Decontamination of Facilities that Have Held Rinderpest Virus

Decontamination of Facilities that Have Held
Rinderpest Virus-Containing Materials
Date:
May 2016
Supersedes:
RP11.0
Contacts:
FAO Secretariat
Email: Rinderpest-Secretariat@fao.org
OIE Secretariat
Email: Rinderpest@oie.int
Changes to previous version
Section
Annex B
Changed square and cubic feet to square and cubic meters.
All
Formatting document
RP11.1 Decontamination of facilities final May 2016
Page 1
Table of Contents
1. Purpose ....................................................................................................................................
2. Background .............................................................................................................................
3. Training ...................................................................................................................................
4. Preparation of the Material .....................................................................................................
5. Witnessing and Confirmation of Decontamination ................................................................
6. Decontamination .....................................................................................................................
6.1 non-RPV materials that have been co-located with RPV-containing material in a fridge
3
3
4
4
5
6
6
6.2 non-RPV materials that have been co-located with RPV-containing material
in an electric freezer ................................................................................................................ 6
6.3 non-RPV materials that have been co-located with RPV-containing material in a liquid
nitrogen freezer or dewar/tank ........................................................................................... 7
6.4 Refrigerators that have been used to store RPV-containing material................................. 7
6.5 Electric Freezers that have been used to store RPV-containing material........................... 7
6.6 Liquid nitrogen freezers/dewars that have been used to store RPV-containing material... 8
6.7 Microbiological safety cabinets (MSCs) that have been used to handle RPV-containing
material ............................................................................................................................. 8
6.8 Rooms and laboratories where RPV-containing material has been stored or used .........
9
7. Annexes for Fumigation Procedures………………………………………………………..
Decontamination of Class II Biosafety Cabinets by Paraformaldehyde Fumigation ……..
Decontamination of Rooms by Paraformaldehyde Fumigation …………………………..
Decontamination of Rooms by Hydrogen Peroxide ………………………………………
10
10
16
23
RP11.1 Decontamination of facilities final May 2016
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1. Purpose
The purpose of this document is to define how facilities must be decontaminated after the
destruction or removal of all rinderpest virus (RPV)-containing material (RPV or material likely
or suspected to contain RPV), as defined in Chapter 8.13 of the OIE Terrestrial Animal Health
Code1, in the facility. The SOP does not cover decontamination of water used for handwashing,
clothes-washing or showering after handling RPV-containing material.
2. Background
RPV is a negative-sense RNA genome virus of the morbillivirus genus. It is the causative agent
of rinderpest, a fatal disease of cattle capable of devastating epidemic spread. The incubation
period ranges from 8 – 11 days and the disease is characterized by pyrexia, nasal and ocular
discharges and necrosis and erosion of the nasal and oral mucosae. Animals develop diarrhoea,
and death generally occurs between 7 and 12 days after onset of signs. RPV has poor
environmental stability and is sensitive to inactivation by heat, desiccation and exposure to
sunlight. The last known case of rinderpest was diagnosed in Kenya in 2001, since which time
the world has been free of the disease. Interruption of the chain of transmission and spread of
infection was achieved by a global eradication campaign organized by the Food and Agriculture
Organization of the United Nations (FAO). FAO and the World Organization for Animal Health
(OIE) have formally accredited global freedom from this disease. The vaccine used against
rinderpest is an attenuated strain of RPV, and the possibility of reversion to virulence means that
despite its widespread use, the vaccine strain must be handled under the same constraints as
virulent strains in the post-eradication era.
The cost and effort of eradication, and the global emergency and severe consequences that are
likely to accompany a re-introduction or release dictate that the containment procedures for
handling RPV-containing material must be enhanced in the post-eradication era, and that the
number of facilities holding RPV should be reduced. RPV must now be handled at Biosafety
Level 3 (BSL 3) Laboratory
Vaccine stocks must be maintained until all RPV material has been destroyed or gathered into
internationally regulated repositories. However, the possibility of cross-contamination of vaccine
stocks or seed-stocks with virulent virus dictate that vaccine and non-vaccine strains should be
stored and handled separately.
“RPV-containing material” means field and laboratory strains of RPV; vaccine strains of RPV including valid
and expired vaccine stocks; tissues, sera and other clinical material from infected or suspect animals; and
diagnostic material containing or encoding live virus. Recombinant morbilliviruses (segmented or nonsegmented) containing unique rinderpest virus nucleic acid or amino acid sequences are considered to be
rinderpest virus. Full length genomic material including virus RNA and cDNA copies of virus RNA is
considered to be RPV-containing material. Sub-genomic fragments of morbillivirus nucleic acid that are not
capable of being incorporated in a replicating morbillivirus or morbillivirus-like virus are not considered as
RPV-containing material
1
RP11.1 Decontamination of facilities final May 2016
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RPV is non-infectious for humans and poses no direct hazard to human health. Containment and
handling regulations are to prevent the accidental transport and introduction of the virus to
susceptible animals.
3. Training
Training is the responsibility of the Director of the institute/organization where the RPVcontaining materials are held and in accordance with the type of holding facility (i.e. training of
vaccine production staff will be different from those doing research on the virus). The training
proficiency should be in accordance with FAO/OIE approved guidelines. Persons directly
involved in the destruction of RPV must be appropriately trained in the handling of dangerous
infectious agents and according to the FAO/OIE approved guidelines.
4. Preparation of the Material
RPV-containing material should be destroyed or shipped in accordance with the SOPs for
destruction and shipment. After destruction and/or shipment, when there is no more RPVcontaining material stored or retained in the facility, the facility should be decontaminated for
RPV. Refrigerators and freezers that have been used solely for storing RPV-containing material
will be empty after removal of all RPV-containing material, and should remain empty until
decontamination is complete.
Wherever possible refrigerators and freezers used for RPV-containing material should not be
simultaneously used to store non-RPV samples. Where refrigerators and freezers used to store
RPV-containing material are simultaneously used to store other, non-RPV material an inventory
of the co-located non-RPV material should be made. Non-RPV material that is not unique and/or
is replaceable or of low value should be destroyed by autoclaving. Examples of such material are
commercial reagents or diagnostic kits, archived experimental samples, cell lines or virus isolates
that can be replaced from other sources. Examples of unique or high value material are non-RPV
virus (e.g. foot-and-mouth disease, peste-des-petit ruminants) or bacterial isolates that are not
held in other locations in the same or another institution. If the laboratory head or other
institutional authority deems that such materials should not be destroyed, the vessels (e.g. vial,
ampoule or tube) in which they are held must be surface decontaminated as described below, and
then removed to storage that has not been used for RPV or which has been decontaminated since
last being used to store RPV.
The interior of refrigerators and freezers must be surface decontaminated with a disinfectant. The
outer surfaces of vessels holding non-RPV material, but which have been co-located with RPV-
RP11.1 Decontamination of facilities final May 2016
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containing material must also be surface decontaminated with a disinfectant. Suitable
disinfectants for surface decontamination are2:
•
5% Virkon™ solution. Virkon™ solution must be made fresh on the day of use.
•
10% Chloros solution. Chloros has a manufacturer’s shelf life and should only be used if
it is “within date” as specified on the container. 10% Chloros must be made fresh on the
day of use. Note: Chloros can corrode some types of metal surface.
•
2% Sodium Hydroxide.
•
Some disinfectants may be chemically incompatible with each other. Wherever possible,
one disinfectant should be chosen and used for all the purposes described.
5. Witnessing and Confirmation of Decontamination
Decontamination is important in ensuring that a former RPV holding facility is clear of the virus,
and the laboratory head and the Chief Executive/overall head of the site or organization must be
satisfied that decontamination has been satisfactorily carried out. To this end, the laboratory head,
biosafety officer and the Chief Executive/overall head of the site or organization (or his/her
nominated representative) must directly supervise the decontamination process.
The laboratory head, and the Chief Executive/overall head of the site or organization (or his/her
nominated representative) must confirm to the veterinary authorities and the FAO3 and OIE4 that
decontamination has been completed. This confirmation should include:
•
•
•
•
The address of the facility
The building(s) and room(s) where RPV-containing material was stored/used and how
they have been decontaminated
The number of refrigerators and freezers used solely to store RPV-containing material
and how they have been decontaminated
The number of refrigerators and freezers where non-RPV material was co-located with
RPV-containing material and how they have been decontaminated
2
Manual on procedures for disease eradication by stamping out (FAO).
(http://www.fao.org/docrep/004/y0660e/y0660e03.htm)
3
The Chief Veterinary Officer,
FAO HEADQUARTERS
Viale delle Terme di Caracalla
00153 Rome, Italy
Telephone: (+39) 06 57051
Fax: (+39) 06 570 53152
Email: Rinderpest-Secretariat @fao.org
4
The Director General
OIE World Organisation for Animal Health 12, rue de Prony 75017 Paris, France
Email: oie@oie.int
RP11.1 Decontamination of facilities final May 2016
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The fate of non-RPV materials that have previously been co-located with RPVcontaining
material
• The number, identity and a general description of retained non-RPV materials that have
been co-located with RPV-containing material and how they have been decontaminated
• Completion date of decontamination
• Signatures of the laboratory head, the biosafety officer, and the Chief Executive/overall
head of the site or organization
6. Decontamination
6.1 non-RPV materials that have been co-located with RPV-containing material in
a fridge
Where a racking or storage system has been used in which non-RPV materials have been stored
in closed or lidded boxes and RPV-containing material has never be been co-located in the same
box, the box must be surface decontaminated by wiping with a cloth impregnated with
disinfectant. The box may then be transferred to a fridge that has never held RPV-containing
material or which has been decontaminated since removal of RPV-containing material.
Where non-RPV materials have not been stored in a closed or lidded box which has not held RPV
material; or where RPV has been stored in the same box, the individual non-RPV vessels must
be surface decontaminated by wiping with a cloth impregnated with disinfectant. The vessels
may then be transferred to a fridge that has never held RPV-containing material or which has
been decontaminated since removal of RPV-containing material.
6.2 Non-RPV materials that have been co-located with RPV-containing material in
an electric freezer
Where a racking or storage system has been used in which non-RPV materials have been stored
in closed or lidded boxes and RPV-containing material has never be been co-located in the same
box, the box should be removed from the freezer and placed on a cloth impregnated with
disinfectant. If there is no accumulation of ice of the box it must be surface decontaminated by
wiping with a cloth impregnated with disinfectant. If there is an accumulation of ice on the box,
it should be opened and the contents transferred to a replacement clean box, which may then be
transferred to a freezer that has never held RPV-containing material or which has been
decontaminated since removal of RPV containing material
Where non-RPV materials have not been stored in a closed or lidded box which has not held
RPV-containing material, or where RPV-containing material has been stored in the same box;
the box or individual vessels should be removed from the freezer and placed on a cloth
impregnated with disinfectant. The individual non-RPV vessels, whether stored in a box or not,
must be surface decontaminated by wiping with a cloth impregnated with disinfectant. The
RP11.1 Decontamination of facilities final May 2016
Page 6
vessels may then be transferred to a freezer that has never held RPV-containing material or which
has been decontaminated since removal of RPV-containing material.
6.3 Non-RPV materials that have been co-located with RPV-containing material in
a liquid nitrogen freezer or dewar/tank
Viruses have previously been shown to transfer between vessels co-located in the liquid phase of
a liquid nitrogen freezer. Consequently, non-RPV materials co-located with RPV materials in the
liquid phase of a liquid nitrogen freezer or dewar should be destroyed by autoclaving.
6.4 Refrigerators that have been used to store RPV-containing material
Refrigerators that have been used to store RPV-containing material should be emptied of all nonRPV material as described above. When empty, the refrigerator should be turned off and allowed
to equilibrate to room temperature. The shelves should be removed and must be surface
decontaminated by wiping with a cloth impregnated with disinfectant. The inside surfaces of the
refrigerator must be decontaminated by wiping with a cloth impregnated with disinfectant. The
door handles and the outside surfaces of the refrigerator, excluding the rear face where the
compressor and radiator are found, should be wiped with a damp cloth impregnated with a
commercial soap or cleaning fluid.
6.5 Electric Freezers that have been used to store RPV-containing material
Electric freezers that have been used to store RPV-containing material should be emptied of all
non-RPV material as described above. When empty, the freezer should be turned off and allowed
to equilibrate to room temperature. For upright freezers care should be taken to prevent possible
contamination of the room as the freezer defrosts. This may be achieved by applying liberal
quantities of a powder-based disinfectant such as Virkon to the inside of the floor of the freezer,
and to the floor of the room around the door area of the freezer. If Virkon is used, it should in
this instance be applied as a powder. Ice that is removed from the freezer should be placed in a
bucket containing enough Virkon powder to make a 5% solution when the bucket is filled. Any
melt water should be transferred to the bucket either from a collecting tray, a cloth or a mop as
appropriate. Although the bucket will have sufficient Virkon powder for the volume it will
eventually hold, there must still be Virkon powder in the collecting tray and anywhere melt water
is likely to flow to prevent any possible contamination beyond the freezer. Shelves must be
removed from the freezer after equilibrating to room temperature and decontaminated by wiping
with a cloth impregnated with disinfectant. When the freezer has equilibrated to room
temperature the inside surfaces must be decontaminated by wiping with a cloth impregnated with
disinfectant. The door handles and the outside surfaces of the freezer, excluding the rear face
where the compressor and radiator are found, should be wiped with a damp cloth impregnated
with a commercial soap or cleaning fluid.
RP11.1 Decontamination of facilities final May 2016
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For chest freezers, the empty freezer should be turned off and allowed to equilibrate to room
temperature. The volume of any melt water should be estimated, and an appropriate amount of
concentrated disinfectant or disinfectant powder added to give a concentration as described in
section 4. After 30 minutes the melt water may then be removed and disposed of.
Baskets/shelves must be removed and decontaminated by wiping with a cloth impregnated with
disinfectant. The inside surfaces must be decontaminated by wiping with a cloth impregnated
with disinfectant. The door handles and the outside surfaces of the freezer should be wiped with
a damp cloth impregnated with a commercial soap or cleaning fluid.
6.6 Liquid nitrogen freezers/dewars that have been used to store RPV-containing
material
The empty freezer or dewar should be disconnected from the automatic fill system if there is one.
If there is no automatic fill system, the person responsible for the freezer of dewar should ensure
that it is not refilled. The freezer/dewar should be left until all the liquid nitrogen has evaporated
and the freezer has equilibrated to room temperature. If a racking system is employed the empty
racks must be removed and decontaminated by wiping with a cloth impregnated with disinfectant.
The inside surfaces must be decontaminated by wiping with a cloth impregnated with disinfectant
if that is possible; for very large dewars this might be done with a mop. For smaller, narrownecked dewars where it is not possible to wipe inside with a cloth, liquid disinfectant should be
poured into the dewar and the dewar then physically agitated and swirled before upending the
dewar to decant the disinfectant. Excess disinfectant may subsequently be removed by rinsing
with water. The outside surfaces of the freezer or dewar should be wiped with a damp cloth
impregnated with a commercial soap or cleaning fluid. The freezer/dewar should be completely
dry inside before refilling with liquid nitrogen.
6.7 Microbiological safety cabinets (MSCs) that have been used to handle RPVcontaining material
Where RPV-containing material has previously been handled in an MSC the MSC should be
decontaminated by Formaldehyde fumigation or Hydrogen Peroxide fumigation. If the user is
familiar with the chosen fumigation procedure then the appropriate procedure should be
followed, and validated by inactivation of spore strips. If the user is not familiar with the chosen
fumigation procedure, they should seek advice from the FAO and/or OIE before proceeding.
Fumigation is a hazardous procedure, which requires appropriate safety protocols to prevent
exposure of staff to the dangerous fumes. Effectiveness of fumigation is affected by the design
of the microbiological safety cabinet, the venting system, and the procedure must be appropriate
for the particular microbiological safety cabinet in use. An example of fumigation procedures is
given in annex A.
Fumigation procedures involve hazardous chemicals that can be easily inhaled. Application and
removal of the fumigation kit should be performed by persons qualified in the safe handling of
such laboratory chemicals and equipment, and equipped with appropriate protective devices and
RP11.1 Decontamination of facilities final May 2016
Page 8
with appropriate measures to prevent accidental exposure to fumes of themselves and other
personnel working in the vicinity.
6.8 Rooms and laboratories where RPV-containing material has been stored or
used
The most effective way to decontaminate a room or laboratory is to fumigate the room with
Formaldehyde or Hydrogen Peroxide. If the user is familiar with the chosen fumigation procedure
then the appropriate procedure should be followed, and validated by inactivation of spore strips.
If the user is not familiar with the chosen fumigation procedure, they should seek advice from
the FAO and/or OIE before proceeding. It should be noted that the quantities of Formaldehyde
or Hydrogen Peroxide vapour produced during room fumigation are extremely hazardous, and
unless the room was designed to be sealable for fumigation, then sealing it appropriately will be
difficult or impossible. It is not recommended to fumigate rooms unless they are already routinely
fumigated and the facility manager is well versed in the process. Examples of fumigation with
Formaldehyde and Hydrogen Peroxide procedures are given in annexes B and C, respectively.
To decontaminate a room where RPV-containing material has historically been used or stored
but where RPV-containing material has not been used since the accreditation of global freedom,
it is sufficient that the room should be thoroughly cleaned. Floors, work-surfaces, chairs etc.
should be cleaned with soap and water or a suitable commercial cleaning fluid. The outer surfaces
of equipment should be cleaned with a damp cloth impregnated with soap or a commercial
cleaning fluid if this is compatible with the equipment. Equipment may alternatively be wiped
down with a disinfectant or 70% ethanol; or where laboratories possess decontamination
chambers, equipment may be placed in such a chamber and decontaminated with Formaldehyde
gas or Hydrogen Peroxide vapour as appropriate.
RP11.1 Decontamination of facilities final May 2016
Page 9
7. Annexes for Fumigation Procedures
Annex A
Decontamination of Class II Biosafety Cabinets5
1.
Purpose
1.1. This procedure is to provide uniform guidance for implementing the decontamination of
Class II Biological Safety Cabinets and their HEPA filtration systems. The procedure
contains specific information, requirements and procedures for Safety Technicians to
use to accomplish decontamination.
2. Prerequisites
2.1. In conducting decontamination procedures the goal is to provide the safest working
conditions possible and wear appropriate personnel protection. Only properly trained
personnel should perform the procedures.
2.2. Materials needed for decontamination:
2.2.1. Two (2) frying pans
2.2.2. Two (2) extension cords
2.2.3. Paraformaldehyde – 20 grams per cubic meter x total cubic meter of the unit. (The
cubic meter is determined by length x width x height in meter)
2.2.4. Ammonium Carbonate – 1.2 grams x total amount of Paraformaldehyde used
2.2.5. Biological indicator spore strips – two (2) test + one (1) control for each two
biological indicator strips used
2.2.6. Petri dishes – one needed for each biological indicator strip gassed
2.2.7. Hygrometer/Thermometer
2.2.8. Two (2) “Danger Formaldehyde in the Area” warning signs
2.2.9. Personal Protective Equipment – Full Face Negative Pressure Respirator with
new Formaldehyde cartridges and Neoprene gloves
2.2.10. Plastic film and duct tape
2.2.11. Plastic bag or containers
2.2.12. Appropriate Formaldehyde dosimetry
2.2.13. Appropriate air monitoring equipment
2.2.14. Formaldehyde and Ammonia detector tubes
2.3. Personal Protective Equipment (PPE)
2.3.1. Safety Shoes
2.3.2. Chemical resistant (neoprene) gloves
2.3.3. Full face Negative Pressure Respirator with new Formaldehyde cartridges
3.
5
Definitions
3.1. BSSMs – Bio-Systems Safety Mechanics
3.2. Class II Biological Safety Cabinet – enclosed, ventilated workspace for safely working
with materials contaminated (or potentially contaminated) with pathogens
Source, Plum Island Animal Disease Center, NY, USA
RP11.1 Decontamination of facilities final May 2016
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3.3. HEPA Filter – High efficiency particulate air filter, having a nominal efficiency of
99.97% for removal of 0.3m (microns) sized particles from air
3.4. Paraformaldehyde – the chemical used in the fumigation process, when heated produces
Formaldehyde gas
3.5. Ammonium Carbonate – the chemical used to neutralize Formaldehyde gas, when
heated produces ammonia gas
3.6. Biological Indicator – spore strips used to determine a successful decontamination. (i.e.
Bacillus subtillus globgii, AMSCO – 764271-00)
4. Responsibilities
4.1. Only properly trained Bio-Safety Systems Mechanics should conduct these procedures.
These procedures are to be followed by all Safety Technicians. Proposed changes in
these procedures need approval by a qualified safety officer or manager.
5.
Process
5.1. Shutdown Procedures
5.1.1. Notify appropriate personnel, person in charge of or responsible for affected area
of the need to shutdown, decontaminate, and replace filters of the Class II
Biological Safety Cabinet.
5.1.2. Prepare a work request or procedure to schedule the procedure.
5.1.3. Coordinate an appropriate time for the procedure with appropriate parties
scientists, security, and operation and maintenance personnel.
5.2. Decontamination Procedure
5.2.1. Place warning sign at all entrances to the area (secure additional signs if needed).
FORMALDEHYDE HAS BEEN DETERMINED TO BE A SUSPECT CARCINOGEN.
THEREFORE, NONESSENTIAL PERSONNEL MUST VACATE NEARBY AREAS
AND ALL BSSM’s PERFORMING THE GASSING ARE REQUIRED TO WEAR A
FULL FACE RESPIRATOR WITH THE APPROPRIATE CARTRIDGES!
5.2.2.
5.2.3.
5.2.4.
5.2.5.
5.2.6.
5.2.7.
5.2.8.
Complete the Paraformaldehyde Gas Set-up Checklist.
Log Formaldehyde amount into Paraformaldehyde Usage Report.
Ensure that the Bio-Safety cabinet is isolated using dampers and/or 6 mil plastic
film secured with duct tape.
Install the frying pans in the biosafety cabinet.
Determine the temperature and relative humidity of the cabinet. A temperature of
between 70 and 80 degrees Fahrenheit and a relative humidity of between 70%
and 80% is desired. If the relative humidity must be raised to 70%, this can be
accomplished by boiling water in the frying pan.
Establish monitoring devices (biological indicators and Formaldehyde
indicators). Leave biological indicator(s) in its envelope(s) and place in separate
sterile petri dish(es). The envelope allows the gas to penetrate the spore strip and
keeps out other contaminants.
Place the petri dish inside the cabinet. The control strip is maintained outside of
the cabinet. Place the Formaldehyde indicator outside the cabinet.
RP11.1 Decontamination of facilities final May 2016
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5.2.9. Don respiratory protection.
5.2.10. When temperature and humidity are within acceptable limits, initiate gassing by
setting the temperature on the Paraformaldehyde frying pan to 450 degrees
Fahrenheit. Ensure that the frying pan can be energized. While off, add the
measured amount of Paraformaldehyde to the pan. Place the measured
Ammonium Carbonate in the other frying pan. Seal the entrance to the cabinet
and post signage 5.2.11. Plug in the extension cord to heat the pan containing the
Paraformaldehyde. Periodically check the pan and when 25% has depolymerized
to Formaldehyde gas, turn on the blower for 15 seconds. Repeat this again at 50%,
75%, and 100%.
5.2.12. Unplug the frying pan after Paraformaldehyde has converted to Formaldehyde
gas.
5.2.13. Allow a minimum of 16 hours Formaldehyde contact time. Typically BSSMs
allow for a 48 contact time. Periodically turn on and off the blower.
5.2.14. The biosafety specialist initiates neutralization by setting the temperature on the
Ammonium Carbonate frying pan to 450 degrees Fahrenheit and ensuring that the
frying pan can be energized.
5.2.15. Plug in the cord to heat the pan. Check the pan and when 25% has converted to
gas, turn the blower on for 15 seconds. Repeat this again at 50%, 75%, and 100%.
5.2.16. Continually check room area for extraneous Formaldehyde gas by using the
Formaldehyde detector tubes.
5.2.17. The trained personnel conducting this procedure, if exposed to Formaldehyde gas,
will shower and change work clothing.
5.2.18. Turn off the frying pan after Ammonium Carbonate has converted to gas.
5.2.19. Allow a minimum of 100 minutes contact time for neutralization.
5.2.20. Inspect the Formaldehyde indicator (Q.C.) for evidence of exposure.
5.2.21. After completion of contact, don PPE and open the plastic enough in order to cover
and retrieve the Petri dishes. The dishes are then secured in a plastic bag.
5.2.22. If biological indicators indicate that decontamination was not complete, have
reviewed by a biosafety specialist to determine if procedure problems. Repeat if
required.
5.2.23. If biological indicators indicate successful decontamination, remove signage,
collect frying pans, tools, equipment, and materials. Return tools and equipment
to their proper location and dispose of all consumables.
5.2.24. Release the cabinet from control after Formaldehyde detector tube testing does not
indicate any Formaldehyde residues.
RP11.1 Decontamination of facilities final May 2016
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PARAFORMALDEHYDE GAS SETUP CHECK LIST
Area to be Decontaminated: _______________________________________________
_______________________________________________
Size of Area
Length _________ x Width _________ x Height _________ = _________ m3.
Amount of Chemicals
= _________ Grams of Paraformaldehyde 
Content (m3) _________ x 20

Grams of Paraformaldehyde ________ x 1.2
Carbonate
= _________ Grams of Ammonium
Items Required
Warning Signs
Frying Pans
Extension Cords
Paraformaldehyde Amount
Ammonium Carbonate Amount
Thermometer
Biological Indicators
Media Broth
Respirators
Personnel Protection Apparatus
Plastic Bags
Notifications
6 Mill Plastic Sheeting
5 – 10 cm Duct Tape
Timer
RP11.1 Decontamination of facilities final May 2016
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Paraformaldehyde Usage Report
Building:
Room/Filter Unit #:
Date:
Equipment:
Para formaldehyde Amount
ID#
Ammonium Carbonate Amount
Items being Treated:
Drager Tube Type
Batch/Lot #
Exp. Date
Activation Tube
Batch/Lot #
Exp. Date
Number of Strokes
Leak Test Pre
Leak Test Post
Remarks
RP11.1 Decontamination of facilities final May 2016
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AIR MONITORING RESULTS
Date:
Time:
PPM:
Action Taken
By:
Date:
Time:
PPM:
Action Taken
By:
Date:
Time:
PPM:
Action Taken
By:
Date:
Time:
PPM:
Action Taken
By:
Unexpected Adverse Effects:
BIT #
Biological Indicator Results:
Approved By:
Comments:
Decontamination Performed By:
Person Conducting Air Sampling
Area Released For Use Yes / No
Released By:
__________________________________________
RP11.1 Decontamination of facilities final May 2016
Page 15
Annex B
Biological Decontamination of Rooms by Paraformaldehyde Fumigation6
Introduction
A contaminated laboratory room that has been identified for space decontamination is reviewed
and whenever possible made compatible for the particular process selected. For example, for a
Formaldehyde gas application, porous materials such as paper and other materials would be
containerized and removed from the space and decontaminated by an alternative method. Once
the room is adequately sealed (supply/exhaust ducting, known penetrations etc) such that the
space can a) maintain an effective concentration of decontaminating agent and b) not allow
leakage of the agent beyond specified safety limits. Of course decontaminating agents should
always be used in accordance with appropriate local, state and federal laws.
1. Purpose
1.1. This procedure is to be utilized for decontamination of spaces such as rooms by
Formaldehyde fumigation. The Safety Staff conducting this procedure will provide the
safest working conditions possible for all employees. All regulatory requirements will be
followed in performance of these procedures. The Safety Staff will comply with the
Paraformaldehyde exemption, currently held by the facility. This procedure is to provide
uniform guidance for implementing the decontamination of airlocks* and other spaces
such as rooms by Paraformaldehyde fumigation. It contains specific information,
procedures and requirements for the properly trained person(s) to use to accomplish
decontamination and describes the procedures to be observed in decontamination.
2. Prerequisites
2.1. For any non-conformances, develop a non-conformance report in compliance with the
procedures used in the laboratory to manage non-conformance reporting and follow-up.
2.2. Personal Protective Equipment (PPE)
2.2.1. Protective eyewear
2.3. Printed Forms and Checklists.
2.4. Review the material safety data sheets (MSDS) for Paraformaldehyde and Ammonium
Carbonate.
2.5. Take the necessary measurements in preparation for organizing the necessary materials.
2.5.1. Measure and record the cube meter of the unit on the "Work to be Conducted" on
the Paraformaldehyde Decontamination Checklist (PDC) attached below.
6
Source is Plum Island Disease Center,
NY USA
* Airlocks are traditionally used in BSL3 & BSL4 laboratories. If your laboratory does not have airlocks,
please refer to this for the remainder of the document: All entrances and exits into the room, including
doors and windows, must be sealed appropriately with duct tape and temporary sealant, which needs to be
airtight, preventing any air escape.
RP11.1 Decontamination of facilities final May 2016
Page 16
2.5.2. Measure and record the square meters of the floor on the Work to be Conducted
PDC Checklist below.
2.6. Materials required
2.6.1. Danger Formaldehyde warning signs.
2.6.2. Frying pans (4).
2.6.3. Extension cords (at least ½ of the number of frying pans to be used).
2.6.4. Measuring device to measure Paraformaldehyde and Ammonium Carbonate in
grams.
2.6.5. Paraformaldehyde.
2.6.6. Ammonium Carbonate.
2.6.7. Plastic or glass containers (for Paraformaldehyde).
2.6.8. Duct tape (to secure plastic bags).
2.6.9. Plastic bags (for Ammonium Carbonate).
2.6.10. Tin foil.
2.6.11. Biological indicator spore strips.
2.6.12. Petri dishes or vials.
2.6.13. Hydrometer/Thermometer-to test temperature and R/H.
2.6.14. Full Face Negative Pressure Respirator with a Formaldehyde cartridge for setup
only.
2.6.15. SCBA for spore strip retrieval.
2.6.16. Neoprene rubber gloves.
2.6.17. Tyvek type clothes
2.6.18. Appropriate air monitoring equipment, Drager Pump with Formaldehyde and
Ammonia detector tubes.
2.6.19. Water (copious amounts to fill drains and traps).
2.6.20. Trypticase Soy Broth/Media Broth.
2.6.21. Obtain the People to Notify list for Airlock Shutdown from the front desk.
2.6.22. Airlock Decontamination form (if applicable).
2.6.23. The use of an incubator in the BSL-2.
2.7. Time Allotted
Number of Hours
For
72
Contact Time (After all product is burned off)
168
Incubation
16
Fumigation
232
TOTAL
2.8. Training
2.8.1. How to read Biological Indicator Strips
2.8.2. How to read a Hydrometer/Thermometer
2.8.3. How to properly utilize a SCBA
2.8.4. How to properly utilize a Respirator
2.8.5. How to properly utilize a Drager Pump
3. Definitions
3.1. Cubic meter is a unit is determined by the length x width x height in meter.
3.2. Hydrometer / thermometer - to measure humidity and temperature.
RP11.1 Decontamination of facilities final May 2016
Page 17
3.3. Trypticase Soy Broth / media broth - noted in Materials Required checklist for Biological
Indicator Strips (at least 5; 3 for gassing, 1 for positive control, and 1 for negative control).
4. Responsibilities
4.1. Safety Manager-to be notified if decontamination is not completed.
4.2. Biological Safety Officer-to be notified if decontamination is not completed.
4.3. Safety Manager-to determine the amount of contact time
5. Process
5.1. Shutdown Procedures
5.1.1. Notify appropriate personnel of the need to shut down and decontaminate the airlock.
Provide the intended date and time that the process will begin.
5.1.2. Prepare and submit work request.
5.1.3. Coordinate an appropriate time for the procedure with appropriate parties.
5.1.4. Ensure that the Air Handling Systems are operational.
5.2. Prepare materials needed for decontamination
5.2.1. Calculate and record the amount of Paraformaldehyde needed. Will need 20 grams per
cubic meter of area.
5.2.2. Place the Paraformaldehyde in plastic or glass container and cover with tin foil.
5.2.3. Calculate the amount of Ammonium Carbonate needed. Will need 1.2 grams per (x)
amount of Paraformaldehyde used.
5.2.4. Place the Ammonium Carbonate into two plastic bags with an equal amount in each,
securing the bags with duct tape.
5.2.5. Calculate and record the number of biological indicator spore strips needed. Will need
a minimum of one per 9 square meters of floor space, plus one control in the same lot
number. Additional biological indicator strips are required in accessible areas.
5.2.6. Calculate the number of Petri dishes or vials needed. One needed for each biological
indicator strip being gassed.
5.2.7. Place frying pans on secure footing in the room, utilize extension cords when
necessary.
5.2.8. Test the frying pans.
5.3. Decontamination Procedure
5.3.1. Display “Danger Formaldehyde” warning signs on the inside airlock door facing the
corridor and on the outside of the door, on the hanger that swings over the corridor, and
coming down the stairway from the second floor.
5.3.2. Notify Security to release the security system on the airlock door, informing them how
long the door will remain open.
5.3.3. Notify all personnel on the list of time the fumigation will commence.
5.3.4. Fill all floor drains and traps with copious amounts of water.
5.3.5. Determine the temperature and relative humidity of the airlock. A temperature of
between 21 and 27 degrees Celsius and a relative humidity of 70% is desired. If the
relative humidity must be raised to 70%, this is accomplished by boiling water in the
frying pan first. Continue to recheck the humidity level until it reaches the optimum level.
5.3.6. Ensure that all lids, compartments, and doors are open. Lids on chemical containers
should be tightly closed.
5.3.7. Vessels should be in the horizontal position.
RP11.1 Decontamination of facilities final May 2016
Page 18
5.3.8. Remove any items which should not be gassed, i.e., wood, paper, or cloth. Remember:
No porous materials are to be treated.
5.3.9. Check the contents of the airlock for tags or labels.
5.3.10. Ensure that all oils and fluids have been drained.
5.3.11. Record all information required by the Airlock Decontamination Form (if applicable).
5.3.12. Place biological indicators in separate Petri dish(s) or vial(s). Place the Petri dish or
vial at varying heights.
5.3.13. Don a full face respirator and neoprene rubber gloves.
5.3.14. Trypticase Soy Broth / media broth stays in BSL-2 for inoculating spore strips.
5.3.15. Ensure that the control switches are in the off position.
5.3.16. When temperature and humidity are within acceptable limits, initiate the steps for
gassing by setting the temperature on each frying pan at 232 degrees Celsius. Do NOT
turn on the control switch to the frying pans at this time.
5.3.17. Place tin foil in each pan that will hold the Ammonium Carbonate. Place the plastic
bags containing the Ammonium Carbonate on the tin foil in each frying pan.
5.3.18. Place the pre-measured amount of Paraformaldehyde into the frying pans.
5.3.19. Close the Airlock door and inflate the air gasket.
5.3.20. Again ensure that all warning signs have been posted.
5.3.21. Turn on the switch that controls the frying pans that contain the Paraformaldehyde.
5.3.22. Turn off the frying pans when all the Paraformaldehyde has converted to Formaldehyde
gas.
5.3.23. Allow a minimum of 72 hours Formaldehyde contact time, some application may take
longer, each case will be determined by Safety Office.
5.3.24. Upon completion of the allowable contact time, Ammonium Carbonate frying pans
should be turned on for 24 hours after complete burn of product.
5.3.25. Properly trained personnel will don PPE including Self Contained Breathing Apparatus
and stand by the outside airlock door.
5.3.26. When the persons are ready to enter the airlock they will notify the person inside to
deflate the outside air gasket and notify security to release the security and restriction to
the door, informing them how long the door will be open.
5.3.27. The person entering the airlock or room wearing an SCBA will locate and remove the
biological indicator. After removing the biological indicator from the airlock, the person
will close the outside door and notify the inside person to inflate the air gasket.
5.3.28. The person that entered the airlock or room and his backup will remove their PPE and
SCBA and properly store them.
5.3.29. One trained person from will go to the BSL-2 lab location and start processing the
biological indicators.
5.3.30. The biological indicators will be incubated for 7 days at 51 degrees Celsius.
5.3.31. If the biological indicator indicates that decontamination was not complete, notify the
Safety Manager and the Biological Safety Officer immediately. Stop the test.
5.3.32. If the biological indicators indicate successful decontamination, aerate the airlock.
5.3.33. Test the air in and around the airlock to ensure that the entire product has been aerated
using the Drager pump with Formaldehyde and Ammonia tubes to ensure the area is safe
for employees to enter. Area should be in compliance with OSHA limit- consult website
for current limits (www.osha.gov).
5.3.34. If area is clear, remove signage, collect frying pans, and remove items that were
decontaminated.
RP11.1 Decontamination of facilities final May 2016
Page 19
Paraformaldehyde Decontamination Checklist (PDC)
MATERIALS REQUIRED
DONE
Warning Signs- Place appropriately in all clearly visible areas
Frying Pans- (4) 2 for the Paraformaldehyde and 2 for the Ammonium
Carbonate. Test the frying pans before using.
Extension Cords- 2 each for two frying pan
Paraformaldehyde- [Treated Volume (m3) x Application Rate (20 g/m3)]/[%
Product Purity x 100] = Paraformaldehyde (g)
Ammonium Carbonate- 1.2 x Paraformaldehyde (g) = Ammonium Carbonate
(g)
Thermometer- To measure temperature and relative humidity
Biological Indicators- 1- each per 9 square meter (4) 3 for the gassing and
1- for the positive control
Media Broth- 5- each, 3-for the gassing strip, 1-for the positive control strip and
1 for negative control
Respirators- with Formaldehyde filters
Self-Contained Breathing Apparatus- 2 outside
Personal Protection Equipment- Gloves, Tyvek type clothes
Tin Foil- The tin foil is to be placed in the frying pans that will hold the bags of
Ammonium Carbonate
Plastic Bags- Two plastic bags are needed to hold equal amounts of Ammonium
Carbonate
Plastic or Glass Containers with tin foil cover- The containers will hold equal
amounts of Paraformaldehyde
RP11.1 Decontamination of facilities final May 2016
Page 20
Procedure
PDC (cont)
WORK TO BE CONDUCTED
DONE
Notification-:
1- Obtain appropriate identification and contact information from operations
manager number or other responsible officials
Ensure that Air Handling Systems are operational
-
Post Warning Signs at all entrances and exits or other applicable openings
including:
Outside Airlock or room door outside the building
Airlock or room Door, inside the building
Doorway from any other floor to the area
-Ensure all warning signs are clearly visible.
Notify Security that you need the door security system released. Inform them of
how long the door will be open.
Fill floor drains and traps with copious amount of water
Measurer proper amount of Paraformaldehyde and Ammonium Carbonate
Place frying pans in the airlock. 2-near the outlets and 2-away from the outlets using
extension cords.
Check temperature and relative humidity. Temperature should be 21 to 27 degrees
Celsius and the relative humidity of about 70% is desired. May need to raise
temperature and R/H by placing water in the frying pans and turning them on.
Place biological indicators in Petri dishes (3). More may be needed if there are areas
that are in-accessible. Placed in hard-to-reach areas and no higher than a foot off the
ground.
Ensure all items that are being gassed have all their lids, compartments, and doors
left open. Note: Lids on chemical containers to remain closed.
Ensure that all oils and fluids have been drained.
All vessels should be horizontal, if possible.
Ensure that there are no paper products, wood, or cloth to be gassed No porous
materials are to be treated.
Inventory all items being decontaminated.
Ensure all power to the frying pans are off prior to placing the chemicals into them.
RP11.1 Decontamination of facilities final May 2016
Page 21
Place tin foil in the two frying pans that will contain the bags of Ammonium
Carbonate. Place the two bags of Ammonium Carbonate in the frying pans as
indicated.
When temperature and R/H are at acceptable levels, place equal amounts of
Paraformaldehyde in the frying pans.
Secure the airlock doors, turn on the Paraformaldehyde switch. And leave on until
all the product has turned to a gas.
Again ensure all warning sign are posted.
RP11.1 Decontamination of facilities final May 2016
Page 22
After the Decontamination Cycle is Completed
WORK TO BE CONDUCTED
DONE
Allow about three (3) days contact time before entering
Ensure that the frying pans are off
Prior to opening the outside door, notify Security that you need the security system
released to the door. Inform them how long the door will be open.
Don proper PPE and an Self-Contained Breathing Apparatus
Have the inside person deflate the outside door gasket (or break the seal into the
room). Open the outside door wide enough to allow you to enter safely. Ensure that
you have a backup person with you prior to entry.
Remove the petri dishes that contain the biological indicators
Exit the airlock, closing the airlock door and have the inside person inflate the
gasket.
Remove the SCBA and the PPE and properly store them.
Deliver the biological indicator to the BSL-2 lab for processing.
Incubate the biological indicator for seven (7) days @ 51 degrees Celsius.
If the biological Indicator indicates successful decontamination, aerate the room or
airlock.
After a few hours of aeration, test the airlock using the Drager indicator tubes for
Formaldehyde to determine if the airlock is safe for personnel to enter
If the biological indicator indicates that the decontamination was not complete,
notify the Safety Officer immediately. Stop the test.
Checklist Conducted By:
Date:
RP11.1 Decontamination of facilities final May 2016
Page 23
Decontamination of BSL3 Rooms by Hydrogen Peroxide (H2O2)7
This standard operation procedure (SOP) is for decontaminating high security rooms which are closed to
the public and with dedicated air circulation!
• Make sure all air vents are closed (including fire flaps)
• Bring the distribution ventilator ( 200 m3/h) to the room(s) that are to be sterilized
• Have Seal tape available for doors and other outlets
• Have 3 spore tests readily available
(1) Preparation of H2O2 disinfection:
• Calculate the amount of H2O2 (35%) that has to be injected for disinfection (400 ml/50 m3)8i
• Start all equipment which should be disinfected (Ventilation, Cages, etc.)
• Detach the screw caps from the inner disinfection vent lines
• Connect the Steris 1000 to the outside connectors of the room to be sterilized
• Set the distribution ventilator on medium speed in the center of the room
• Fix spore tests to 3 separate points (i.e. Wall, Cage, etc.)
• Close door and seal with the tape; Attach the Disinfection Warning Sign
• Switch on STERIS 1000; enter volume of H2O2 and the program (i.e. Disinfection VUW-L3,
etc.)
• Press START button
(2) Monitoring the disinfection:
• Check the print out and status of the program hourly
o Drying cycle (to reduce humidity in the room)
o Disinfection cycle (~ 3 hours/15m2 room)
o H2O2 inactivation cycle ( ~ 2 hours)
(3) Post disinfection
• Open HEPA ventilation in the room and wait for 2 hours for 20 times air change
• Open the door to the room and remove the spore tests for analysis and the ventilator
• Re-cap the air ducts and close the disinfection valves.
• Run the ventilation for 1 day on standard rate and commence work.
7
8
Courtesy of Veterinary University of Vienna
Concentration for 35% H 2O 2 should be minimum 1g/ m3 i.e. 3 ml/ m3; Max 3g/ m3
RP11.1 Decontamination of facilities final May 2016
Page 24
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