Guidelines for Safe Work Practices in Human and …

1 Supplement / Vol. 61 January 6, 2012 Department of Health and Human ServicesCenters for Disease Control and PreventionMorbidity and Mortality Weekly ReportGuidelines for safe work Practices in Human and Animal Medical Diagnostic LaboratoriesRecommendations of a CDC-convened, biosafety Blue Ribbon PanelSupplementThe MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services, Atlanta, GA citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60(Suppl):[inclusive page numbers].Centers for Disease Control and PreventionThomas R. Frieden, MD, MPH, DirectorHarold W. Jaffe, MD, MA, Associate Director for ScienceJames W. Stephens, PhD, Director, Office of Science QualityStephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory ServicesStephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program OfficeMMWR Editorial and Production StaffRonald L.

2 Moolenaar, MD, MPH, Editor, MMWR SeriesChristine G. Casey, MD, Deputy Editor, MMWR SeriesTeresa F. Rutledge, Managing Editor, MMWR SeriesDavid C. Johnson, Lead Technical Writer-EditorLynne McIntyre, Project EditorMartha F. Boyd, Lead Visual Information SpecialistMaureen A. Leahy, Julia C. Martinroe, Stephen R. Spriggs, Terraye M. StarrVisual Information SpecialistsQuang M. Doan, MBA, Phyllis H. KingInformation Technology SpecialistsMMWR Editorial BoardWilliam L. Roper, MD, MPH, Chapel Hill, NC, ChairmanVirginia A. Caine, MD, Indianapolis, INMatthew L. Boulton, MD, MPH, Ann Arbor, MIJonathan E. Fielding, MD, MPH, MBA, Los Angeles, CADavid W. Fleming, MD, Seattle, WAWilliam E. Halperin, MD, DrPH, MPH, Newark, NJKing K. Holmes, MD, PhD, Seattle, WADeborah Holtzman, PhD, Atlanta, GATimothy F. Jones, MD, Nashville, TNDennis G. Maki, MD, Madison, WIPatricia Quinlisk, MD, MPH, Des Moines, IAPatrick L.

3 Remington, MD, MPH, Madison, WIBarbara K. Rimer, DrPH, Chapel Hill, NCJohn V. Rullan, MD, MPH, San Juan, PRWilliam Schaffner, MD, Nashville, TNAnne Schuchat, MD, Atlanta, GADixie E. Snider, MD, MPH, Atlanta, GAJohn W. Ward, MD, Atlanta, GACONTENTS1. Introduction: A Culture of Safety for Diagnostic Laboratories ..22. Biological Risk Assessment and biosafety Guidelines ..73. Fundamental Safety Practices in Diagnostic Laboratories ..134. Tuberculosis Laboratory ..345. Autopsy/Necropsy, Surgical Pathology ..386. Parasitology Laboratory ..477. Mycology Laboratory ..528. Virology Laboratory ..559. Chemistry Laboratory ..6610. Hematology and Phlebotomy Laboratory ..6811. Blood Bank ..7212. Veterinary Diagnostic Laboratory ..7413. Storing, Packaging, and Shipping Infectious Emergency Procedures and Responsibilities ..8715. biosafety Education ..9116. Continuous Quality Improvement ..94 References.

4 95 Appendix ..102 MMWR / January 6, 2012 / Vol. 61 1 SupplementGuidelines for safe work Practices in Human and Animal Medical Diagnostic LaboratoriesRecommendations of a CDC-convened, biosafety Blue Ribbon PanelPrepared byJ. Michael Miller, PhD1 Rex Astles, PhD2 Timothy Baszler, DVM, PhD3 Kimberle Chapin, MD4 Roberta Carey, PhD1 Lynne Garcia, MS5 Larry Gray, PhD6 Davise Larone, PhD7 Michael Pentella, PhD8 Anne Pollock, MT1 Daniel S. Shapiro, MD9 Elizabeth Weirich, MS1 Danny Wiedbrauk, PhD101 National Center for Emerging and Zoonotic Infectious Diseases, CDC2 Laboratory Science, Policy and Practice Program Office, CDC3 College of Veterinary Medicine, Washington State University, Pullman, WA4 Lifespan Academic Medical Centers, Providence, RI5 LSG and Associates, Santa Monica, CA6 TriHealth Laboratories, Cincinnati, OH7 Weill Medical College of Cornell University, New York, NY8 University of Iowa Hygienic Laboratory, Iowa City, IA9 Lahey Clinic, Burlington, MA10 Warde Medical Laboratory, Ann Arbor, MISummaryPrevention of injuries and occupational infections in laboratories has been a concern for many years.

5 CDC and the National Institutes of Health addressed the topic in their publication biosafety in Microbiological and Biomedical Laboratories, now in its 5th edition (BMBL-5). BMBL-5, however, was not designed to address the day-to-day operations of diagnostic laboratories in Human and animal medicine. In 2008, CDC convened a Blue Ribbon Panel of laboratory representatives from a variety of agencies, laboratory organizations, and facilities to review laboratory biosafety in diagnostic laboratories. The members of this panel recom-mended that biosafety Guidelines be developed to address the unique operational needs of the diagnostic laboratory community and that they be science based and made available broadly. These Guidelines promote a culture of safety and include recommendations that supplement BMBL-5 by addressing the unique needs of the diagnostic laboratory. They are not requirements but recommenda-tions that represent current science and sound judgment that can foster a safe working environment for all these Guidelines , quality laboratory science is reinforced by a common-sense approach to biosafety in day-to-day activities.

6 Because many of the same diagnostic techniques are used in Human and animal diagnostic laboratories, the text is presented with this in mind. All functions of the Human and animal diagnostic laboratory microbiology, chemistry, hematol-ogy, and pathology with autopsy and necropsy guidance are addressed. A specific section for veterinary diagnostic laboratories addresses the veterinary issues not shared by other Human laboratory departments. Recommendations for all laboratories include use of Class IIA2 biological safety cabinets that are inspected annually; frequent hand washing; use of appropriate disinfectants, including 1:10 dilutions of household bleach; dependence on risk assessments for many activities; development of written safety protocols that address the risks of chemicals in the laboratory; the need for negative airflow into the laboratory; areas of the laboratory in which use of gloves is optional or is recommended; and the national need for a central site for surveillance and nonpunitive reporting of laboratory incidents/exposures, injuries, and material in this report originated in the National Center for Emerging and Zoonotic Infectious Diseases, Beth P.

7 Bell, MD, MPH, Director. Corresponding preparer: J. Michael Miller, PhD, Microbiology Technical Services, LLC, Dunwoody, GA 30338. Telephone: 678-428-6319; Fax: 770-396-0955; E-mail: 2 MMWR / January 6, 2012 / Vol. 61 Supplement1. Introduction: A Culture of Safety for Diagnostic LaboratoriesThis report offers guidance and recommends biosafety Practices specifically for Human and animal clinical diagnostic laboratories and is intended to supplement the 5th edition of biosafety in Microbiological and Biomedical Laboratories (BMBL-5), developed by CDC and the National Institutes of Health (1). This document was written not to replace existing biosafety Guidelines , but to 1) improve the safety of activities in clinical diagnostic laboratories, 2) encourage laboratory workers to think about safety issues they might not previously have considered or addressed, and 3) encourage laboratorians to create and foster a culture of safety in their laboratories.

8 Should any of the Guidelines provided herein conflict with federal, state, or local laws or regulatory requirements, the laboratorian should defer to the federal, state, or local require-ments. This culture of safety is also supported by the Clinical and Laboratory Standards Institute (2). work in a diagnostic laboratory entails safety considerations beyond the biological component; therefore, these Guidelines also address a few of the more important day-to-day safety issues that affect labo-ratorians in settings where biological safety is a major to the Bureau of Labor Statistics, in 2008, approximately 328,000 medical laboratory technicians and technologists worked in Human diagnostic laboratories in the United States. An estimated 500,000 persons in all professions work in Human and animal diagnostic laboratories. Any of these workers who have chronic medical conditions or receive immunosuppressive therapy would be at increased risk for a laboratory-acquired infection (LAI) after a laboratory exposure.

9 Precise risk for infection after exposure is unknown because determining the source or the mode of transmission often is difficult. No national surveillance system is and exposures have been reported since early in the 20th century, but only in the 1970s were sufficient data available to attempt quantitative assessments of risk. Recent MMWR reports (3 11) have indicated that bacteria account for >40% of infections, with >37 species reported as etiologic agents in LAIs; however, other microbes are often implicated. Hepatitis B has been the most frequent laboratory-acquired viral infection, with a rate of cases per 1000 workers, which is two to four times that of the general population. Any laboratorian who collects or handles tubes of blood is vulnerable (12).Early surveys of LAIs found that laboratory personnel were three to nine times more likely than the general population to become infected with Mycobacterium tuberculosis (13,14).

10 In a 1986 survey of approximately 4000 workers in 54 public health and 165 hospital laboratories in the United States, employee infections occurred in hospital laboratories, and employee infections occurred in public health laboratories (15). In a 1994 1995 survey of 25,000 laboratory workers from 397 clinical laboratories in the United Kingdom, the overall rate of LAI was 18/100,000 employees (16).In a 2005 CDC study of bacterial meningitis in labo-ratorians, Neisseria meningitidis accounted for a substantial number of LAIs. The attack rate of this organism in the general population was 13/100,000 persons. The attack rate in the gen-eral population aged 30 59 years (the estimated age range of the average laboratorian) was per 100,000. The attack rate for microbiologists (aged 30 59 years) was 20/100,000 (17).LAIs have also included fungal and parasitic infections. The most common agents of laboratory-acquired fungal infections are the dimorphic fungi Blastomyces, Histoplasma, and Coccidioides (18,19); most reported infections were caused by inhalation of conidia.