POLICY ON LABORATORY BIOSAFETY AND BIOSECURITY

POLICY AND PROCEDURE ON LABORATORY BIOSAFETY AND BIOSECURITY

BIOSAFETY
Laboratory biosafety describes the containment principles, technologies and practices that are
implemented to prevent the unintentional exposure to pathogens and toxins or their accidental release.

A. PHYSICAL BIOSAFETY
Ventilation
 Windows should be available in the area.
 No smoking in the laboratory and hospital premises.
 Minimize aerosol production.

Electrical
 Only electrical plugs are to be placed into an electrical outlet
 Circuit box, ports, and outlet should be well labeled.
 know the voltage of each electrical equipment
 Keep all cords, wires and appliance away from the water.
 Avoid octopus connection.
 Emergency lights should always be charged and working during circuit breakdown.

Water
 Potable and non-potable water sources in the laboratory should be clearly labeled.
 Quarterly testing of water source is implemented.
 Any leaks of water and source of contamination should be reported to the hospital
management for any immediate action.

Fire
 In the discovery of real smoke or fire – R (escue), A (larm), C (onfine/Control), E
(xtinguish/Evacuate)
 Use the fire extinguisher
 Annual fire drill program.

Sewage
 Drains should contain sufficient liquid to ensure that the trap is sealed to prevent escape
of noxious gases. If a drain is never used, the trap must be filled on a regular schedule or
the drain should be sealed.
 Blood, urine, stool, cerebrospinal fluid and other infectious specimens that are disposed
directly in the sink should be flushed with Lysol immediately.
 Other specimens in huge amount are disposed through Safe Waste.
 The hospital uses Sewage Treatment Plant to treat water waste of the whole building.

Waste Handling
 Contaminated material must be segregated from non-contaminated material by physical
facilities or appropriate containers
  All waste are segregated from non-infectious to infectious
 Small vials, syringes, needles and other reagent bottles are segregated accordingly
 Slides, cover slips, test tubes and other glass wares must treat first with bleaching
solution before they are disposed or washed.
 Syringe needles are disposed in a sharps disposal provided by Safe Waste.
 All containers of infectious samples or wastes are placed in yellow garbage bag.
 Biodegradable waste materials are disposed through the use of green garbage bag then
send to sanitary land field or composting.

Safety Equipment
 Autoclaves and other biosafety equipment should be properly installed and checked to
ensure correct operation
 Equipment should be recertified and recalibrated if it is moved to another location
 Frequent cleaning and disinfection of work area and equipment

Storage areas
 Storage areas for infectious materials, actively used infectious materials, and bio
hazardous waste, should be designed to control access and minimize the possibility of
contamination of personnel or the environment
 It is desirable that all hazardous chemicals be stored below eye level
 Labels and signs bearing a red biohazard warning logo shall be affixed to locations and
containers used to store and transport biomedical and bio hazardous materials.

Maintenance
 Maintenance and physical plant personnel entering a laboratory where work with bio
hazardous material is being done, should either be informed in proper methods for
safely conducting their activities or have proper techniques explained by safety or
laboratory supervisory personnel
 Ensure that the area is decontaminated as needed before any maintenance work or
inspections are carried out

B. CHEMICAL BIOSAFETY

Chemical Reagents
 Careful handling of all chemicals, particularly dangerous chemicals
 Store chemicals properly and correctly labeled
 Making MSDS sheets available to all staff
 Certficate of Product Registration of all chemicals should be presented.
 Correct disposal of time-expired and other chemicals that is no longer required.

Chemical Spills
I. Minor Chemical Spill
A minor chemical spill is considered one that laboratory staffs are capable of
handling safely without assistance and where there is no injury or threat of imminent
injury. Typically, a minor spill would be considered less than 0.5 liter (as a rule of thumb)
of a material that is not highly toxic.
 Basic procedures are as follows:
1. Only qualified persons knowledgeable of the material(s) spilled should perform
the cleanup.
2. Alert all persons nearby spill area.
3. Use eyewash or safety shower if needed to decontaminate.
4. Use spill kit to clean up and segregate clean up materials for hazardous waste
disposal.
5. Use proper personal protective equipment, which at a minimum will include
chemical resistant gloves and safety glasses.
6. Decontaminate spill area with water or soap/water mixture if a non-reactive
chemical.
7. Wash hands thoroughly and seek medical attention if necessary.
8. Save the spill cleanup materials containing hazardous materials for proper
disposal.

II. Major Chemical Spills

All other spills that are highly toxic are considered major spills.
Basic procedures are as follows:
1. Avoid breathing vapors of spilled material
2. If possible and safe to do so, turn off any ignition source or gas emergency
shutoff valve.
3. Remove any contaminated persons from spill area and decontaminate via
eyewash or safety shower. The use of a safety shower is never a mistake do not
be reluctant to use the shower in the event of personal chemical contamination.
4. Evacuate the area and close the door to the lab.
5. Post a sign stating “Hazard – Do Not Enter” on the exterior surface of the door
once all personnel are evacuated, if safe to do so.
6. Seek medical attention.
Chemical Storage
 Physically segregate your chemicals into their respective hazard categories—corrosive,
flammable, reactive, and toxic
 Acids, flammable liquids, oxidizers and highly reactive chemicals should all be separated
and stored properly to avoid an unwanted chemical reaction
 All shelves and containers should be labeled accordingly.
 Proper incident and accident reporting and recording.

Chemical Waste
 Characteristic Hazardous Wastes are defined as wastes that exhibit the following
characteristics: ignitability, corrosivity, reativity, or toxicity.
 Toxic waste must undergo pre-treatment prior to disposal.
 Non chemical hazardous waste can be disposed or directly into the sink or
treated as ordinary domestic waste
 Non Hazardous Chemical Waste
 General Wet Waste – are stored in green garbage bag.
 General Dry Waste – are stored in black garbage bag.

C. BIOCHEMICAL BIOSAFETY

Personal Protective Equipment Policy

 All laboratory personnel are provided by their own Personal Protective Equipment like
laboratory gown, goggles or eye protectors, facemask and gloves. Such PPEs are advised
to be worn at all times in the laboratory.
 Frequent hand washing with the correct hand washing technique is practiced. Using
hand sanitizers and alcohol is encouraged.
 No food or drinks inside the laboratory

Eye and Face Protection

 Protective glasses or goggles should be worn
 No smoking inside the laboratory and hospital premises.
 No application of cosmetics inside the laboratory.
 Eye wash station should be available in case a chemical goes to one’s eye.
 Keep all long hair tied back.

Laboratory Coats, Gloves and Other Protective Clothing

 Laboratory coats preferably ¾ sleeves in length should be worn at all times.
 Laboratory shoes should be worn when performing laboratory work. Open toed shoes,
sandals, flip-flops, clogs, etc. are prohibited.
 Use non-latex gloves, such as nitrile or vinyl. Gloves should be replaced immediately if
they are contaminated or torn.
 Double gloves are recommended when handling extremely hazardous chemicals.
 Report any allergies to latex, nitrile or vinyl gloves to the laboratory manager to address
the concern to the supplies personnel.
 Never engage in practical jokes, horse play and rough house.

Vaccines
 In case of events like spread infectious diseases in hospital areas like Emergency Room,
prophylactic drugs and pre-exposure drugs are given to the laboratory staff exposed to
the infection. Drugs are provided by the hospital in such cases.
 All hospital personnel are provided by vaccines or vitamins from PPK Committee
depending on their program every year.
BIOSECURITY
Laboratory biosecurity describes the protection, control and accountability for valuable
biological materials within laboratories, in order to prevent their unauthorized access, loss, theft,
misuse, diversion or intentional release.

A. PHYSICAL BIOSECURITY

Hospital Premises
 24 hours security personnel are available.
 Security personnel require guests and visitors for their identification cards and giving
them visitor’s pass in return upon entering the premises.
 Fire escape plan is posted on all areas.

Laboratory Premises
 Closed-circuit television (CCTV) is installed on the entry of the laboratory area and
operational 24/7 surveillance..
 Area is situated where it can be easily secured by the security personnel at any time.
 Fire escape plan is posted on all areas.
 Controlled temperature and humidity is maintained.

Extraction Area
 One at a time admittance of patients for extraction is allowed.
 Limited companion is encouraged.
 Taking photos and videos are not permitted.
 Good laboratory practice in handling patients should always be done.
 Precautions for the following cases should be observed:

1. Hepatitis B Virus
 Routinely use of barriers such as gloves and goggles when anticipating contact
with blood and other body fluids.
 Immediately wash hands and other skin surfaces after contact with body fluids
and blood.
 Avoid needle stick injury. Carefully handle and dispose sharps during and after
use.
 Practice one-hand scoop method.
 All laboratory personnel are also encouraged to have their Hepatitis B virus
vaccine and check their antigen level every year.
 Hepatitis B Immune globulin (HBIG) is given together with HepB vaccine for post
exposure prophylaxis.

2. Human Immunodeficiency Virus

 Routinely use of barriers such as gloves and goggles when anticipating contact
with blood and other body fluids.
  Immediately wash hands and other skin surfaces after contact with body fluids
and blood.
 Carefully handle and dispose sharps during and after use.
 Avoid recapping! Use one-hand scoop method.

3. Measles, Chicken pox and shingles

 Always wear personal protective equipment like mask, gloves, goggles and
gown.
 Always practice hand hygiene.

4. Pneumonia and Tuberculosis

 Wear masks preferably N95 on known and diagnosed patients.
 Personal protective equipment should also be used.
 Prophylaxis drugs are available for health care workers that are always exposed
to tuberculosis.
 Always practice hand hygiene.

5. Meningitis
 Prophylaxis drugs are given for health care workers that are exposed to the
disease.

B. PERSONNEL MANAGEMENT

Medical Technologists and Technicians

 All laboratory staffs are encouraged to wear identification cards issued by BMMGHSC as
well as their Professional Regulatory Commission license card.
 Ensure that members of the workforce have appropriate personal and technical
qualifications and skill.
 Documented procedures for the recruitment of personnel should be clearly established
and followed, along with their training proficiencies.

Hospital Personnel
 Only hospital personnel are authorized to enter the premises.

Suppliers
 Only authorized suppliers are allowed to enter the laboratory.
 Engineers and technicians are allowed to work on, calibrate, and clean their designated
equipment only.

Visitors
 Visitors are allowed to stay at the waiting area.
C. SECURING LABORATORY EQUIPMENT

Computer System
 All hospital personnel are given an individual access on the hospital information system
by using their personal username and passwords.

Machines and Equipments

 Some machines have their passwords and only the laboratory personnel allowed to
operate it are disclosed with the username and passwords.

D. INFORMATION SECURITY

Records
 All files and records are stored on their designated sections; the cabinets are labeled to
easily identify the files.
 Only authorized laboratory personnel are allowed to get, check, keep and secure files
and records.
 Duplicate copies of official results are forwarded to Records Sections for in-patients that
are already discharged.

Hospital Information System

 All information of patients as well as their diagnostic results is kept in the back up
storage computer at the Information Technology Room.
 Hospital workforces are given their personal username and password to access their
own account.
 Each personnel can only open their account on their designated department.
 Restrictions are prearranged to some staffs’ account.
 Every employee is encouraged to log-in on their account at the start of their duty, and
also logging out after their duty hours.