Excluded and Exempt Select Agents and Toxins Use Policy

Policy Statement

Institutional Biosafety Committee Policy #: 120.2

I. Purpose

Dartmouth College is not a registered entity with the Federal Select Agent Program; therefore only research involving excluded select agents or toxins or permissible amounts (exempt quantities) of select agent toxins (SAT) is permitted. This Institutional Biosafety Committee (IBC) policy describes the requirements on the use of exempt or excluded select agents and toxins at Dartmouth. These requirements have been established to ensure safe handling and disposal procedures, effective tracking and security, and to be in compliance with federal regulations regarding select agent and toxin use. Any person wishing to begin research involving excluded or permissible amounts of select agents or toxins must receive prior approval from the Dartmouth IBC before possession of the agent/toxin.

II. Definitions

i. Select Agents and Toxins: a subset of biological agents and toxins that the Departments of Health and Human Services (HHS) and Agriculture (USDA) have determined to have the potential to pose a severe threat to public health and safety, to animal or plant health, or to animal or plant products.

The current list of select agents and toxins is updated every two years and can be found at: http://www.selectagents.gov/SelectAgentsandToxinsList.html.

NOTE: Dartmouth is not part of the Federal Select Agent Program, so only excluded select agents or exempt quantities of select agent toxins are permitted.

ii. Select Agent and Toxin Nucleic Acids: nucleic acids that are capable of producing infectious forms of select agents and functional forms of select toxins, including complete genomes as well as recombinant and/or synthetic nucleic acids. The following are regulated as select agents:

a. Nucleic acids that can produce infectious forms of any of the select agent viruses.
b. Recombinant and/or synthetic nucleic acids that encode for the functional form(s) of select toxins 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.

c. Select agents and toxins that have been genetically modified.

NOTE: Dartmouth is not part of the Federal Select Agent Program, so select agent and toxin nucleic acids, as defined above, are not permitted.

iii. Select Agent Regulations: The select agent regulations can be found at http://www.selectagents.gov/regulations/. The regulations include:

1. 42 CFR Part 73 = covers human pathogens/toxins (HHS/CDC select agents/toxins) and those that can also affect animals (called the "overlap" select agents/toxins)
2. 9 CFR Part 121 = covers animal pathogens/toxins (USDA/APHIS) and those that can also affect humans (called the "overlap" select agents/toxins)
3. 7 CFR Part 331 = covers plant pathogens/toxins (USDA/APHIS Plant Protection and Quarantine)

iv. Permissible Toxin Amounts (Exempt Quantities): Certain toxins are not regulated if the amount under the control of a principal investigator does not exceed, at any time, the amounts indicated in Section VI.ii below. Please refer to the list provided on the Select Agent website for the most current information: http://www.selectagents.gov/PermissibleToxinAmounts.html.

v. Excluded Select Agent or Toxin: An attenuated strain of a select biological agent or toxin that does not pose a severe threat to public health and safety, animal health, or animal products may be excluded from the requirements of the select agent regulations. Please refer to the Excluded Select Agents List for the most up to date information: http://www.selectagents.gov /SelectAgentsandToxinsExclusions.html.

vi. Tier 1 Agent: A subset of select agents and toxins have been designated as Tier 1 (per Executive Order 13546) because these biological agents and toxins present the greatest risk of deliberate misuse with significant potential for mass casualties or devastating effect to the economy, critical infrastructure, or public confidence, and pose a severe threat to public health and safety.

NOTE: NO Tier 1 agents are permitted at Dartmouth. Please refer to the Select Agents and Toxins list for the most current list of Tier 1 agents: http://www.selectagents.gov/SelectAgentsandToxinsList.html.

III. Regulatory Background

The Federal Select Agent Program (FSAP) is jointly comprised of HHS/CDC Division of Select Agents and Toxins (DSAT) and the USDA/APHIS Agriculture Select Agent Services (AgSAS). The FSAP oversees the possession, use, and transfer of biological select agents and toxins that have the potential to pose a severe threat to public, animal or plant health or to animal or plant products. The select agent regulations implement the Bioterrorism Preparedness and Response Act of 2002 (42 USC 262a), Agricultural Bioterrorism Protection Act of 2002 (7 USC 8401) and Executive Orders 13486 and 13546 (http://www.selectagents.gov/faq-legislature.html). Any individual or entity wishing to work with select agents or toxins must register with the FSAP to comply with these regulations.

IV. Repercussions of Non-Compliance (pursuant to the USA Patriot Act)

i. Administrative:

a. The Federal Select Agent Program has the authority to deny, suspend, or revoke registration to use, possess, or transfer select agents and toxins.

b. The Federal Select Agent Program has the authority to deny an individual access to select agents and toxins to protect public health and  safety.

ii. Civil:

a. In addition to any other penalties that may apply, any person who violates any provision of select agent regulations shall be subject to a civil money penalty in an amount <$250,000 (individual) or <$500,000 (institution).

iii. Criminal: Violations of 18 USC 175b

a. A "restricted person" that possesses a select agent or toxin, or transfers select agent or toxin in interstate or foreign commerce, (and is not excluded or exempted under select agent regulations) is subject to a criminal fine and/or imprisonment for up to 10 years.

b. Whoever transfers a select agent or toxin to a person who the transferor knows or suspects is not operating in accordance with the select agent regulations is subject to a criminal fine and/or imprisonment for up to 5 years.

c. Whoever knowingly possesses a select agent or toxin and is not operating in accordance with the select agent regulations is subject to a criminal fine and/or imprisonment for up to 5 years.

V. Responsibilities

i. Principal Investigators (PIs) are responsible for:

a. Compliance with the Federal Select Agent Regulations.

b. Restricting use of select agents and toxins to those that are on the exclusions list or are of permissible levels (see above, Definitions).

c. Obtaining approval for any select agent and toxin work with the Dartmouth Institutional Biosafety Committee prior to possession.

d. Never exceeding the permissible quantity at any time of any select agent toxin on the permissible level list (see Section VI.iii below).

e. Maintaining an active inventory of any select agent or toxin. This includes tracking the use, transfers, and destruction/disposal.

f. Keep any permissible amounts of select agent toxins locked and secured.

g. Training (and documenting training) of all lab personnel in the safe handling, PPE, and decontamination and segregation procedures of select agents/toxins

h. The proper deactivation/decontamination and disposal of any select agent or toxin or material that has been in contact with a select agent or toxin. See decontamination procedures below.

i. Notifying the IBC of any loss of containment, non-compliance, or exposures.

ii. Dartmouth College is responsible for:

a. Ensuring compliance with the Federal Select Agent Regulations

b. Institutional Biosafety Committee (IBC) oversight of select agent and toxin use

c. Reporting any instances of non-compliance

d. Ensuring compliance with this institutional policy

e. Registering as an entity with the Federal Select Agent Program if the need arises

VI. Procedures

i. Authorization

Any person wishing to begin research involving excluded or permissible amounts of select agents or toxins must receive prior approval from the Dartmouth Institutional Biosafety Committee (IBC) before possession of the agent/toxin. A lab-specific standard operating procedure (SOP) must be submitted to the IBC as part of the review. Contact the Biosafety Officer for assistance.

ii. Lab Specific Standard Operating Procedures (SOPs)

Lab specific SOPs for safe use of excluded or permissible amounts of select agents or toxins must be based upon the recommendations found in the HHS/CDC/NIH Biosafety in Microbiological and Biomedical Laboratories (5th Ed., 2009). Modifications or additional requirements may be made by the IBC. SOPs should contain information that includes the name of the agent or toxin, laboratory procedures using the agent or toxin, a risk assessment and how potential exposures will be avoided, appropriate personal protective equipment and facility/engineering containment measures, required training, deactivation and disposal procedures, signage, and any occupational health considerations (signs/symptoms of exposure, how to respond to an exposure, available treatments, etc.) See Appendix A for an example.

iii. Permissible Levels

The following toxins are not regulated if the amount under the control of a principal investigator does not exceed, at any time, the amounts indicated in the FSAP Permissible Amounts List (Table 1).

Table 1. Permissible Amounts of Select Agent Toxins (as of 2/16/17*):

HHS Toxins [§73.3(d)(3)]:

• Abrin — 100 mg
• Botulinum neurotoxins — 1 mg
• Short, paralytic alpha conotoxins — 100 mg
• Diacetoxyscirpenol (DAS) — 10000 mg
• Ricin — 1000 mg
• Saxitoxin — 500 mg
• Staphylococcal Enterotoxins (Subtypes A, B, C, D, and E) — 100 mg
• T-2 toxin — 10000 mg
• Tetrodotoxin — 500 mg

*Consult current list here: http://www.selectagents.gov/PermissibleToxinAmounts.html

In the event that a PI mistakenly acquires a quantity of select agent toxin greater than the permissible amount, they should contact the Biosafety Officer immediately.

iv. Training

All personnel possessing, using, transferring, or receiving select agents or toxins must have agent-specific training as required by the IBC and Environmental Heath & Safety (EHS). Training may be included as part of the lab-specific SOP. Retraining is required annually.

At a minimum, agent specific training should include:

• Review MSDS and physical properties and hazards of toxin
• Discuss routes, signs, and symptoms of exposure
• Discuss potential risks of experimental procedures that may result in an exposure
• Plan emergency actions and what to do in case of exposure
• Review available vaccinations or post-exposure (anti-toxin) management procedures
• Outline control measures for working with toxin (PPE, fume hood, transporting, never working alone, etc.)
• Identify appropriate methods for decontamination and disposal
• Discuss inventory control, lock box, and restricted access
• Review BMBL Appendix I "Guidelines for work with toxins of biological origin"

This training must be specific to each lab and is the responsibility of the PI (assistance is available from EHS). Documentation of training including dates, material covered and signatures of attendees must be kept on file in the lab. These records should be maintained indefinitely.

v. Lab Inspections

Laboratories and campus facilities possessing, using, transferring or receiving exempt quantities or excluded select agents and toxins will be inspected periodically by EHS. If a facility is found to be in non-compliance, approval to work with the materials may be revoked by the IBC. See Appendix B for an example inspection checklist.

vi. Security

All laboratories using, transferring, or receiving excluded or permissible amounts of select agents or toxins must comply with all of the security, inventory, and containment requirements as follows:

• Select agents/toxins must be secured against unauthorized access
• Select agents/toxins must be under lock and key security when not in use, including freezers, refrigerators, cabinets and other storage containers.
• An accurate inventory must be maintained (see Appendix C).
• Only authorized personnel are allowed in laboratory use areas during select agents/toxins use or transfer. Door signage must be in place when SAT are in use.
• Key control programs must be in place to track lab door and storage cabinet keys, including dates issued and returned. Locks must be changed if keys are lost or unaccounted.

vii. Decontamination/Deactivation of Select Agents and Toxins

a. Excluded Select Agents: Decontamination of excluded select agents should be conducted in accordance with the Dartmouth College Biohazard Waste Guide and the Emergency Response and Biohazard Exposure Control Plan.

b. Select Agent Toxins (permissible levels): General guidelines for laboratory decontamination of selected toxins are summarized HHS/CDC/NIH Biosafety in Microbiological and Biomedical Laboratories, (BMBL, 5th Ed.) Appendix I, Guidelines for Work with Toxins of Biological Origin.

c. General guidelines for laboratory decontamination of selected select agent toxins are summarized in Table 2. Many toxins are susceptible to inactivation with dilute sodium hydroxide (NaOH) at concentrations of 0.1-0.25N, and/or sodium hypochlorite (NaOCl) bleach solutions at concentrations of 0.1-0.5% (w/v). Use freshly prepared bleach solutions for decontamination; undiluted, commercially available bleach solutions typically contain 3-6% (w/v) NaOCl. Consult the BMBL Appendix I, Guidelines for Work with Toxins of Biological Origin for more specific information.

Depending upon the toxin, contaminated materials and toxin waste solutions can be inactivated by incineration, autoclaving, or by soaking in suitable decontamination solutions. All disposable material used for toxin work should be placed in secondary containers, decontaminated in accordance with the appropriate method used to inactivate the toxin, autoclaved, and disposed of as hazardous waste. The initial decontamination step (ex: bleach soak) should occur immediately following use of the SAT. Contaminated waste should be autoclaved promptly. Contact EHS for assistance.

Contaminated or potentially contaminated protective clothing and equipment should be decontaminated using suitable chemical methods or autoclaving before removal from the laboratory for disposal, cleaning or repair. If decontamination is impracticable, materials should be disposed of as hazardous waste. Contact EHS for assistance.

In the event of a spill, avoid splashes or generating aerosols during cleanup by covering the spill with paper towels or other disposable, absorbent material. Apply an appropriate decontamination solution to the spill, beginning at the perimeter and working towards the center.

Inactivation procedures should not be assumed to be 100% effective without validation using specific toxin bioassays. Please review the table below for appropriate measures for biological toxins. If you are working with a biological toxin not listed here, consult the EHS office for further assistance.

Table 2. Inactivation Methods for a Few Select Agent Toxins

NaOCl = Sodium hypochlorite; NaOH = Sodium hydroxide; YES = complete inactivation; YES? = assumed inactivation; NO = no inactivation; * see recommendations below Adapted from BMBL, Appendix I; Biological Safety Principles and Practices; and UC Denver/Anschutz EHS

* Recommendations

• For complete inactivation of T-2 mycotoxins, all liquid samples, spills, and nonburnable waste shall be soaked in 2.5% NaOCl with 0.25N NaOH for 4 hours. All solid wastes will be segregated in a closed container for incineration in the chemical hazardous waste stream. It is further recommended that cages and bedding from animals exposed to T-2 mycotoxin be exposed to 0.25% NaOCl
  and 0.025 N NaOH for 4 hours, prior to further cage-cleaning/cage-wash operations.
• Exposure to 1% NaOCl for 30 minutes is an effective inactivation method for saxitoxin, tetrodotoxin, ricin, botulinum toxin, or staphylococcal enterotoxins (SEB) for working solutions, equipment, working area and spills.
• Autoclaving can be used for protein toxins, i.e. ricin, botulinum toxin, and SEB, but should not be used with any of the low molecular weight toxins.
• Conotoxin inactivation depends on the presence or absence of disulfide bonds.
  i. For conotoxins with disulfide bonds: incubate with an excess of dithiothreitol (DTT) (10-20mM buffered solution, pH 8.7) for at least 1 hour at room temperature or 30 minutes at 50°C. Add an equal volume of 50-100mM solution of iodoacetamide (buffered solution, pH 8.7) and incubate for 1 hour at room temperature.
  ii. For conotoxins without disulfide bonds, incubate in a fume hood in a closed glass vial with 6N HCl for 24 hours at 90-110°C.

viii. Transfers – Due Diligence Provision

The Federal Select Agent Program has a provision to address the concern that someone might stockpile toxins by receiving multiple orders below the excluded amount. The "Due Diligence Provision" requires a person (registered or unregistered) transferring toxins in amounts that would otherwise be excluded from the provisions to:

1. use due diligence to assure that the recipient has a legitimate need to handle or use such toxins; and
2. report to FSAP if they detect a known or suspected violation or become aware of suspicious activity related to the toxin. The "due diligence" provision required under Section 16 applies to anyone (registered or unregistered individuals or entities) that transfers toxin listed under Section 73.3 in amounts that otherwise would be excluded from the regulations.

To document those individuals who have a legitimate purpose to handle and use such toxins, the transferor can either require the recipient to complete documentation stating their intended use of the toxins or the transferor can document their knowledge of the recipient's legitimate need for the toxins. Information pertinent to the person requesting and using the toxins includes the individual's name, institution name, address, telephone number, and e-mail address.

ix. Reporting Suspected Violation of Federal Law Suspicious Activity

The FSAP has established a confidential means for reporting safety and security issues associated with the possession, use and transfer of select agents and toxins.  The HHS, Office of Inspector General (OIG) maintains a hotline that allows individuals to anonymously report fraud, waste and abuse in all departmental programs. This hotline is now available to anonymously report safety or security issues related to select agents and toxins. When reporting these issues to OIG, please ensure that you indicate it is a "Select Agent Program" issue.
 
OIG Hotline Info:
Phone: 1-800-447-8477
Fax: 1-800-223-8164
Web: http://oig.hhs.gov/fraud/hotline

Mail:
Office of Inspector General
Dept of Health & Human Services
Attn: Hotline
PO Box 23489
Washington, DC 20026

VII. Resources

• Federal Select Agent Program: http://www.selectagents.gov/
• NIH Guidelines for Research Involving Recombinant and Synthetic Nucleic Acid Molecules (HHS, 2016)
• HHS/CDC/NIH Biosafety in Microbiological and Biomedical Laboratories (5th Ed.), 2009.
• Fleming, DO and Hunt, DL. Biological Safety Principles and Practices. (4th Ed.) ASM Press, 2006.
• Evers, DL, et al. 2013. Laboratory Decontamination of HHS-listed and HHS/USDA Overlap Select Agents and Toxins. Applied Biosafety 18(2); 59-71.