Autoclave Management Program for Biological Waste Decontamination

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1 Autoclave Management Program for Biological Waste Decontamination Document Number: EHS.AUTOVER Effective Date:07/25/07 Revision Date: 1.0 Purpose 1.1 The purpose of the Autoclave Management Program for Biological Waste Decontamination is to comply with state regulations (105 CMR ) and protect the public health, safety, welfare, and environment. Implementation of this program by all research laboratories within the University of Massachusetts at Amherst will ensure that all biological waste generated in the laboratories will be decontaminated and/or deactivated prior to disposal as solid waste. Examples of biological waste are: Human and animal cell lines Tissue cultures Organisms with recombinant DNA Cultures and stocks of infectious agents and non-infectious microbial agents Bacteria, viruses, and fungi Blood and blood products Labware that has come into contact with the aforementioned waste steams (e.g. contaminated plastic pipettes, pipette tips, Petri dishes, centrifuge tubes, Eppendorf tubes, disposable gloves, wipes, etc.) 1.2 For this protocol, decontamination is defined as a minimum of a 4 log 10 reduction in infective organisms, not sterilization. Sharps waste is not covered under this program because they are handled as medical waste and are shipped off-site for incineration. 2.0 Program Description 2.1 The Autoclave Management Program for Biological Waste Decontamination depends on four core components: appropriate use of the autoclave to decontaminate biological waste record keeping performance verification annual calibration and maintenance 2.2 Individuals shall be designated within each department to ensure these components are met and the corresponding documentation is recorded. Proper documentation of this program is both essential and mandatory, and will be maintained by all users of the autoclaves. This documentation will be monitored by the Biological Safety Program. 1

2 2.3 Biological waste for decontamination and disposal should be stored in covered, leakproof containers lined with autoclavable RED biological hazard bags that meet OSHA and ASTM standards. Once this waste has been decontaminated, an adhesive label with NON-INFECTIOUS AUTOCLAVED BIOLOGICAL WASTE with a notation of the building on the label is placed on them, and the waste is then placed in black bags for disposal in the landfill. Autoclave bag ordering information for Fisher Scientific: Bag Size Catalog # # in Box 8 x 12 in. (20 x 30cm) A Pack of x 19 in. (36 x 48cm) B Pack of x 23 in. (48 x 58cm) C Pack of x 35 in. (64 x 89cm) D Pack of x 48 in. (94 x 122cm) E Pack of The requirements of 105 CMR shall not apply to biological waste that is contained in a mixture which, due to the presence of other materials, should not be autoclaved. These mixtures may include but are not limited to amalgam (mercury), lead foil, adjuvants and chemotherapeutics and are regulated by either hazardous or radioactive waste laws or regulations. Ethidium bromide gels are an example of biological waste that is NOT autoclaved as it has its own waste stream. Complete a hazardous waste pick-up request which can be found on the EH&S website at: All biological waste, except sharps, shall be contained in a primary container which is a strong red plastic bag that is impervious to moisture and has sufficient strength to resist ripping, tearing, or bursting under normal conditions of use and handling. Sharps are placed in rigid, red plastic containers and are disposed of as medical waste and shipped offsite to a treatment facility for disposal. Complete a hazardous waste pick-up request for sharps pick up which can be found on the EH&S website at: Animal carcasses are stored frozen until they are removed for off-site incineration. 3.0 Roles and Responsibilities 3.1 Principal Investigator Individual responsible for ensuring that autoclave logs are kept and that autoclaves are properly used, maintained, and validated. 3.2 Biosafety Officer at EH&S Staff member responsible for advising researchers on autoclave validation, maintenance, record keeping, and procedures for use. 4.0 Autoclave Use and Training 4.1 Equipment manuals shall be made available to all autoclave users and stored in the departmental office. In addition, a master copy of the equipment manual will be kept near the autoclave for reference. 2

3 4.2 Adherence to Autoclave Management Program will be monitored by the Biosafety program. 4.3 All new Students, Faculty and Staff must be trained according to this program and the use of the autoclave. 5.0 Logs/Records An Autoclave Waste Decontamination log (see attached) must be used for each autoclave and will be a crucial tool in ensuring proper use and care of the autoclave. These logs will have secured, consecutively numbered pages and shall be kept on file in the departmental office or by the designated responsible individual for a minimum of three years. These logs will include a description of the equipment, each event relative to a piece of equipment, manufacturer s instructions, results of monthly verification tests, and contact information for the calibration contractor, as follows: Name of the equipment, current location, manufacturer s name, serial number, UMass inventory number, date placed in service, condition when received (e.g. new, used, reconditioned; if known), and name or initials of the person completing the results of monthly verification tests are listed on the log sheet. A copy of the manufacturer s instruction, dates and results of calibrations, date of next calibration, each event relative to the piece of equipment to include date, event, any corrective action taken, and name or initials of the person completing the tasks are maintained in a notebook near the autoclave. 6.0 Performance Verification 6.1 Performance of the autoclave must be verified for each run with indicator tape and monthly by a biological indicator test (Prospores ). The frequency of biological indicator testing will vary with the hazard levels of the waste. These policies are based on the requirements for processing waste as described in Biosafety in Microbiological and Biomedical Laboratories, fifth edition, HHS Publication No. (CDC) Each set of conditions (time, temperature, pressure) used to decontaminate biohazardous waste by each autoclave must be verified monthly using a biological indicator such as Prospores. Results are recorded on the Autoclave Log sheet, listing the conditions, date, and signature of person performing the test. All autoclaves that issue tapes with instrument operation parameters on them shall have the tapes stored in date order for a minimum of three years. 6.3 Every BSL-3/ABSL-3 autoclave load must conduct a biological indicator test (Prospore ) for validation and results are recorded on the Autoclave Log sheet. 6.4 Autoclaves that are not used for decontamination of biohazardous materials must be validated quarterly to ensure proper autoclave performance. 3

4 6.5 Autoclaves must be inspected and certified annually by a professional. The following companies have performed these services on campus: Getinge Castle, 1777 E. Henrietta Rd., Rochester, NY , Ranger Engineering, P.O. Box 3111, Framingham, MA 01705, (508) Procedures for Use 7.1 Autoclave Validation / Spore Testing Procedures: Exposure: Prospore Procedure: To test autoclave performance with a biological indicator place a Prospore ampoule in the most difficult location to sterilize, usually near the drain, between animal cages or suspended in a volume of liquid. Use as many ampoules as needed to get an accurate measurement of steam penetration throughout the load. After the autoclave run place the processed ampoule in a vertical position in an incubator at C for 48 hours. Mark a control ampoule from the same package and incubate it along with the autoclaved ampoule to ensure spore viability. Leave the ampoules at 50-60C for 48 hours. Interpretation: Control ampoule should exhibit a color change to or toward yellow. If the control ampoule does not exhibit growth via a color change the test is considered invalid because the spores are not considered to be viable. Autoclaved ampoule will exhibit no growth and retain the original purple color if the autoclave is working properly meaning that both time and temperature were reached for decontamination. If the ampoule remains purple this indicates that the autoclave sterilization was successful. If the ampoule changes color towards a yellow or the liquid becomes turbid this indicates spore growth and failed autoclave sterilization. Test Failure If the control ampoule or the autoclaved Prospore ampoule tests fails, the load must be re-autoclaved and retested with Prospores again before disposal. The failure of a spore test may be the result of improper loading or incorrect parameter settings. If the autoclave spore test fails for a second time the autoclave needs to be serviced and use of the autoclave for decontamination suspended. 4

5 Prospore Storage and Disposal: Store in a non-food refrigerator at 2-8C. Do not freeze. Prospores have an expiration date stamped on the outside of the box. Do not use after expiration. Sterilize all positive and expired units prior to disposal. The deactivated glass ampoules must be disposed of in a sharps container. Precautions: Do not use damaged ampoules. Do not use Prospores after the expiration date. Since Prospores contain live cultures, ampoules should be handled with care. Do NOT freeze. If the Prospores have frozen, discard them. After sterilization handle the Prospore ampoules with care. The contents of the ampoule are hot and under pressure. Failure to allow sufficient cooling time (10-15 minutes) may result in bursting of the ampoule. Hold all autoclaved waste until the biological indicator tests have been shown to be functioning correctly/validated. If the tests are not satisfactory, the autoclave must be repaired, new biological indicators run and the waste is re-autoclaved before it is disposed of. The waste can NOT be disposed of until there is a valid indicator test. 7.2 Prospore /Geobacillus sterothermophilus Purchasing Prospores / Geobacillus sterothermophilus ampoules can be purchased through Thermo Fisher Scientific, Catalog# (pack of 10) or (pack of 50) or directly through Raven Labs. Raven Labs phone # Prospores typically have a six month to one year expiration date so take care not to order too many at one time. 8.0 Annual Calibration 8.1 All autoclaves are considered pressure vessels and must be calibrated annually to meet Massachusetts State regulations 105 CMR : Minimum Requirements for Medical or Biological Waste (State Sanitary Code Chapter VIII). Calibration consists of a preventative maintenance service which entails replacing valves and check valves that warrant it as well as door gaskets that may need replacing. Test cycles are run with chemical indicators to verify proper operation by the service representative(s). Documentation shall be kept in the departmental office and entered into the Maintenance Log. The following companies have performed these services on campus: 5

6 Getinge Castle, 1777 E. Henrietta Rd., Rochester, NY , A service contract is available and that covers four visits a year as well as the annual maintenance/certification. Ranger Engineering, P.O. Box 3111, Framingham, MA 01705, (508) Documentation 9.1 All autoclave runs must be documented. The autoclave log must include date, time, load characteristics, run time, and if there were spore test results. 9.2 Accurate and timely documentation is necessary to ensure proper decontamination of waste. Documentation procedures are mandatory and are included in each component of the autoclave verification program. 9.3 Autoclave Log sheets, completed work orders and maintenance records should be stored in a unique folder for each individual autoclave to facilitate review of these materials. Save any tapes from autoclaves in date order for at least three years Key References 10.1 Maureen O Leary, Ph.D., Assistant Director for Academic Safety and Environmental Health, Department of Environmental Health & Safety, 117 Draper Hall, University of Massachusetts/Amherst, (413) /Fax: (413) Judy LaDuc, Biological Safety Services, Department of Environmental Health & Safety, 117 Draper Hall, University of Massachusetts/Amherst, (413) /Fax: (413) Biosafety in Microbiological and Biomedical Laboratories. CDC/NIH. 5 th edition, Getinge Castle, 1777 E. Henrietta Rd., Rochester, NY , Ranger Engineering, P.O. Box 3111, Framingham, MA 01705, (508) Thermo-Fisher Scientific, 9999 Veterans Memorial Drive, Houston, TX Telephone: CMR Minimum Requirements for the Management of Medical or Biological Waste 6

7 University at Massachusetts Amherst: Biological Waste Record for On-Site Treatment Department: Building: Room: Manufacturer: Model #: Serial #: UMass Tag #: Date Placed in Service: Autoclave was: New/Used Date Quantity Type Treatment Method Process Parameters Printed Name QC Results Time Pressure Temp Signature Chemical or Spore + or - Chart prepared in accordance with M.G.L.c , 5 and 105 CMR , minimum requirements for medical or biological waste. Results should be reviewed, signed and dated by a laboratory supervisor, coordinator, principal investigator or EH&S Biosafety staff at regular intervals. 7

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