By Dr. Mushira Ismail Head of SNRL of T.B. - Egypt

1. By Dr. Mushira Ismail Head of SNRL of T.B. - Egypt Today,the infection control update will include a short OSHA update Statistical information about injuries I.C. monitoring results for the year Today,the infection control update will include a short OSHA update Statistical information about injuries I.C. monitoring results for the year

2. Introduction Mycobacterium Tuberculosis is classified by WHO as a risk group III laboratory Pathogen. Transmission is through aerosols generated during microbiological techniques. Aerosols producing droplet nuclei less than 5 �m in size that may contain viable tubercle bacilli suspend in air for long time and can cause infection when inhaled.

3. Microbiological Activities that generate aerosols : Collecting sputum specimens from coughing patients. Adding decontamination solutions. Working with bacteriological loops. Pippetting. Centrifugation. Pouring into disinfectant.

4. Safety in the tuberculosis laboratory must start at the administrative level to ensure that laboratory staff are: Trained properly in safe laboratory procedures. Informed of especially dangerous techniques and procedures that require special care . Provided with adequate safety equipment and clothing. Prepared for prompt corrective action following a laboratory accident. Educated about their increased risk of acquiring tuberculosis should they be or become HIV positive. Monitored regularly by medical personnel.

5. 5 All activities with MTB are associated with containment levels. Each containment level includes the requirements of the lower levels & adds some specific infrastructure & technical measures.

6. 6 Containment Level & Organization within the L1, L2 and L3 Facilities

7. 7 The work in L3 facilities carries an additional risk because relatively large proportion of the isolates may be multi-drug resistant or even XDR.

8. Infrastructure : space enough for 3 areas : Defined space for handling samples, area for smearing and Staining & area for registration and microscopical examination. Wall & floor should be smooth with few interconnection i-e big tiles. Benches should be appropriately chosen to work with and allowing efficient decontamination. Surfaces are resistant to H2O, acids alkalis , solvent & disinfectant. Good aeration & sufficient natural light. Reliable supply of water, good drainage & sink for washing hands. Restricted access is recommended. Infection Control in Peripheral Laboratory� L1�

9. II. Lab. Technicians : Medical history & records for any complaint or symptoms. X- ray , tuberculin test on job. BCG for �ve tuberculin . training for infection control measures. Written instructions on procedures related to safety are required in the lab. Smoking , eating , drinking , storing food & mouth pippetting are not allowed in the lab. For TB work with sputum , the use of gloves is discouraged (except for preparation of staining solutions). Respirator are rarely of any value in DSM labs. Infection Control in Peripheral Laboratory� L1�

10. III. Sample collection : Patient should be instructed to cover his mouth with hand when coughing . He must bring the sputum sample in open place outside the lab . Containers should be hard, wide mouth , transparent & screw capped. If patient failed to spit the container should be discarded. Request form are contaminated & should be autoclaved before preservation. Infection Control in Peripheral Laboratory� L1�

11. IV. Processing : If bacteriological loop is used for Smearing a bottle with sand & alcohol to clean loop before flaming is required. Smearing should be with direction of the air current. Avoid using fan during smearing. Avoid drying of the smear using flame to avoid aerosols. Infection Control in Peripheral Laboratory� L1�

12. V. Disposal of waste & disinfectant : Validated method for inactivation of biological waste is required. Gloves, sputum containers, wooden sticks, disposable loops, filter paper should be collected in biohazard bag to be incinerated. It is preferable to use disinfectant 5 % phenol or 10 % dettol added on the sputum container before incineration. Alcohol 70% for disinfection of hands after washing with soap and water. Infection Control in Peripheral Laboratory� L1�

13. VI. Equipment & other supplies : Extraction fan in case of insufficient ventilation. U.V lamp used after finishing work for sterilization of surfaces. Sufficient number of tables & chairs .(stool) Sink for hand washing. Cupboard for storing chemicals , records �etc . No need for S.C. Infection Control in Peripheral Laboratory� L1�

14. At least 3 rooms : 1 For sample processing with BSC, centrifuge, incubator & refrigerators. 2 For decontamination & sterilization room with 2 autoclaves , hot air oven , 2 sink for washing autoclavable reused material. 3 For media preparation with water bath , inspissators , refrigerators , incubators & water distiller. N.B. : Store for reagents is required. Infection Control in Intermediate Laboratory� L2�

15. In addition to measures taken in L1: Infrastructure and technical requirements : Windows are closed during activities. Furniture should be designed in such a way to facilitate control programs for insects and rodents. Hand washing sink & hangers for protective clothing are required. Benches should be resistant to water, acids, alcohol, solvents, disinfectants, decontamination agents and easy to clean. Specific measures to adequately ventilate the controlled area to minimize air contamination. Infection Control in Intermediate Laboratory� L2�

16. Safety Equipment : Bio-safety cabinet (BSC) class I is recommended. 2 Autoclaves should be available, 1 for decontamination and 1 for sterilization. Centrifuge with cover for the rotor and each bucket in the controlled area is required. Metallic bins for disposal of materials. Infection Control in Intermediate Laboratory� L2�

17. Working Procedures & Waste Management : Restricted access is required. Mention on the door (Biohazard sign � coordinates of the responsible persons � containment level 2) Protective clothing is required (lab. coat). Validated method for inactivation of biological waste before disposal is required by autoclaving. Validated method for inactivation of contaminated materials before cleaning for re-use is required by autoclaving e.g. culture bottles , pipette. Infection Control in Intermediate Laboratory� L2�

18. In addition to the rooms mentioned in the intermediate lab , Identification & DST room is needed supplied with its own equipment � incubators , BSC , water bath & refrigerators . In addition to safety measures in L1 & L2 the following is needed : Infection Control in NRL Laboratory� L3�

19. Infrastructure and technical requirements : Laboratory is separated from other working areas in the same building. Self closing doors , sealed windows & sealable room allowing decontamination with an appropriate gas (fumigation). Emergency generator should power failure occur is recommended. Negative pressure in the controlled area relative to the pressure outside should be controlled with alarm system. Extract air from the laboratory should be HEPA filtered. Infection Control in NRL Laboratory� L3�

20. Safety Equipment : B.S.C. class 1 or II is required. Autoclave in the lab. or if in adjacent room , validated procedures for safe transportation of infectious material to the autoclave outside the lab. are required. Working Procedures & Waste Management : Restricted access. Mention on the door: Biohazard sign, coordinates of the responsible persons, containment level, description of the biological risk, list of nominated personnel, criteria for access to the controlled area. Lab. Contain its own equipment. Protective clothing specific for this lab. � coat , gloves , � is required Waste management inside the S.C.: 5 liter container with 10% dettol for disinfection of small contaminated liquids , & absorbing paper. Bins for disposable materials . Infection Control in NRL Laboratory� L3�

21. Prepare the martial you need before start. Warm up the cabinet for 5 minutes before starting work. Check the air speed of the cabinet. Decontaminate the surface and the grids with disinfectant followed by sterile distill water. Place a minimum of all supplies needed in the cabinet as too much material in the cabinet will create turbulence disturbing the normal air stream. Never place any material on the grids on either sides of the surface. Make sure to respect a �clean side� and �dirty side�. Correct use of A Class II B.S.C.

22. Move the arms slowly inside but also in and out the cabinet in order to avoid disturbing the air stream. Minimize the use of a Bunsen burner that disturb the air circulation too much. Disinfect your materials after the experiment before taking them out of the cabinet . Decontaminate the surface and the grids. Leave the cabinet on for 5 minutes after the experiment. Close the front of the cabinet and switch on UV lamp ( for 30 min.) . Yearly control is advised. Correct use of A Class II B.S.C.

23. 23 Decontamination and inactivation of Biological Waste Decontamination using disinfectant. Mechanism as follow :

24. 24 Decontamination and inactivation of Biological Waste Disinfectant used in TB lab. 70 % alcohol for hands , skin , physical injuries & for material like rotor of centrifuges exposure time 10 min. Dettol 5 % exposure 10-30 min. Decontamination of liquid 10% of dettol is needed for working surfaces & equipment. Inactivation or Sterilization. To kill bacteria through autoclaving at 121 o c for 20 min. Biological waste Collected in biohazard bags or containers dedicated for transport of infectious waste & transferred to an incinerator on a regular base.

25. 25 Decontamination and inactivation of Biological Waste Fumigation For disinfection of small spaces e.g. Safety Cabinet, incubators: disinfection is with formaldehyde which is afterwards neutralized with ammonia. formaldehyde is carcinogenic & irritant & should not be inhaled

26. 26 Maintenance Procedures By maintenance staff Responsible for cleaning floors , sinks with soap & water. (daily) Collecting house hold waste daily. Windows , outside equipment & cupboards weekly. Thorough cleaning of floors with displacement of loose elements weekly. Maintenance By Lab. staff Decanting & disposal of 5 liters 10% dettol containers after minimum incubation of 48 hr. present inside the SC. General maintenance of the equipment present in the L2/L3-facilities.

27. 27 Maintenance Procedures General maintenance of equipment present in the lab. is the responsibility of lab. Staff. S.C : daily after finishing the work , working area is decontaminated with 10% dettol rinsed with tap water & dried with absorbing paper. Every 6 months working surface is removed and disinfected with alcohol 70% & rinsed with soap. Yearly SC should be controlled by external company. Centrifuge : after each run the inside, holders & adaptors if smudged are disinfected using 10% dettol solution and soap. Every 6 months as above Incubator : (70% alcohol) daily if dirt or fungi contamination. Yearly: cleaning of the total interior including layers are disinfected as above.

28. 28 Maintenance Procedures General maintenance of equipment present in the lab. is the responsibility of lab. Staff.( Cont.) Autoclave: Monthly interior is rinsed using water with a soft detergent and filter is cleaned Yearly : general maintenance by the company Freezers : -80 o c , -20 o c . Monthly : superfluous ice in the area of doors or lid is removed to guarantee optimal closing. Yearly : or if needed , the freezers will be undone from all contents , thawed and cleaned and dust will be removed from the backside. Refrigerators. yearly : or if needed , as above . The contents are verified on expiration date and un-used products are removed . At the same time dust will be removed from the backside.

29. 29 Emergency Procedure Carelessness is the main cause of accidents. Incidents with infected material inside B.S.C. : Use new pair of gloves. Place absorbent paper on site of incident, spray 10% dettol , then remove it by absorbent paper. Repeat another time & deposit everything in autoclave bag. Clean with sterile water & dry. If the liquid has penetrated below the work surface , whole worktop is removed & cleaned under it by applying the previous method.

30. 30 Emergency Procedure Spillage of infected material onto the lab. Coat. : Take off the lab. Coat & put in autoclave bag . Put on a new lab. Coat. Possible exposure to aerosols after an incident outside BSC. : Leave the lab. For half an hour to allow aerosols to settle down. Inform lab. Staff. Put on lab. Coat , mask , gloves & enter the lab. Treat the area of the incident as described for incident inside B.S.C.

31. 31 Emergency Procedure Spillage onto the skin : Rinse the exposed area with hot water. If there is wound , let it bleed. Disinfect the exposed area with alcohol 70%. Press on the wound with absorbent paper. Perforation of gloves & injury of hands during manipulation: Remove gloves inside BSC and rinse with hot water. Disinfect the wound with 70% alcohol. If there is bleeding , press on the wound with absorbent paper. Seek medical advice if needed.

32. 32 Emergency Procedure Splashes in the eyes Rinse the eyes for 15 mins. Keep the eyes open during rinsing. N.B.: After any accident, the incident is reported to the lab. Manager and medical doctor and a written report is done quickly including information about the incident & the victim and the action taken.

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35. 35 Country Example NRL of Egypt

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