Biosafety

Biosafety means protecting people and the environment from exposure to infectious biological materials in the event of incidents and accidents in laboratories. In biosafety, it is therefore important to act proactively, and it is essential that a risk assessment is carried out for each activity that is conducted. Based on the risk assessment, a decision is then made on what measures must be taken to ensure that the work can be carried out in a sufficiently safe manner. Work with biological agents (e.g. bacteria, viruses and cell cultures) is governed by a comprehensive set of regulations designed to prevent harm to people and the environment. There are special regulations for biological agents that are genetically modified: genetically modified microorganisms (GMMs).

Biological agents: biological agents include bacteria, fungi, algae, viruses, prions, parasites and cell cultures.

Microorganism: the Swedish Work Environment Authority defines microorganisms as follows: "A microorganism is any cellular or non-cellular microbiological entity that can reproduce or transfer genetic material. This includes viruses and viroids, as well as animal and plant cell cultures."

GMM: According to the Swedish Work Environment Authority's provision 2023:19, chapter 9, GMM is defined as follows: ‘Genetically modified microorganisms (GMMs) are microorganisms in which the genetic material has been altered by technology in a way that does not occur naturally through mating or natural recombination.’

Note that the term genetically modified organisms (GMOs) includes all organisms that have been genetically altered in a way that does not occur naturally. GMMs are covered by and included in the term GMOs, but not all GMOs are GMMs.

Infectious agents: microorganisms, prions and human internal parasites that can cause infections in humans.

Blood-borne infections: hepatitis B and C, as well as HIV, are the main infections that can be transmitted through handling human blood. Note that blood-borne infections can be transmitted not only through handling blood, but also through materials contaminated with blood, such as tissues, wound fluid, spinal fluid, urine, pipette tips and similar items.

Risk assessment in biosafety

Infectious agents are classified into four risk classes based on their ability to infect humans and cause disease. Risk class 1 covers microorganisms that are not infectious agents. Risk class 2 includes infectious agents that can infect humans but do not cause permanent illness, or where the illness can be effectively cured or prevented. The most dangerous infectious agents belong to risk classes 3 and 4. These are described in more detail later in the text.

Under current legislation, the use of biological agents in risk class 2 must be risk assessed and reported (with a few exceptions) to the Swedish Work Environment Authority, while agents in risk classes 3 and 4 must have a permit from the Swedish Work Environment Authority. The risk assessment forms the basis for the protective measures that the user needs to apply to prevent or counteract damage to health and the environment. The use of biological agents is regulated in the Swedish Work Environment Authority's provision AFS 2023:10 ‘Risks in the working environment’ and under Section VI: Infection, Chapter 11. Infection risks are described in more detail, when and how a risk assessment should be carried out and documented.

All contained use of genetically modified micro-organisms (GMMs) must, under current legislation, be risk assessed and notified (with a few exceptions) to, or have permission from, the Swedish Work Environment Authority. The risk assessment forms the basis for the protective measures that the user needs to apply to prevent or counteract damage to health and the environment.

An effective risk assessment or risk management procedure is important for making work as safe as possible for staff, people in the surrounding area and the environment. In order to assess the risks and determine protective measures, knowledge is required about the infectious agent, which methods and procedures should be used, who should carry out the work, and how these factors interact. The risk assessment should therefore be carried out by the employee together with the immediate manager and sometimes additional expertise, such as a safety representative, biosafety specialist or biosafety committee, needs to be consulted.

Risk assessments must be documented and stored so that they are easily accessible to staff. The risk assessments carried out should then be considered living documents and continuously evaluated so as to correspond to current conditions.

The risk assessment should be carried out as early as at the planning stage for a particular laboratory activity.

Appropriate occasions for risk assessment are when:

• New projects are started
• New biological materials are introduced into the activities
• New work procedures are introduced
• New premises are put into use
• Follow-up of incidents/work-related injuries is done

Biological risks are difficult to quantify and the assessment must instead be qualitative through a subjective process based on the information available. There is no strict manual for how a risk assessment should be carried out, but some microbiology laboratories have prepared forms with a number of guiding questions that are discussed with the personnel concerned. The Swedish Work Environment Authority's provision Infection risks (AFS 2023:10, section VI) describes which elements should be included in the risk assessment.

The risk management may be divided into the following steps:

1. Identify the risks
2. Evaluate the information obtained
3. Take appropriate risk mitigation measures
4. Ensure that the necessary permits are in place

1. Identify the risks

The infectious agent:

• How pathogenic?
• What are the routes of transmission?
• What is the infectious dose?
• Are there any preventive or curative measures?

Chosen methods:

• What volumes and concentrations are handled?
• Aerosol production?
• Processes with pressure?
• Sharp or cutting objects?
• Animal experimentation?

The personnel:

• Are there sufficient skills?
• Is proof of competence required?
• Are there any influencing health factors (pregnancy, weakened immune system etc.)?

2. Evaluation

Go through the information obtained and make an evaluation. Particularly risky work, such as at protection levels 3 and 4 and activities involving animals, requires special supervision and may need to be evaluated by an independent third party consisting of an expert panel, such as a biosafety committee. At this stage, a risk matrix may be useful.

3. Risk mitigation measures

Make a final assessment and determine the appropriate level of protection. Are the risks associated with the biological material and the working procedures applied compatible with the chosen level of protection? Do laboratory staff have adequate protection to avoid exposure to laboratory-transmitted infection, or are additional protective measures needed beyond the selected level of protection?

Risk matrix

The risk matrix is a tool used to determine whether a particular activity is acceptable from a risk perspective. The risk is determined by combining the probability that an unwanted event will occur with how serious the consequences will be if something were to occur. Depending on which box in the matrix the risk falls into, you can see whether it is an acceptable level or whether protective measures must be taken to reduce the risk.

 

 

Protective measures

Based on the risk assessment, the protective measures necessary to ensure that the work can be carried out without causing ill health or accidents are taken.

Protective measures may include organisational measures as well as appropriate design of premises, technical devices and work procedures. One form of protective measure is to select an appropriate level of protection, i.e. the degree of containment required for a particular biological material.

Protection level: laboratories are divided into four protection levels, depending on the protective measures they include. A list of specific protective measures required for the different protection levels can be found in the provision on infectious risks. The different protection levels are adapted for the use of microorganisms with similar risks (see definition of risk class below).

Laboratories working with biological agents are divided into four protection levels, 1-4, where 1 is the lowest protection level and 4 is the highest. Work at each protection level is regulated in accordance with the Swedish Work Environment Authority's AFS 2023:10.

Risk classes

Risk class: biological agents are divided into four classes, where a microorganism with poor conditions for causing serious infection in people and where the consequences of a possible infection are mild is placed in a low risk class. A list of how specific microorganisms are classified can be found in the provision on infection risks. Note that the classification of the microorganism does not relate to how serious the consequences of a possible infection may be in society.

The Swedish Work Environment Authority's provisions AFS 2023:10 and Directive 2000/54/EC of the European Parliament and of the Council contain a list of biological agents belonging to each risk class in Sweden and Europe, respectively. The WHO Laboratory Biosafety Manual defines the four different risk classes, but does not provide a list of infectious agents, as classification may vary from country to country.

When classifying an infectious agent, factors such as the following are assessed:

• Probability of developing an illness after exposure
• Can the illness be prevented or cured?
• How probable is it, and what are the consequences if the infectious agent spreads in the community?

The risk class of infectious agents is linked to, but not directly synonymous with, the choice of protection level. The final choice of protection level is determined after a risk assessment in which a number of other factors are taken into account.

Biological agents are divided into different risk classes depending on their ability to cause illness in people:

• Risk class 1: does not normally cause infection in people but may cause other health problems.
• Risk class 2: may cause infection in people. Possible to prevent, cure or self-heal.
• Risk class 3: may cause serious illness or is highly infectious. Difficult to cure or prevent.
• Risk class 4: risk of very serious consequences upon exposure, e.g. serious illness with little chance of cure, combined with high infectiousness and risk of epidemic spread.

AFS 2023:10, Appendix 7 specifies which infectious agents and associated risk classes have been defined to date. Please note that the list is not exhaustive. It also describes the classification criteria in more detail.

F, L, and R activities: GMM activities are divided into four different protection levels based on the risk posed by the uses involved in the activities and, consequently, the protective measures that must be taken. Usually, the classification of biological agents into three different risk classes (see 2023:13, Chapter 9) can be used when classifying GMM activities:

• F activities (negligible risk), infectious agents of risk class with protection level 1.
• L activities (low risk), infectious agents of risk class with protection level 2.
• R activities (moderate or high risk), infectious agents of risk class with protection level 3 or 4.

4. Laws and legal compliance

For all work where there are microbiological work environment risks, there are requirements for identification and management of the risks. When handling infectious agents, various requirements in Swedish legislation must be met. The rules that the Swedish Work Environment Authority has formulated in the area of biosafety are covered by:

• Infection risks: AFS 2023:10 Section VI
• Contained use of genetically modified microorganisms: AFS 2023:13 Chapter 9
• Working with laboratory animals: AFS 2023:1, 2023:10, 2023:12 2023:15                    

Permits and notifications for handling microorganisms:

Infectious agents in classes 2, 3 and 4 are listed in AFS 2023:10, Appendix 7. The list is not exhaustive. If a microorganism is not included in the list, this does not therefore mean that it automatically belongs to risk class 1.

In order to work with biological agents in risk class 2, a complete notification of the activity must be submitted to the Swedish Work Environment Authority. When submitting a notification, a documented risk assessment must also be attached.

In order to work with biological agents in risk classes 3 and 4, a permit must be obtained from the Swedish Work Environment Authority. Documented risk assessment and selection of protective measures, as well as protective and handling instructions, must be available at the laboratory for relevant personnel and be available for inspection by the Swedish Work Environment Authority.

All GMM activities must be reported to the Swedish Work Environment Authority, and in some cases a permit needs to be obtained.

In a workplace that has received a permit/has a notification to handle infectious microorganisms, the following applies:

• that the handling instructions drawn up in connection with the notification are followed,
• that only those who have been informed about the risks are allowed to work there,
• that the work only takes place in the premises specified,
• that the premises are marked
• that the documentation regarding the notification/permit should be easily accessible, for example in a laboratory folder

The permit application/notification specifies, among other things, which microorganisms are to be used. If you want to handle additional microorganisms in the same laboratory, or otherwise want to supplement/change your handling, an update of the permit/notification is required.

The Swedish Work Environment Authority website contains information about what information they require when notifying/applying for a permit.

When working with any type of potentially infectious material such as blood and human specimen material, infectious microorganisms or genetically modified microorganisms (GMM), you must always consider the risks by risk assessing your work. Based on the risk assessment, there is then an assessment of what personal protective equipment and other protective measures are required to work safely, as well as what procedures should be in place and the level of protection needed in the laboratories where the work is to be carried out.

Work with microorganisms that can cause infection in people and all work with GMMs requires an approved notification or a permit from the Swedish Work Environment Authority.

Work with infectious and/or genetically modified microorganisms is mainly regulated by two provisions from the Swedish Work Environment Authority:

Smittrisker (AFS 2018:4), Infection risks (AFS 2018:4)

Innesluten användning av genetiskt modifierade mikroorganismer (AFS 2011:2 med ändringar i AFS 2018:9), Contained use of genetically modified microorganisms (AFS 2011:2 with amendments in AFS 2018:9)

If you want to learn more about this area, the WHO has published an informative handbook on biosafety in English.

General information about blood handling

Before any work where human blood is handled, all personnel involved must receive a review of the applicable safety regulations from their immediate superior. For students, this briefing is normally given by their supervisor.

All individuals working in the blood handling room must be familiar with both general and local regulations, which are compiled at each respective facility.
Consider all biological samples to be potentially infectious. Protective gloves must be worn when handling biological material.

Areas for sample handling shall be separate from areas for other work, such as paperwork or analysis instruments. Food or drink may generally never be consumed in laboratory premises.

Specific training and instructionsr 

All work with human blood must be carried out in accordance with applicable legislation. For the Swedish Work Environment Authority provisions on microbiological work environment risks – infection, toxin exposure, hypersensitivity", see AFS 2017:7 

The employer must ensure that the person managing the work and all employees who may be exposed to microbiological work environment risks have appropriate training and sufficient knowledge of the biological agents that occur in the activity. New and temporary staff should receive induction training when they start their work. Training and skills should be updated as necessary. The employer must also ensure that employees have received handling and safety instructions on how to perform the work with adequate safety. The employer must ensure that the instructions are understood correctly by everyone concerned and that they are followed. The instructions must also include measures needed to protect others than those to whom the instructions are addressed. Instructions should be repeated as necessary and reviewed in collaboration between employer and employee to adapt to new or changed conditions.

Everyone who works or supervises work with human blood or blood products must be aware of and understand the meaning of applicable general and local regulations. To document that this has happened, each supervisor and user must verify this with their signature. A list of signatures is kept by the person responsible for blood safety within each unit. The person responsible for blood safety must be named under “Contact persons” on Linnaeus University's website for environmental safety.

Protective equipment

The equipment needed to maintain good hygiene should be easily accessible. When working where there is a risk of infection, hand washing facilities and skin disinfectant must be available in the immediate vicinity of the work area. For work that may involve exposure to the eyes, an eye wash station should be readily available.

Work clothes, such as lab coats or smocks, should protect against contact with biological material and should therefore be worn buttoned up.

Protective gloves should be worn when there is a risk of contact with biological material, e.g. when unplugging and decanting blood test tubes. When removing gloves, turn them inside out. NOTE that gloves should always be removed before contact with door handles, telephones, etc.

Safety goggles should be used when there is a risk of splashes.

Disinfection

Spills are wiped up immediately, after which the surface is disinfected with 1% Virkon or equivalent for 10 minutes and then rinsed with water.

Reusable materials (such as Bürker chambers) are disinfected in 1% Virkon (or equivalent) for 10 minutes and then rinsed with water and 70% ethanol. Incubation of blood and blood products takes place in disposable tubes that are discarded after use, see Waste management.

After completing a job, remove the gloves, wash your hands with soap and water and dry with a paper towel.

Alternatively: any blood spills should be wiped up immediately with a 70% alcohol solution. Use disposable gloves if you are dealing with someone else's blood. Blood-contaminated glassware is taken care of and cleaned. All blood should be treated as potentially infectious.

Solutions containing blood can be destroyed using a 70% ethanol solution or Jodopax iodine solution. (Jodopax with an original iodine content of 5% is diluted 1:100.) Blood-contaminated material that has been collected and decontaminated can be autoclaved or disposed of as hazardous waste. (See general waste management procedures).

Small amounts of blood do not need to be decontaminated and can be poured down the sink.

Taking samples

All blood donation is voluntary. Hands must be washed before and after sampling. The use of protective gloves is mandatory.

For teaching in courses that do not specifically teach blood sampling, only capillary samples are taken from the middle finger or ring finger. Blood is then preferably taken from the student who will then perform the relevant laboratory work. Please note the mandatory instruction/review and registration described above.

For training courses with patient sampling, local blood sampling procedures apply.

If larger quantities of blood, plasma or serum are required, these should be purchased from a blood bank or similar source. Note that a permit may be required.

For research and education where blood sampling is included as part of the course, sampling can also be done through venipuncture in Vacutainer tubes if necessary. Note that local procedures and risk assessments apply in such cases.

It is important to consider that there is an increased risk of splashing when taking capillary blood samples compared to venipuncture. However, determining whether there is a risk of blood-borne infection is practically impossible. The risk that samples may be infectious must always be considered. Capillary sampling can involve the risk of splashing and blood spillage, so remember to protect your eyes and mouth.

Handle blood or blood-contaminated fluids according to good hygiene practice. Follow local procedures to protect yourself and those around you against possible infection.

No procedure may be performed that poses a risk of infectious agents coming into contact with mucous membranes in the eyes, mouth or nose.

Pregnant women and infection risks

An employee who has notified the employer that she is pregnant may not be employed in work where she risks being exposed to rubella or toxoplasma, if an assessment of the work has shown such a risk.

Procedures for accidents

If anyone gets blood from another person on their skin, wash thoroughly with soap and water. If there is reason to believe that a blood infection may have been transmitted, contact the healthcare system.

Procedures should be in place for dealing with people who feel unwell or faint during blood sampling.

Waste management

Used needles, lancets and tubes are collected in a separate container for glass, sheet metal or hard plastic sharps. To avoid puncture injuries, this may be filled to a maximum level of 2/3. Pipette tips are collected for autoclaving or left in yellow containers for infectious waste.

Filled jars and emptied blood bags that are/have been in contact with human blood are placed in designated yellow plastic boxes that are labelled: "Infectious waste". For further handling, see each faculty's own procedures for handling infectious waste.
Gloves and dried blood on paper go in regular waste.

Responsibility

The course coordinator has overall responsibility for the laboratory work and sampling that is carried out within the framework of each course. This means assessing the risks involved in laboratory work and sampling and ensuring that students' information on local regulations for blood handling is updated before each laboratory session where human blood is used.

Students, nurses and laboratory supervisors must also confirm with their signature that they are aware of the applicable local regulations for blood handling.

Sampling for research purposes is carried out with ethical approval from an ethics committee. The application and permit must be kept in a folder at the department's office. Studies that are only carried out within the framework of first or second cycle education are not considered research. However, if the work is intended to be published in a scientific context or included in a doctoral dissertation, it is considered research.

The head of department has ultimate responsibility for all handling of human blood and blood products at the department.