The University of Chicago
Safety Manual
Biological Safety Programs

Please note that this program has a glossary.  The glossary contains the definitions for various terms used in the program.   These terms are highlighted in bold print the first time they appear in the body of the program.

Policy

All potentially infectious waste (PIW) generated at the University of Chicago shall be disposed of in accordance with regulations promulgated by the Illinois Environmental Protection Agency, City of Chicago and the University of Chicago.  No employee shall treat and/or dispose of PIW unless done so in full accordance with applicable regulations and the knowledge of Environmental Health and Safety and Biological Sciences Division (BSD) Office of the Dean.  PIW generated in the University of Chicago Medical Center shall be disposed of in accordance with the University of Chicago Medical Center policies and procedures with the exception of PIW generated in the Animal Resources Center (ARC) facilities which shall be disposed of in accordance with ARC policies and procedures.  The removal of potentially infectious waste from the University of Chicago campus and the Medical Center shall be facilitated by a contracted service which is licensed, bonded and permitted by the Illinois Environmental Protection Agency.

Authority and Responsibility

The Biological Sciences Division (BSD) and Social Science Division (SSD) are responsible for:

1. Providing red or black reusable containers (BSD);
2. Providing Stock Clerks for inner building transportation of BSD, SSD and future locations (BSD);
3. Reviewing all documentation and signing manifests (BSD/SSD Facility Managers);
4. Paying invoices and appropriating cost allocations between Divisions/Departments (BSD);
5. Submitting Manifests to Environmental Health and Safety (BSD); and
6. Ensuring all employees have been appropriately trained (BSD/SSD).

Generators are responsible for:

1. Providing plastic liners and sharps containers;
2. Packaging all PIW in accordance with the procedures identified in this policy; and
3. Attending required training.

Environmental Health and Safety is responsible for:  

1. Maintaining all waste manifests; 
2. Providing Bloodborne Pathogens training;
3. Providing Department of Transportation training; and
4. Coordinating the processing of the annual report with BSD and the contractor.  

Procedure

Work Station Procedures

All handling, segregating, packaging, labeling and storing of PIW shall be done in accordance with the procedures listed below.

1. Prior to generating PIW, the generator shall obtain the appropriate disposal container for the disposal of PIW.

2. Plastic liners shall be a red bag or a bag with the International Biohazard Symbol and the word “biohazard” affixed.  All bags used shall be of sufficient strength to prevent tearing or bursting under normal conditions of use and handling.
3. All handling of infectious material and sharps by the generator shall be conducted in accordance with appropriate procedures and good practice.
4. Once infectious material or other items (e.g., unused sharps) are to be disposed, the generator shall properly segregate the PIW from all other waste and place it in the appropriate container.  If PIW becomes mixed with any other waste, all of the waste shall be treated as PIW.
5. Regular PIW shall be placed inside an appropriate plastic liner prior to placement in a red reusable container. 
6. Pathological waste shall be placed inside an appropriate plastic liner prior to placement in a black reusable container.  Chemical preservatives (e.g., formaldehyde) shall be separated from the pathological waste prior to placement in the liner.  Preservatives shall be disposed of as chemical waste in accordance with Section 6.2, Hazardous Materials Management Program.
7. Sharps shall be placed in a sharps container identified with the words "Biohazard/Sharps" and display the biohazard symbol.  Once the sharps container is full (no greater than three-quarters full), it shall be closed and placed inside a red reusable container.
8. Over-sized PIW shall be addressed on a case-by-case basis and generators shall contact the appropriate Building Manager to arrange for packaging and disposal. 
9. Generators shall place the regular PIW, pathological waste or sharps waste in reusable containers provided by the division that are located in laboratories or nearby common-use rooms (e.g., autoclave rooms). 
10. If the PIW container becomes contaminated by PIW, generators shall clean and disinfect the receptacle by wiping down or immersing the surface in a bleach solution of one part bleach to ten parts water.
11. Once an item is placed in a reusable container, no attempt shall be made to remove the item(s) from the waste container.
12. When full, all liners in red/black reusable containers shall be tied closed and the lid of the container firmly secured before the container is transported for disposal. 
13. The room housing the work station in which potentially infectious waste or agents known to be infectious to humans is used or stored shall be identified by signage warning unauthorized individuals of the potential danger.

On-Site Decontamination

Bio-hazardous materials (e.g., human blood, bacterial cultures in liquid media, body fluids or animals experimentally infected with pathogens) may be decontaminated by autoclaving or treatment with an appropriate chemical disinfectant for the sufficient contact time that is proven to decontaminate the bio-hazardous material and is approved by the Biological Safety Officer.  After decontamination, liquids may be disposed of by pouring them down the drain to the sanitary sewers and then flushing the drain with copious amounts of water. 

Do not autoclave materials containing solvents, radiation, volatile or corrosive chemicals (e.g., formalin, bleach, chloroform, phenol) due to the possibility of dangerous gases being produced.  Trace amounts of bleach used to decontaminate laboratory materials during procedures (e.g., decontaminating pipette tips or other laboratory ware) may be autoclaved. 

On-Site Removal

On-site removal of PIW shall be conducted in accordance with the procedures listed below.

1. On a regular basis, BSD Stock Clerks shall remove full containers and replace them with empty containers for generator use.  BSD Stock Clerks shall transport the full containers to a central storage area within buildings for future pick-up.
2. If a new container(s) is needed prior to a regular pick-up or a container is putrescent, generators shall contact the appropriate BSD or SSD Building Manager who will make arrangements to provide an additional container to replace the full/malodorous container. 
3. Prior to removing a container, BSD Stock Clerks shall visually verify appropriate closure of liners/sharps containers, proper segregation of waste and closure of reusable container(s).  BSD Stock Clerks shall not sort through the waste to confirm these items.
4. If no problems are identified, the BSD Stock Clerks shall remove full containers and replace them with empty containers for generator use.  BSD Stock Clerks shall transport the full containers to a central storage area within buildings for future pick-up.
5. If problems are identified, BSD Stock Clerks will not remove the container.  The BSD Stock Clerks shall provide empty containers so as not to impede proper disposal of newly generated waste, attach a notice to the unacceptable container identifying the problems and notify the appropriate Building Manager of the unacceptable container.  The Building Manager shall contact the generator to resolve the matter. 
6. If the PIW container becomes contaminated by PIW or leaks during transport, the Stock Clerks shall clean and disinfect the receptacle by wiping down or immersing the surface in a bleach solution of one part bleach to ten parts water.

Off-Site Removal

Off-site removal shall be conducted in accordance with the procedures listed below.

1. On an established schedule, the approved disposal vendor shall pick up containers of PIW and provide clean, empty containers for use.  
2. Prior to off-site shipment, Building Managers shall verify containers are properly marked, labeled and packaged for shipment.  
3. Building Managers shall also verify containers are properly loaded and secured within the transport vehicle prior to off-site shipment.

Manifests

All documentation shall be processed in accordance with the procedures listed below.  

1. Building Managers shall review all documentation associated with the shipment prior to the vendor leaving the building.  Building Managers shall sign the Illinois Potentially Infectious Medical Waste Manifest only after the review is complete and accuracy of the Manifest information is verified. 
2. Building Mangers shall forward the Generator Copy (Copy 4) of the Manifest and all other documentation (e.g., weight tickets) to the BSD Director of Facilities Services (DFS).  The DFS shall log the Manifest and other information into a tracking system to be used for verification of cost from the vendor, payment of invoices and appropriate cost allocations between Divisions/Departments.  The DFS shall forward the Generator Copy of the Manifest to Environmental Health and Safety for review and record retention for a period of three years commencing with the date noted on the manifest indicating when the waste was shipped.
3. The disposal vendor shall send the completed Manifest (Copy 1) to the DFS who will note the waste treatment was performed.  This notation shall be used for verification or costs and payment of invoices.  The DFS shall forward the completed Manifest to Environmental Health and Safety for review and record retention for a period of three years commencing with the date noted on the manifest indicating when the waste was shipped.
4. The disposal vendor shall send all invoices to the DFS for payment.  The DFS shall approve payment and obtain reimbursement from appropriate Departments (ARC) or Divisions (SSD) via University procedures. 

Bulk Storage

If under a waste removal contractual agreement, the potentially infectious waste is to be removed from the work station periodically and stored in a central accumulation point to await removal from the University.  The central accumulation point(s) and the waste stored in them shall meet the following requirements:

1. Store the potentially infectious waste in a manner and location that maintains the integrity of the package and provides protection from wind, rain and water;
2. Maintain the potentially infectious waste in a non-putrescent state using refrigeration if necessary;
3. If the storage area is outdoors, such as in a trailer, the area shall be secured to prevent unauthorized access;
4. Limit access to on-site storage areas to authorized persons only by securing the room.  The central accumulation point shall also be identified by signage that reads "Biohazard" and displays the biohazard symbol;
5. Store the potentially infectious waste so that the materials do not become a food source or breeding place for vectors;
6. The packages of potentially infectious waste shall not be compacted or subjected to stress that would damage the integrity of the container;
7. Multiple generators may use the same central accumulation point;
8. Potentially infectious waste shall be stored so as to prevent contamination of other waste or materials;
9. The containers shall be stored off the floor at a height of three inches.  The base used to elevate the container off the floor shall permit for the periodic cleaning under the containers;
10. Oversized potentially infectious waste shall be covered or packaged in such a way as to minimize the threat to human health and the environment.  In addition, the packaging shall be labeled with signage that reads "Biohazard", the generator's name, address, telephone number and display the biohazard symbol; and
11. All reusable containers such as trash cans or shipping containers used at the work station for the accumulation of potentially infectious waste shall be cleaned once a week or sooner if visibly soiled.  The containers shall be cleaned by wiping down or immersing the surface in a bleach solution of one part bleach to ten parts water.

Signage identifying the storage operation shall be prominently displayed at the points of access to the secured storage area.  Signs shall be marked in lettering that is readable at a minimum distance of five feet.  At a minimum, the signs shall display the International Biohazard Symbol and the word "biohazard".  

Transportation

Since a contracted removal service shall be used for the transportation of PIW from the point of generation to the treatment facility or transfer station, the transporter shall provide the following:

1. Proper permitting of the vehicle by the regulating agency and the permit shall be displayed on the vehicle;
2. Provide the generator with a completed manifest for signature.  After signing the manifest, the transporter shall provide the generator one copy; upon arriving at the treatment facility, the transporter shall retain a copy and give the remaining two copies of the manifest to the treatment facility; the facility treating the waste shall keep one copy of the manifest and return the final copy to the generator;
3. The generator does not need to have a permit or manifest to transport the potentially infectious waste from the work station to the central accumulation point as long as the waste generated at his/her facility(s) is transported or no more than 30 pounds of waste is generated in a calendar month; and
4. Compliance with all other aspects of the regulation.

Documentation

Annual Report

Facilities that treat 50 pounds or more of potentially infectious waste or are permitted by the Illinois Environmental Protection Agency, shall compile an annual report.  The report shall specify the amount of waste generated and the disposition of the waste treated during the previous calendar year.

All reports shall be completed by the contractor and provided to Environmental Health and Safety for signature and mailing.  Environmental Health and Safety shall maintain copies of the completed report.

Spills

If the spill is an unknown agent, an inhalation hazard, and/or the quantity spilled is greater than one liter, immediately evacuate the area and contact the University Police at extension 123 or 702-8181.  If the spill occurs in the Medical Center, contact Public Safety at 702-6262.  If applicable, refer to the Material Safety Data Sheets (MSDS) that can be found with Health Canada. 

If a spill of infectious agent occurs that does not meet any of the aforementioned criteria, respond as follows:

1. Warn people in the immediate area of the PIW spill;

2. Allow sufficient time for aerosols to settle (15 minutes);

3. If your clothing is contaminated, remove the contaminated clothing with care to avoid contamination of exposed skin and fold the contaminated area inward;

4. Wash all contaminated body parts, including arms, face and hands with soap and water and flush any contaminated mucous membranes with water immediately or as soon as feasible following contact with PIW;

5. Change into clean clothing, laboratory coat or disposable tyvek suit;

6. Obtain spill response equipment including plastic liners, reusable containers, sharps containers to contain all contaminated material, ten percent bleach solution (made fresh daily), paper towels, broom, dust pan and personal protective equipment;

7. Put on personal protective equipment including disposable gloves (interior), utility gloves (exterior), disposable apron, goggles and disposable mask to prevent exposure to the skin and mucous membranes while cleaning up the spill;

8. Enter the contaminated area and carefully pour, avoiding any splashing, or mist using a spray bottle with a bleach solution over the entire contaminated area, cover it with paper towels, and allow thirty minutes of contact time;

9. Pick up the paper towels, disinfectant and spilled material working toward the center of the spill in a manner which will minimize splashing, spraying and splattering of the spilled material;

10. Place the material into a plastic liner and then into a reusable container;

11. If broken glass or other sharp objects are present the in the spill, they shall be handled with the aid of a mechanical device (e.g., brush and dustpan, tongs, forceps);

12. Dispose of all spilled material and paper towels into a plastic liner and reusable container;

13. Remove all personal protective equipment such as tyvek suits, aprons and gloves with care to avoid contamination by folding the contaminated area inward;

14. Dispose of all personal protective equipment inside a plastic liner and reusable container for disposal; 

15. Close all plastic liners and reusable containers;

16. Wash all body parts, including arms, face and hands immediately;

17. Notify your supervisor of the spill at the earliest possible time; and

18. Contact the appropriate facility manager for pick-up and disposal in campus buildings or Environmental Services for areas in the Medical Center.

Small Laboratory Equipment

Liquid spills on small laboratory equipment shall be contained as follows:

1. Drain excess liquid with Kimwipes and/or paper towels;

2. Immerse the contaminated equipment in a ten percent bleach solution and allow to penetrate for five minutes;

3. Remove equipment from the decontaminant, blot off excess liquid with Kimwipes and/or paper towels;

4. Repeat immersion and soaking in a ten percent bleach solution;

5. Blot off excess liquid with Kimwipes and/or paper towels;

6. Spray with a seventy percent isopropyl alcohol solution, wipe clean; and

7. Dispose of paper towels and Kimwipes as biohazard waste. 

Large Laboratory Equipment

 Liquid spills on large laboratory equipment (e.g., centrifuge, incubator, autoclave) shall be contained as follows:

1. Drain excess liquid with Kimwipes and/or paper towels;

2. Spray contaminated area with a ten percent bleach solution (made fresh daily), including area surrounding the spill;

3. Allow to penetrate for five minutes;

4. Wipe with paper towels;

5. Repeat decontamination steps;

6. Spray with a seventy percent isopropyl alcohol solution, wipe clean; and

7. Dispose of paper towels and Kimwipes as biohazard waste. 

Protective Devices

Refer to Section 3.15, Personal Protective Equipment, for additional information.

Training

All employees with the potential for occupational exposure to blood or other potentially infectious materials shall be trained in accordance with the Bloodborne Pathogens Program, Section 3.2 and Building Managers required to sign manifests shall be trained in accordance with the Hazardous Materials Transportation Program,  Section 3.7.

Section 2 Index

 Table of Contents

Environmental Health and Safety
Issued:  01/24/96
Revised:  06/04/09