Biological Safety Manual – Chapter 14: Select Agents and Toxins

Title

Biological Safety Manual – Chapter 14: Select Agents and Toxins

Introduction

The CDC and USDA have designated certain biological agents and toxins as Select Agents, because they have the potential to pose a severe threat to public, animal or plant health, or to animal or plant products. These materials require federal registration and approval to receive, posses, or transfer them.

The 1996 Antiterrorism and Effective Death Penalty Act first regulated the transfer of select agents between persons and institutions. The 2001 USA Patriot Act prohibits certain individuals from shipping, transporting or possessing a select agent. The 2001 North Carolina Biological Agents Registry requires UNC to register all select agents with the NC Department of Health and Human Services. The 2002 Public Health Security and Bioterrorism Preparedness and Response Act require federal registration for possession and transfer of select agents, plant pathogens, and high consequence livestock pathogens and toxins.

The CDC Department of Health and Human Services (HHS) regulates select agents targeting public health (42 CFR 73), the United States Department of Agriculture (USDA) regulates select agents targeting agriculture, animal and animal products (7 CFR 331 and 9 CFR 121), and agents regulated by both HHS and USDA are called “overlap” agents. Investigators at UNC using overlap agents need to comply only with the HHS rules (42 CFR 73).

Faculty, staff and students may access or possess a select agent only for reasonably justified bona fide research purposes. EHS manages UNC’s compliance program for these agents under the oversight of the Institutional Biosafety Committee (IBC). EHS tracks select agent use on campus, including the specific agent, the Principal Investigator, his or her laboratory personnel and their training, where the agent is used, security measures, and facility engineering controls. Please contact EHS for help in complying with these rules, policies and procedures.

If you discover a select agent (see Select Agents and Toxins) in your lab that has not been registered, contact EHS immediately.

Table of Contents

1. Definitions
2. Registration
3. Select Agent Authorization
4. Requirements for Select Agent Personnel
5. Required Plans and SOPs
   1. Biosafety Plan
   2. Incident Response Plan
   3. Security Plan
   4. BSL-3 Laboratory Standard Operating Procedures
6. Required Documentation
7. Annual Inspections
8. Select Agents and Toxins
   1. 42 CFR 73.3 HHS Select Agents and Toxins
   2. 42 CFR 73.4 HHS Overlap Select Agents and Toxins
   3. 7 CFR 331.3 USDA Plant Protection and quarantine Select Agents and Toxins
   4. 9 CFR 121.3 USDA Veterinary Services (VS) List of Select Agents and Toxins
9. Permissible Toxin Amounts (HHS Toxins [§73.3(d)(7)])
   1. Due Diligence Provision: [§ 73.3(d)(7)(i)]

Definitions

• Access: The freedom or ability to obtain or make use of or the ability to carry, use or manipulate select agents
• Biosafety Plan: A written biosafety plan that is commensurate with the risk of the select agent or toxin, given its intended use. The plan must contain sufficient information and documentation to describe the biosafety and containment procedures for the select agent or toxin, including any animals (including arthropods) or plants intentionally or accidentally exposed to or infected with a select agent.
• On-going Suitability Assessment Program: After the initial pre-access suitability assessment, a standardized procedure to determine if an individual displays behaviors determined by UNC that would increase the risk of a theft, loss, or release of a select agent or toxin.
• Personnel Suitability: Personnel with access to select agents or toxins should not display behaviors determined by UNC that would increase the risk of a theft, loss, or release of a select agent or toxin.
• Pre-Access Suitability Assessment Program: The evaluation of an individual using a standardized procedure to determine if the individual displays behaviors determined by UNC that would increase the risk of a theft, loss, or release of a select agent or toxin.
• Repository materials: Agents for which select agent inventory records will be maintained. These include: non-excluded select agent toxins, virulent select agents, nucleic acids that can produce infectious forms of select agent viruses, nucleic acids that encode for functional forms of select agent toxins (if they can be expressed in vivo or in vitro or are in a vector or recombinant host genome), and animal tissue containing virulent select agents.
• Responsible Official: The individual designated by UNC with the authority and responsibility to act on behalf of UNC to ensure compliance with Section 9 of the select agent regulations. UNC has designated the Executive Director of Environment, Health and Safety to be the Responsible Official. The Biological Safety Officer and the Associate Biosafety Officer serve as Alternate Responsible Officials (ARO).
• Select agent laboratory: A room or suite of rooms, such as a laboratory or animal care area, which EHS has authorized for the storage or use of a select agent. This area must be delineated in the Laboratory Safety Plan and meet the security standards described in the Security Plan. In most cases, security measures are also in place outside of the select agent laboratory, which creates a larger secure area.
• Security Risk Assessment (SRA): An FBI procedure for obtaining approval under Section 73.10 for access to a select agent or toxin. As described below, an approved FBI security risk assessment is required for UNC’s Responsible Official, Alternate Responsible Officials, select agent authorized users, other select agent personnel and any other person who—in the normal scope of his or her duties—would have (or be permitted) unescorted access to a select agent or toxin. When FBI approval is granted individuals are considered, “SRA-approved.” Access approval is valid for a maximum of 3 years.
• Select agent: Biological agents and toxins listed in Section 8 of this chapter, in 42 CFR 73, 7 CFR 331, 9 CFR 121 and the NC Biological Agents Registry Law.
• Select agent authorized user: A principal investigator who is authorized by EHS and the IBC to work with a select agent. The select agent authorized user may designate an SRA-approved co principal investigator for certain responsibilities as described in this chapter.
• Select agent tracking system: A secure web-based information system used at UNC to meet the inventory, recordkeeping and tracking requirements.
• Select agent worker: A student, staff member, visiting scientist or faculty member (including the select agent authorized user) who has obtained a security risk assessment, has satisfied training requirements, and has met all other applicable UNC training, occupational health and EHS requirements. Only select agent workers may ship, transport or access a select agent.
• Suitability Assessment Program: A combination of pre-access and on-going suitability practices, in conjunction with comprehensive and consistent review mechanisms, determining the reliability of personnel for access to Tier 1 BSAT, and allowing individuals to report risks and threats to safety and security concerning Tier 1 BSAT UNC leadership.
• Tier 1 BSAT: A subset of select agents or toxins designated in the select agent regulations as “Tier 1” because these agents and toxins present the greatest risk of deliberate misuse with the most significant potential for mass casualties or deleterious effects on the economy, critical infrastructure, or public confidence.

Registration

If you wish to begin work with a select agent or toxin contact EHS to begin the registration process. Before possessing, using, or receiving select agents, the Universitymust register with the CDC and/or the USDA and demonstrate compliance with specific safety and security standards for handling these agents. Registration includes security risk assessment and criminal background checks for individuals seeking access to the agents, security plans, and inventories. EHS will coordinate and submit the registration, and any updates. The registration is valid for 3 years.

Prior to making any changes, principal investigators must notify EHS so that the CDC is promptly notified and to obtain prior approval. Changes that require notification include modifications to the list of individuals designated for access to select agents, changes in work locations, or changes in protocols or objectives of the studies.

The Principal Investigator or Co-Principal Investigator must contact EHS to request authorization for access for an individual to a select agent laboratory. EHS will send an amendment to the CDC. The individual will need to fill out a lab worker registration form. Select agent workers must notify EHS immediately when they intend to terminate employment in the select agent laboratory or at UNC.

Select Agent Authorization

Authorization is agent-specific. The University must seek separate authorization for each select agent they plan to work with. Authorization requires:

• Approved Safety Protocols: Select agent authorized users must have an approved Laboratory Safety Plan and BSL-3 Laboratory SOP that describes the facilities, equipment, procedures, and security for safely handling these agents. The Plan should document: the individual agents and the type of work being done, safety procedures appropriate for work with these agents, including access control, employee safety, and laboratory security; and agent destruction and disposal procedures.
• Safe and Appropriate Facilities: Select agent laboratories must meet the applicable standards in the current edition of Biosafety in Microbiological and Biomedical Laboratories (BMBL).
• Adequate agent, laboratory, building and cyber security: Select agent laboratories must meet strict security requirements to prevent access from unauthorized persons. Security procedures are detailed in UNC’s Security Plan. This plan is a secure document and will only be provided to registered select agent personnel.
• Compliance with UNC safety policies and procedures: In addition to legal requirements, select agent personnel must comply with UNC safety policies and procedures found in the EHS Laboratory Safety and Biological Safety Manuals, applicable standards in Biosafety in Microbiological and Biomedical Laboratories, training requirements, annual medical surveillance and procedures described in the Laboratory Standard Operating Procedure.
• Compliance with suitability assessments: Select agent workers must comply with pre-access suitability, ongoing suitability, self and peer reporting requirements to remain in the select agent program.
• Compliance of Select Agent Personnel: The select agent authorized user is responsible for the conduct of all select agent personnel who have access to the select agent under his or her authorization.
• Security Risk Assessment (SRA): No person may access a select agent or toxin unless the CDC and the FBI have approved their security risk assessment. Students, staff, visiting scientists or faculty (including the principal investigator) who may ship, transport, access or possess a select agent must obtain an FBI security risk assessment prior to gaining access to a select agent. Following the FBI assessment, the individual will receive authorization from the RO/ARO for access to the select agent laboratory.

An unresolved security breach, a serious variance identified by an EHS safety survey or noncompliance with other UNC safety and security policies and procedures may result in the suspension of select agent authorization, confiscation of the select agent or toxin, or denial of access to the select agent laboratory until the matter is resolved.

Requirements for Select Agent Personnel

Only an SRA approved select agent worker may ship, transport or have unescorted access to a select agent or toxin. A select agent worker is a student, staff member, visiting scientist or faculty member (including the principal investigator) who has:

• Met minimal education and experience requirements: Individuals may not have access to select agents or toxins unless they have the following minimal education and experience:
  • A bachelor’s degree and/or training and experience to handle such agents and toxins. PI and EHS to determine final approval for entry.
  • Training specific for select agent laboratory. This currently includes review of the Laboratory Safety Plan, Laboratory SOP, Biosafety Plan, Security Plan, Incident Response Plan and a tour of the research laboratories by a qualified lab member.
  • At least 6 months of experience involving aseptic technique in a biological safety cabinet.
  • At least 6 months of experience with applicable techniques (e.g., plaque assay, cell culture infections, centrifugation, etc.)
• Been designated for select agent access by the select agent authorized user: Honest, reliable and conscientious workers represent the foundation of an effective security program. The security risk assessment is retrospective, limited and does not obviate the need for exercising good judgment in selecting honest, reliable and conscientious workers. Extra care should be taken when selecting laboratory personnel and authorizing access. The selection process should include others so that a consensus judgment is made. References must be checked. The select agent authorized user, or his/her designated SRA-approved co-principal investigator, are responsible for notifying the Responsible Official of any new faculty, staff, students, visiting scholars or other individuals who wish to apply for access to a select agent.
• Obtained a security risk assessment: No person may access a select agent or toxin unless the CDC and the FBI have approved their security risk assessment. Anyone, including visitors, who have the freedom or ability to obtain and make use of a select agent or toxin, must be approved. To obtain a security risk assessment:
  • EHS will provide the employee with a Unique Identifying Number (UIN). The employee will complete the FD-961. The completed form must be reviewed and signed by the RO. The employee will take the completed and signed FD-961 to UNC Police and get two sets of fingerprint cards completed. EHS will mail the completed FD-961 and the two fingerprint cards to the FBI.
• Obtained a pre-assessment suitability: Individuals that need access to Tier 1 BSAT, must complete a pre-access suitability interview with the RO and are subject to UNC’s ongoing suitability assessment program.
• Satisfied security and safety training requirements: This training will ensure that all select agent personnel understand security requirements and are trained and equipped to follow estogglelished procedures. EHS will provide this training and retain training records.
• Met all other applicable UNC training, occupational health and EHS requirements: These requirements include attending UNC Laboratory Safety Training and compliance with UNC Environment, Health and Safety policies and procedures. Other requirements may apply depending on the particular risks associated with the work to be performed.

Required Plans and SOPs

Biosafety Plan

The Biosafety Plan (BSP) is commensurate with the risk of the select agent or toxin, given its intended use identified by the U.S. Department Health and Human Services (HHS) under Title 42, Part 73 of the Code of Federal Regulations (42 CFR 73) at UNC. The goal of UNC’s BSP is to describe BSAT biosafety and containment, including for any animals (including arthropods) or plants intentionally or accidentally exposed to or infected with select agents.

UNC’s BSP is intended for use as a guidance document for select agent personnel. The CDC Guidance document entitled “Select Agents and Toxins Biosafety and Biocontainment Plan Guidance,” the “Biosafety in Microbiological and Biomedical Laboratories” (BMBL) and “NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules” were used as a reference documents for preparing the plan.

A hard copy of the Biosafety Plan is available at Environment, Health and Safety and an electronic version is also available for select agent personnel to review. The Biosafety Plan is reviewed at least annually by EHS and Principal Investigators.

Incident Response Plan

This Incident Response Plan (IRP) addresses emergency and incident responses to prevent the theft, loss, or release of select agents and toxins identified by the U.S. Department of Health and Human Services (HHS) under Title 42, Part 73 of the Code of Federal Regulations (42 CFR 73) at UNC. The goal of UNC’s IRP is to preserve the safety and security of the University’s staff, emergency responders, the public and the environment.

UNC’s IRP is intended for use as a guidance document for select agent and emergency personnel responding to incidents involving UNC select agent laboratories. The CDC Guidance document entitled “FSAP Guidance-IRP” was used as a reference document for preparing the plan. UNC’s IRP is based upon a site-specific Risk Assessment.

This plan is coordinated with the Emergency Plan of the University of North Carolina at Chapel Hill. A hard copy is available at Environment, Health and Safety and an electronic version is also available for select agent personnel to review. The IRP is reviewed at least annually by EHS and Principal Investigators.

Security Plan

The Security Plan addresses the safety, security, and compliance of Select Agents and toxins identified by the U.S Department of Health and Human Services (HHS) under Title 42, Part 73 of the Code of Federal Regulations (42 CFR 73) at UNC. The goal of UNC’s Security Plan is to safeguard select agents or toxins against unauthorized access, theft, loss, or release.

UNC’s Security Plan is intended for use as a guidance document for select agent personnel. The CDC Guidance document entitled “Security Plan Guidance” was used as a reference document for preparing the plan. UNC’s Security plan is based upon a site-specific Risk Assessment.

A hard copy of the Biosafety Plan is available at Environment, Health and Safety and an electronic version is also available for select agent personnel to review. The Security Plan is reviewed at least annually by EHS, Principal Investigators and Chief of UNC Police.

BSL-3 Laboratory Standard Operating Procedures

Each select agent lab is required to have a lab-specific SOP. The SOP is required to have hazard information, facility descriptions, entry and training requirements, medical surveillance requirements, daily operating procedures, entry and exit procedures and information regarding lab equipment. The SOP is reviewed at least annually by the PI/Lab Manager, EHS and the IBC.

Required Documentation

Select agent records are maintained by the Select Agent Authorized User as well as centrally at EHS and within the University’s select agent tracking system. All records must be maintained for a minimum of three years.

• Inventory Records: Each select agent authorized user shall maintain an accurate, current inventory of each select agent held in storage and implement effective inventory control procedures. The Select Agent Inventory and Tracking System used to maintain these records is described in the Security Plan.
• List of approved individuals: EHS maintains a current list of all SRA-approved personnel.
• Records of access into the select agent laboratory: For SRA-approved individuals, access to and exit from a select agent laboratory is recorded and maintained by the keycard access system for that area. A logbook is used to record entry to select agent laboratories by visitors and other individuals who are not SRA approved. The logbook is maintained by the laboratory and reviewed by EHS during the annual laboratory inspection.
• Records of internal inspections: EHS will maintain inspection records and laboratory responses to inspections.
• Transfer Documents: EHS maintains Form 2 and intra-entity transfer documents.
• Training records: EHS will maintain training records.
• Safety and security incident reports: EHS and the UNC Police will maintain safety and security incident reports.

Annual Inspections

UNC Police and EHS will perform an annual security inspection of buildings and laboratories where select agents are in use. UNC Police and EHS will jointly review agent, laboratory and building security.

EHS will verify the accuracy and authenticity of the laboratory’s entry logs (i.e., keycard system reports and visitor logbook) by verifying that the listed select agent workers, visitors and other personnel had an approved security risk assessment and/or other authorizations at the time they accessed the area where select agents are used or stored.

EHS will perform an annual inspection that reviews:

• safety practices
• personal protective equipment
• training compliance
• facility operational parameters
• biological safety cabinet and HEPA filter certifications
• engineering controls
• compliance with the occupational health program

EHS will verify the accuracy and authenticity of select agent inventory records by conducting a physical inventory yearly.

Select Agents and Toxins

42 CFR 73.3 HHS Select Agents and Toxins

Except for exclusions listed in §73.3(d) and (e) of the regulations, the biological agents and toxins listed in this section have a potential to pose severe threat to public health and safety. The select agents and toxins marked with an asterisk (*) are designated as Tier 1 select agents and toxins and are subject to additional requirements.

Viruses

1. Crimean-Congo haemorrhagic fever virus
2. Eastern Equine Encephalitis
3. Ebola viruses*
4. Lassa fever virus
5. Lujo virus
6. Marburg virus*
7. Monkeypox virus
8. Reconstructed replication competent forms of the 1918 pandemic influenza virus containing any portion of the coding regions of all eight gene segments (Reconstructed 1918 Influenza virus)
9. SARS-associated coronavirus (SARS-CoV)
10. South American Haemorrhagic Fever viruses (Chapare, Guanarito, Junin, Machupo, Sabia,)
11. Tick-borne encephalitis complex (flavi) viruses (Far Eastern subtype, Siberian subtype, Kyasanur Forest disease, Omsk Hemorrhagic Fever)
12. Variola major virus (Smallpox virus)*
13. Variola minor virus (Alastrim)*

Bacteria

1. Bacillus cereus Biovar anthracis*
2. Botulinum neurotoxin producing species of Clostridium*
3. Coxiella burnetti
4. Francisella tularensis*
5. Rickettsia prowazekii
6. Yersinia pestis*

Toxins

Excluded quantities of toxins are listed in § 73.3(d) (7).

1. Abrin
2. Botulinum neurotoxins*
3. Conotoxins (Short, paralytic alpha conotoxins containing the following amino acid sequence X₁CCX₂PACGX₃X₄X₅X₆CX₇)
4. Diacetoxyscirpenol
5. Ricin
6. Saxitoxin
7. Staphylococcal enterotoxins A, B, C, D, E subtypes
8. T-2 toxin
9. Tetrodotoxin

Genetic Elements, Recombinant and/or Synthetic Nucleic Acids, and Recombinant and/or Synthetic Organisms

1. Nucleic acids that can produce infectious forms of any of the select agent viruses listed above.
2. Recombinant and/or synthetic nucleic acids (synthetic or naturally derived) that encode for the toxic form(s) of any of the toxins listed above if the nucleic acids:
   1. Can be expressed in vivo or in vitro; or
   2. Are in a vector or recombinant host genome and can be expressed in vivo or in vitro.
3. HHS select agents and toxins listed above that have been genetically modified.

42 CFR 73.4 HHS Overlap Select Agents and Toxins

Except for exclusions listed in § 73.4(d) and (e) of the regulations, the biological agents and toxins listed in this section have a potential to pose severe threat to public health and safety, to animal health, or to animal products. The select agents and toxin marked with an asterisk (*) are designated as Tier 1 select agents and toxins and are subject to additional requirements.

Viruses

1. Hendra virus.
2. Nipah virus.
3. Rift Valley fever virus.
4. Venezuelan Equine Encephalitis virus.

Bacteria

1. Bacillus anthracis*
2. Bacillus anthracis Pasteur strain
3. Brucella abortus.
4. Brucella melitensis.
5. Brucella suis.
6. Burkholderia mallei*
7. Burkholderia pseudomallei*

Genetic elements, recombinant and/or synthetic nucleic acids, and recombinant and/or synthetic organisms:

1. Nucleic acids that can produce infectious forms of any of the overlap select agent viruses listed above.
2. Recombinant and/or synthetic nucleic acids that encode for the toxic form(s) of any overlap toxins listed above if the nucleic acids:
   1. Can be expressed in vivo or in vitro; or
   2. Are in a vector or recombinant host genome and can be expressed in vivo or in vitro.
3. Overlap select agents and toxins listed above that have been genetically modified.

7 CFR 331.3 USDA Plant Protection and quarantine Select Agents and Toxins

Except for exclusions listed in §331.3(d) and (e) of the regulations, the biological agents and toxins listed in this section have been determined to have the potential to pose a severe threat to plant health or to plant products.

Bacteria

1. Peronosclerospora philippinensis (Peronosclerospora sacchari)
2. Phoma glycinicola (formerly Pyrenochaeta glycines)
3. Ralstonia solanacearum
4. Rathayibacter toxicus
5. Sclerophthora rayssiae
6. Synchytrium endobioticum
7. Xanthomonas oryzae

Genetic elements, recombinant and/or synthetic nucleic acids, and recombinant and/or synthetic organisms

1. Nucleic acids that can produce infectious forms of any of the select agent viruses listed above.
2. Recombinant and/or synthetic nucleic acids that encode for the functional form(s) of any toxin listed above if the nucleic acids:
   1. Can be expressed in vivo or in vitro; or
   2. Are in a vector or recombinant host genome and can be expressed in vivo or in vitro.
3. Select agents and toxins listed above that have been genetically modified.

9 CFR 121.3 USDA Veterinary Services (VS) List of Select Agents and Toxins

Except for exclusions listed in § 121.3 (d) and (e) of the regulations, the biological agents and toxins listed in this section have a potential to pose severe threat to animal health or to animal products. The select agents and toxin marked with an asterisk (*) are designated as Tier 1 select agents and toxins and are subject to additional requirements.

Animal agents and toxins

1. African horse sickness virus
2. African swine fever virus
3. Avian influenza virus
4. Classical swine fever virus
5. Foot-and-mouth disease virus*
6. Goat pox virus
7. Lumpy skin disease virus
8. Mycoplasma capricolum
9. Mycoplasma mycoides
10. Newcastle disease virus
11. Peste des petits ruminants virus
12. Rinderpest virus*
13. Sheep pox virus
14. Swine vesicular disease virus

Genetic elements, recombinant and/or synthetic nucleic acids, and recombinant and/or synthetic organisms

1. Nucleic acids that can produce infectious forms of any of the select agent viruses listed above.
2. Recombinant and/or synthetic nucleic acids that encode for the functional forms of any toxin listed above, if the nucleic acids:
   1. Can be expressed in vivo or in vitro; or
   2. Are in a vector or recombinant genome and can be expressed invivo or in vitro.
3. VS select agents and toxins listed in this section that have been genetically modified.

Permissible Toxin Amounts (HHS Toxins [§73.3(d)(7)])

Except as required in § 73.16(l), the following toxins are not regulated, if the aggregate amount of toxin under the control of a principal investigator, treating physician or veterinarian, or commercial manufacturer or distributor does not, at any time, exceed the following amounts indicated in the table below

Due Diligence Provision: [§ 73.3(d)(7)(i)]

The Federal Select Agent Program developed this provision because there is always a concern that someone might stockpile toxins by receiving multiple orders below the excluded amount. In order to address this issue, the Federal Select Agent Program has put in place the “toxin due diligence” provision.

This provision requires a person transferring toxins in amounts which would otherwise be excluded from the provisions to use due diligence and document the identification of the recipient and the legitimate need (e.g., prophylactic, protective, bona fide research, or other peaceful purpose) claimed by the recipient to use such toxin. Information to be documented includes, but is not limited to, the recipient identity information, including the recipient’s name, institution name, address, telephone number and email address; name of the toxin and the total amount transferred; and the legitimate need claimed by the recipient.

Notwithstanding the provisions of paragraph (d) in the regulations, the HHS Secretary retains the authority to, without prior notification, inspect and copy or request the submission of the due diligence documentation to the CDC.

UNC has implemented this provision by asking the Principal Investigator the following questions on the Lab Safety Plan.

“I will require the recipient to complete and submit to me documentation stating their intended use of the toxins, information pertinent to the person requesting and using the toxins includes the individual’s name, institution name, address, telephone number, and email address.” “I will document my knowledge of the recipient’s legitimate need for the toxins pertinent to the person requesting and using the toxins. Information pertinent to the person requesting and using the toxins includes the individual’s name, institution name, address, telephone number and email.”

“Those toxins that are stored and/or manipulated in our laboratory do not fall under the Select Agent regulations.”

When completed, the lab safety plan “Due Diligence” section is submitted online to the Biosafety Section for review to ensure Principal Investigators are complying with the regulations.

Through the lab safety plan, the Biosafety Section tracks which researchers have toxins and can run a report for inspection purposes.

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