e. pasteur pipettes) Must be professionally decontaminated/recertified before moving Recertify annually

36. BSL2: Lab facilities Lockable doors Sink for handwashing No carpets/rugs Chairs covered in non-porous material BSC away from doors Eyewash station

37. Emergency procedures for spills Inform others in lab and restrict access Leave area and allow aerosols to settle Don personal protective equipment If broken glass present, never handle directly by hand, use forceps to remove and dispose into sharps containers Place paper towels/absorbent over spill Apply disinfectant(10% bleach) directly onto paper towels and allow 15 minute contact time to disinfect Clean spill by wiping around the perimeter and moving inwards Discard materials as biohazardous waste Wash hands with soap and water

38. Emergency procedures for exposures Flush affected area with water for 15 minutes Inform supervisor Know where to get treatment Avoid working alone in lab!

39. Exposure Incident Report incident to supervisor immediately and seek medical treatment! File Supervisor’s report of injury File Sharps Injury Form Report all exposure incidents to IBC

40. Example of Exposure Control Plan http://capsnet.usc.edu/LabSafety/BioSafety/BloodBorne PathogensProgram http://capsnet.usc.edu/LabSafety/BioSafety/BloodBorne PathogensProgram How to elim/minim exposure to human/NHP materials that might contain BBP Outlines PI responsibility: Update ECP, GLS/BBP, Hep B vaccination Methods of Compliance: Safety Equipment Good Work Practices : PPE, hand washing, labeling Medical Surveillance Program: PE eval./follow up