overview [generalist | immunology | microbiology and virology | management/administration and training]

Biosafety Measures in the Clinical Laboratory

Peggy Prinz Luebbert, MS, MT(ASCP), CIC, CHSP
From the Department of Risk Management, Alegent Health, Omaha, NE

왘 The Centers for Disease Control and Prevention’s 4 biosafety levels for laboratories handling infectious agents
왘 Basic laboratories, containment laboratories, and maximum containment laboratories
왘 Biologic safety cabinets
Clinical laboratories are special, often unique, work environments that may pose identifiable infectious disease risks to per-
sons in or near them. These infections have been recognized for many years. In a series of published early surveys, Pike and asso-
ciates1-4 reported over 3,000 cases of laboratory-acquired infections, including brucellosis, tuberculosis, typhoid, streptococcal
infections, and hepatitis. These incidents, along with considerable anecdotal information, suggest that most laboratory-acquired
infections occur as a result of error, accident, or carelessness in the handling of a known pathogen; often the mode of transmis-
sion is unknown.
During the 1970s, in an effort to reduce the risks of infection in the laboratory, scientists devised a system for categorizing
etiologic agents into groups based on the mode of transmission, type and seriousness of illness resulting from infection, availabil-
ity of treatment (eg, antimicrobial drugs), and availability of prevention measures (eg, vaccination). The etiologic agent groupings
were the basis for the development of guidelines for appropriate facilities, containment equipment, procedures, and work
practices to be used by laboratorians. These guidelines, now referred to as biosafety levels 1 through 4 [T1], are published and
regularly reviewed by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH).5
Biosafety level guidelines recognize that facility design is important in providing a barrier to protect persons working in the
facility as well as those in the community. An accidental release of certain airborne infectious agents could be catastrophic. To
assist in planning and managing a laboratory, the CDC describes 3 facility designs based on functions in handling infectious
agents.

Basic Laboratory
The first design, known as the basic laboratory, provides general space in which work is done with viable biosafety level 1
agents (eg, Bacillus subtilis, Naegleria gruberi), which are not associated with disease in healthy adults, and biosafety level 2
agents (eg, hepatitis B, salmonellae), which pose minimal potential aerosol hazard to laboratory personnel and the environment.
Basic laboratories include those that use biosafety levels 1 and 2. While work is commonly conducted on the open bench, certain
operations are confined to biologic safety cabinets. Public areas and general offices to which nonlaboratory staff require frequent
access should be separated from spaces that primarily support laboratory functions. Biosafety level 2 used in the basic laboratory
differs from biosafety level 1 in that:
1. Laboratory personnel have specific training in handling pathogenic agents and are directed by competent scientists;
2. Access to the laboratory is limited when work is being conducted;
3. Extreme precautions are taken with contaminated sharp items; and
4. Certain procedures in which infectious aerosols or splashes may be created are conducted in a biologic safety cabinet or
other physical containment equipment.
There is no specification for single-pass directional inward flow of air (a system in which air goes through the laboratory area
once before being filtered) from a biosafety level 2 laboratory. However, because most microbiology laboratories also work with
potentially hazardous chemicals, negative air pressure is usually present as well. There are published recommendations for pre-
venting buildup of chemical vapors in laboratories, including use of chemical fume hoods and/or single-pass air when recircula-
tion would increase the ambient concentration of hazardous materials.

Containment Laboratory
The containment laboratory has special engineering features that make it possible for laboratory personnel to handle
aerosolized hazardous materials (eg, Mycobacterium tuberculosis, Coxiella burnetii, and St Louis encephalitis virus) without en-
dangering themselves. More emphasis is placed on primary and secondary barriers to protect personnel in contiguous areas and
the community from exposure to potentially infectious aerosols and to prevent contamination of the environment. This laboratory
is usually described as a biosafety level 3 facility.
The unique features that distinguish this laboratory from the basic laboratory are the provisions for access control and a spe- 435
cialized ventilation system. The containment laboratory may be an entire building or a single room (eg, for tuberculosis testing) in
a basic laboratory. A containment laboratory is separated from other parts of the building by an anteroom with 2 sets of doors or
by access through a basic laboratory area. Because of the potential for aerosol transmission, air movement is unidirectional into
the laboratory (ie, from clean areas into the containment area), and all exhaust air is directed outside the building without any re-
circulation, or it undergoes high-efficiency particulate air (HEPA) filtration.

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 All procedures involving the manipulation of infectious materials are conducted within biologic safety cabinets or other phys-
ical containment devices. These facilities have solid floors and ceilings and sealed penetrations. They are designed and
maintained to allow appropriate decontamination in the event of a significant spill. All waste from these laboratories must be ren-
dered noninfectious before final disposal.

Maximum Containment Laboratory

The maximum containment laboratory has special engineering and containment features that allow activities associated with
infectious agents (eg, Lassa virus, Ebola virus) that are extremely hazardous to laboratory personnel or that may cause serious
epidemic disease. This laboratory is considered a biosafety level 4 facility. Although the maximum containment laboratory is usu-
ally a separate building, it can be constructed as an isolated area within a building. The laboratory’s distinguishing characteristic
is that is has secondary barriers to prevent hazardous materials from escaping into the environment. Such barriers include sealed
openings into the laboratory, air locks or liquid disinfectant barriers, a clothing-change and shower room contiguous with the lab-
oratory, a double-door autoclave, a biowaste treatment system, a separate ventilation system, and a treatment system to decontam-
inate exhaust air.
Within work areas of the facility, all activities are confined to class III biologic safety cabinets or class II biologic safety cab-
inets used by personnel wearing 1-piece positive-pressure body suits ventilated by a life-support system. Members of the labora-
tory staff have specific and thorough training in handling extremely hazardous infectious agents, and they understand the primary
and secondary containment functions of the standard and special practices, the containment equipment, and the laboratory design
characteristics. They are supervised by competent scientists who are trained and experienced in working with these agents.
All wastes are decontaminated before leaving the maximum containment laboratory, and the exhaust air is passed through
HEPA filters. Except in extraordinary circumstances (eg, suspected hemorrhagic fever), the initial processing of clinical
specimens and identification of isolates can be done safely at a lower level containment. The containment elements are consistent
with the Occupational Safety and Health Administration Bloodborne Pathogen Standard as well as those recommended by the Na-
tional Committee for Clinical Laboratory Standards (M29-A).6,7

Biologic Safety Cabinets

Various laboratory procedures generate aerosols that may spread biohazardous materials in the work area and pose a risk of
infection to personnel. Biologic safety cabinets are used to prevent the escape of aerosols or droplets and to protect the research
product from airborne contamination. These devices are distinct from horizontal or vertical laminar flow hoods, which should
never be used for handling biohazardous, toxic, or sensitizing material. Chemical fume hoods also should not be used for biohaz-
ards as they are solely designed to protect the individual from exposure to chemicals and noxious gases. These chemical fume
hoods are not equipped with HEPA filters. BSCs are designed to protect the individual and the environment from biologic agents
and to protect the specimens and other materials from biologic contamination.
There are 3 general types of BSCs: class I, II, and III [F1] [F2] and [F3].5 There is 1 type of class I BSC. This cabinet is
similar to a chemical fume hood with an inward airflow through the front opening. The exhaust air from the biologic safety cabi-
net is passed through a HEPA filter so that the equipment provides protection for the worker and the public. However, the speci-
mens and other materials are potentially subject to contamination. Class I cabinets are not generally recommended for biohazard
work.
Class II biologic safety cabinets are
designed to protect personnel, the general
public, and the specimen. The
airflow velocity at the face of the work
opening is at least 75 linear feet per minute
(lfpm). Both the supply and the exhaust air
are HEPA filtered. There are 4 types of
class II cabinets (IIA, IIB1, IIB2, and
IIB3). They differ in the amount of recircu-
lation, downflow, and inflow. Usually, all
but IIA are considered satisfactory for bio-
hazard and toxic agents.
Class III cabinets are totally enclosed,
ventilate cabinets of gas-tight construction,
and offer the highest degree of protection 437
from infectious aerosols. They also protect
research materials from biologic contami-
nation. Class III cabinets are most suitable
for work with hazardous agents that require
biosafety level 3 or 4 containment. All op-
erations in the work area of the cabinet are

© laboratorymedicine> august 2001> number 8> volume 32

 performed through attached rubber gloves.
The cabinets are operated under negative
pressure. Supply air is HEPA filtered, and
the cabinet exhaust air is filtered by 2
HEPA filters in series or HEPA filtration
followed by incineration, before discharge
outside of the facility.
Every day, new organisms are discov-
ered that could potentially become patho-
genic to the laboratory staff, patients, and
visitors. It is up to the laboratory specialists
in infection control, safety, and microbiol-
ogy to recognize these potential diseases
and handle the organisms according to the
NIH’s most-recent biosafety guidelines.

1. Sulkin SE, Pike RM. Viral infections contracted in the

laboratory. New Engl J Med. 1949;241:205-213.
2. Sulkin SE, Pike RM. Survey of laboratory-acquired
infections. Am J Public Health. 1951;41:769-781.
3. Pike RM, Sulkin SE, Schulze ML. Continuing
importance of laboratory-acquired infections. Am J Public
Health. 1965;55:190-199.
4. Pike RM. Laboratory-associated infections: summary
and analysis of 3921 cases. Health Lab Sci. 1976;13:105-
114.
5. US Department of Health and Human Services,
Biosafety in Microbiological and Biomedical Laboratories.
4th ed. Washington, DC: US Government Printing Office;
1999. Also available at
www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm. Accessed
June 25, 2001.
6. National Committee for Clinical Laboratory Standards
(NCCLS). Protection of Laboratory Workers from Instrument
Biohazards and Infectious Disease Transmitted by Blood, Body
Fluids, and Tissue; M29-A. Wayne: PA: NCCLS; 1997
7. OSHA. Occupational Exposure to Bloodborne
Pathogens; 29 CFR

InterNetConnect
[F2] Class II Cabinets. The Centers for Disease Control and Preven-
tion: <www.cdc.gov>
The National Committee for Clinical Labora-
tory Standards: <www.nccls.org>

438

The Centers for Disease Control and Prevention biosafety Web page: <www.cdc.gov/od/ohs/biosfty/bmbl4toc.htm>
Suggested Reading

laboratorymedicine> august 2001> number 8> volume 32 ©