New substances: advisory note January 2016
Advice to stakeholders working with micro-organisms within a contained facility under the New Substances Notification Regulations (Organisms)
The purpose of this advisory note is to advise stakeholders on the physical and operational requirements for working with micro-organisms in a contained facility under the New Substances Notification Regulations (Organisms) (the Regulations). This information is relevant to regulatees working with a micro-organism that is a research and development organism not for introduction outside a contained facility (subsection 2(3) of the Regulations), and for those regulatees intending to import into or manufacture micro-organisms within a contained facility under Schedule 2 (subsection 3(4) of the Regulations).
A contained facility is defined under subsection 1(1) of the Regulations as a facility where containment is in accordance with the physical and operational requirements of a level set out in either of two guidelines: 1) the Laboratory Biosafety Guidelines (LBG), 3rd edition, published in 2004 or 2) Appendix K of the Guidelines for Research Involving Recombinant DNA Molecules (NIHFootnote Guidelines) June 1994Footnote.
In 2013, the LBG was replaced with the Canadian Biosafety Standards and Guidelines (CBSG), 1st edition. The CBSG was then replaced in December of 2015 with the Canadian Biosafety Standards (CBS) 2nd edition and the Canadian Biosafety Handbook (CBH) 2nd edition. The CBS sets out the physical containment, operational practice, and performance and verification testing requirements to ensure the safe handling and storing of human and terrestrial animal pathogens and toxins. The CBH is a companion document to the CBS that provides the core information and guidance on how the biosafety requirements outlined in the CBS can be achieved. The CBS and CBH are available at: Canadian Biosafety Standards and Guidelines. The CBS and CBH no longer provide physical and operational requirements in relation to Risk Group 1 micro-organisms.
Guidance on physical and operational requirements for micro-organisms in a contained facility under the Regulations
Until the definition of a contained facility in the Regulations is updated, regulatees are advised to follow the physical and operational requirements listed in either the CBS and CBH, or the NIH Guidelines that are relevant to the risk group for the micro-organism they are working with.
Persons manufacturing or importing Risk Group 1 micro-organisms in a contained facility for the purposes of research and development (subsection 2(3) of the Regulations) or for commercial purposes under a Schedule 2 (subsection 3(4) of the Regulations), should ensure that the contained facility is an enclosed building with walls, floor, and ceiling, or an area within such a building, where the containment is in accordance with the physical and operational requirements for Containment Level 1 as set out originally in the LBG (replicated in Appendix 1 of this note) or the requirements described in Appendix K of the NIH Guidelines. Additionally, it is also recommended to apply the good microbiological practices recommended in the CBS.
Persons submitting a Schedule 2 notification (subsection 3(4) of the Regulations) should indicate which of the guidelines (original LBG, CBS & CBH or NIH) is applicable to their facility, as well as specify how they adhere to them.
Activities Involving the Use of External Fermentors
Regulatees are reminded that the definition of a contained facility under subsection 1(1) of the Regulations is strict in specifying that a contained facility is an enclosed building (indoor facility). Therefore, activities involving the use of fermentors or other vessel located outside of a building are considered to occur outside a contained facility, regardless of measures in place for the monitoring and control of the flow of materials and personnel into and out of the area. As such, micro-organisms imported into or manufactured within an external fermentor would not meet the R&D exemption criteria identified in subsection 2(3) of the Regulations and would not be eligible for a Schedule 2 notification under subsection 3(4) of the Regulations.
However, the use of external fermentors which have walls, floor and ceiling and are connected to a “contained facility” through a closed-loop recirculationsystem and where the micro-organisms are only accessible via sterile sample ports from inside the contained facility would be considered to be part of this contained facility and may be eligible for an R&D exemption under subsection 2(3) of the Regulations, or a Schedule 2 notification under subsection 3(4) of the Regulations.
Although not required, the New Substances (NS) Program recommends that notifiers of micro-organisms request a pre-notification consultation (PNC). A PNC is an option for any person who wishes to consult with the NS Program during the planning or preparation of their New Substances Notification (NSN) package. A PNC is an opportunity to discuss any questions or concerns a notifier may have about the prescribed information, and to determine the acceptability of waiver requests and/or test protocols.
If you have any questions, please contact the Substances Management Information Line:
Telephone: 1-800-567-1999 (toll-free in Canada)
1-819-938-3232 (outside Canada)
You may also visit the New Substances Website
Program Development and Engagement Division
Signed on May 3, 2016
Appendix 1. Operational Practices for the Handling of Risk Group 1 Organisms(as set out in the Laboratory Biosafety Guidelines 3rd Edition, 2004for Containment Level 1)
Purpose: This appendix provides the operational practices for the handling of Risk Group 1 micro-organisms for those regulatees that wish to follow the practices originally set out in the Laboratory Biosafety Guidelines 3rd Edition, 2004 for Containment Level 1. This information is relevant for regulatees working with Risk Group 1 micro-organisms that meet the definition of a research and development micro-organism (subsection 2(3) of the New Substances Notification Regulations (Organisms)), or who are, or want to import into or manufacture within a contained facility under Schedule 2 (subsection 3(4) of the same Regulations). Alternatively, regulatees can meet the requirements outlined in Appendix K of the Guidelines for Research Involving Recombinant DNA Molecules (NIH Guidelines) June 1994.
Operational Practices and Physical Requirements for all regulatees handling Risk Group 1 organisms
- A documented procedural (safety) manual must be available for all staff, and its requirements followed; it must be reviewed and updated regularly.
- Personnel must receive training on the potential hazards associated with the work involved and the necessary precautions to prevent exposure to infectious agents and release of contained material; personnel must show evidence that they understood the training provided; training must be documented and signed by both the employee and supervisor; retraining programs should also be implemented.
- Eating, drinking, smoking, storing of either food, personal belongings, or utensils, applying cosmetics, and inserting or removing contact lenses are not permitted in any laboratory; the wearing of contact lenses is permitted only when other forms of corrective eyewear are not suitable; wearing jewelry is not recommended in the laboratory.
- Oral pipetting of any substance is prohibited in any laboratory.
- Long hair is to be tied back or restrained so that it cannot come into contact with hands, specimens, containers or equipment.
- Access to laboratory and support areas is limited to authorized personnel.
- Doors to laboratories must not be left open (this does not apply to an open area within a laboratory).
- Open wounds, cuts, scratches and grazes should be covered with waterproof dressings.
- Laboratories are to be kept clean and tidy. Storage of materials that are not pertinent to the work and cannot be easily decontaminated (e.g., journals, books, correspondence) should be minimized; paperwork and report writing should be kept separate from such biohazardous materials work areas.
- Protective laboratory clothing, properly fastened, must be worn by all personnel, including visitors, trainees and others entering or working in the laboratory; suitable footwear with closed toes and heels must be worn in all laboratory areas.
- Where there is a known or potential risk of exposure to splashes or flying objects, whether during routine operations or under unusual circumstances (e.g., accidents), eye and face protection must be used. Careful consideration should be given to the identification of procedures requiring eye and face protection, and selection should be appropriate to the hazard.
- Gloves (e.g., latex, vinyl, co-polymer) must be worn for all procedures that might involve direct skin contact with biohazardous material or infected animals; gloves are to be removed when leaving the laboratory and decontaminated with other laboratory wastes before disposal; metal mesh gloves can be worn underneath the glove.
- Protective laboratory clothing must not be worn in non-laboratory areas; laboratory clothing must not be stored in contact with street clothing.
- If a known or suspected exposure occurs, contaminated clothing must be decontaminated before laundering (unless laundering facilities are within the containment laboratory and have been proven to be effective in decontamination).
- The use of needles, syringes and other sharp objects should be strictly limited; needles and syringes should be used only for parenteral injection and aspiration of fluids from laboratory animals and diaphragm bottles; caution should be used when handling needles and syringes to avoid auto-inoculation and the generation of aerosols during use and disposal; where appropriate, procedures should be performed in a BSC; needles should not be bent, sheared, recapped or removed from the syringe; they should be promptly placed in a puncture-resistant sharps container (in accordance with Canadian Standards Association [CSA] standard Z316.6-95(R2000)) before disposal.
- Hands must be washed after gloves have been removed, before leaving the laboratory and at any time after handling materials known or suspected to be contaminated.
- Work surfaces must be cleaned and decontaminated with a suitable disinfectant at the end of the day and after any spill of potentially biohazardous material; work surfaces that have become permeable (i.e., cracked, chipped, loose) to biohazardous material must be replaced or repaired.
- Contaminated materials and equipment leaving the laboratory for servicing or disposal must be appropriately decontaminated and labelled or tagged-out as such.
- Efficacy monitoring of autoclaves used for decontamination with biological indicators must be done regularly (i.e., consider weekly, depending on the frequency of use of the autoclave), and the records of these results and cycle logs (i.e., time, temperature and pressure) must also be kept on file.
- All contaminated materials, solid or liquid, must be decontaminated before disposal or reuse; the material must be contained in such a way as to prevent the release of the contaminated contents during removal; centralized autoclaving facilities are to follow the applicable containment level 2 requirements.
- Disinfectants effective against the agents in use must be available at all times within the areas where the biohazardous material is handled or stored.
- Leak-proof containers are to be used for the transport of infectious materials within facilities (e.g., between laboratories in the same facility).
- Spills, accidents or exposures to infectious materials and losses of containment must be reported immediately to the laboratory supervisor; written records of such incidents must be maintained, and the results of incident investigations should be used for continuing education.
- An effective rodent and insect control program must be maintained.
- Laboratory is separated from public areas by a door.
- Size of door openings to allow passage of all anticipated equipment.
- Surfaces to be scratch, stain, moisture, chemical and heat resistant in accordance with laboratory function (recommended).
- Surfaces to provide impact resistance in accordance with laboratory function (recommended).
- Interior coatings to be gas and chemical resistant in accordance with laboratory function (e.g., will withstand chemical disinfection, fumigation) (recommended).
- Bench tops to have no open seams (recommended).
- Bench tops to contain spills of materials (e.g., with marine edges and drip stops) (recommended).
- Benches, doors, drawers, door handles, etc. to have rounded rims and corners (recommended).
- Backsplashes, if installed tight to wall, to be sealed at wall-bench junction (recommended).
- Reagent shelving to be equipped with lip edges (recommended).
- Drawers to be equipped with catches, i.e., to prevent the drawer from being pulled out of the cabinet (recommended).
- Cabinet doors not to be self-closing (recommended).
- Autoclave or other acceptable means of waste treatment/disposal to be provided (recommended).
- Windows, if they can be opened, to be protected by fly screens.
- Hooks to be provided for laboratory coats at laboratory exit; street and laboratory clothing areas to be separated.
- Handwashing sinks to be located near the point of exit from the laboratory or in anteroom.
Operational Practices and Physical Requirements for Containment Level 1 Large Scale:
(These are in addition to the Operational Practices and Physical Requirements for all regulatees handling Risk Group 1 organisms, listed above)
- Visual inspections of the integrity of the containment systems are important to detect small leaks.
- Spills and accidents that result in exposures to organisms to be immediately reported to the facility director and facility Biological Safety Officer; medical attention and surveillance to be provided as appropriate; written records to be maintained.
- Emergency plans and procedures to be readily available and to include appropriate equipment and training for emergency response to spills or accidental release of organisms (i.e., personal protective equipment, disinfectants); training to be documented.
- Cultures of viable organisms to be contained within a closed system or other primary containment equipment (e.g., BSC) that is designed to reduce the potential for release of aerosols.
- Culture fluids, except as allowed below, are not to be removed from a closed system or other primary containment equipment without prior inactivation of the organisms by a validated procedure. A validated inactivation procedure is one that has been demonstrated to be effective against the organism in use. Culture fluids that contain viable organisms intended as the final product may be removed from the primary containment equipment by way of closed systems for sample analysis, further processing or final fill.
- Sample collection, the addition of materials and the transfer of culture fluids from one closed system to another to be performed in a manner that prevents the release of aerosols or contamination of exposed surfaces.
- Process equipment, closed systems or other primary containment equipment to be provided with treatments (i.e., HEPA or equivalent filters, incineration, or gaseous decontamination through chemical disinfectants) to prevent the release of the viable organisms.
- A closed system or other primary containment equipment that has contained viable organisms is not be opened for maintenance or other purposes without prior inactivation of the organisms by a validated procedure; a validated inactivation procedure is one that has been demonstrated to be effective against the organism in use.
- Facilities to be designed to prevent the release of viable organisms to sanitary sewer (e.g., capping or raising of floor drains).
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