Hazard Prevention Strategies

in the Histopathology Lab

Manuelito A. Madrid, MD, FPSP

The laboratory is a hazardous

place
Hstopathology personnel work with:
Potentially infectious and radioactive
tissues
Potentially flammable, explosive, toxic,
and carcinogenic reagents
Fairly complex electrical equipments
Sharps, glasses, hot liquids
Repetitive motions
(Potentially irate doctors and patients!)

Laboratory environment
There is less chance of an accident
occurring in a clean, tidy laboratory.
Good ventilation for removal of toxic
and noxious fumes
Sufficient space for personnel,
equipment and supplies
Smooth flow of traffic and easy
communication

Work Practice Controls

Handwashing
In ample running water
liquid soap dispenser preferred

Cleaning work areas from clutter and

work surfaces with disinfectants
No eating, drinking, smoking in area
Job rotation minimizes repetitive tasks
Orientation, training, continuing
education
Warning signage of potential hazards

Chemical hazard warnings

Personal Protective Equipment

(PPE), barriers, and procedures
Gloves must be worn when
doing procedures with high risk of hand
contamination (staining, dissecting).
preparing liquid stains/reagents from
powder form.
open cuts/skin conditions are present that
increases infection risk from accidental
contamination.
when mopping up a spill.

PPE, barriers, and procedures

Gowns and laboratory coats
Masks: cutting bone, gross dissection
or activity that induces aerosolization
Protective goggles and safety glasses
Eyewash station and shower
Safety goggles and face shields
splashing with infectious or corrosive
liquids e.g. during staining procedures.

Avoid recapping of needles/sharps

Emergency shower

Eye wash station

Engineering Controls
Puncture-resistant containers for
disposal/transport of needles/sharps
Including broken glass, slides, coverslips

Color-coded biohazard bags (yellow)

Splash guards
Centrifuge safety buckets
Biological safety cabinets and fume
hoods
Mechanical pipetting devices
Computer wrist/arm pads

Sharps container

Equipment hazards
Each instrument should meet electrical
safety specifications and have written
instructions regarding use
Well grounded electrical outlets with
stable voltage.
Emergency power supply (brownouts)
Maintenance: refrigerating/ heating
elements
Wiring by qualified, skilled electrician
Frequent inspection of continuously-run
equipment

Equipment hazards
Mechanical
Centrifuge: balanced load, increase rotor
speed slowly, allow to stop before opening
lid
Periodic evaluation to assure proper
functioning at all times
Documentation:
1. date of inspection, validation, or
performance evaluation
2. significant action to remedy deficiencies
3. daily temperature recordings for all
temperature-controlled equipment

Chemical Hazard Plan

Each chemical compound used should have a
materials safety data sheet (MSDS) on file
specifies the nature, toxicity, and safety
precautions to be taken when handling the
compound. Must be in ENGLISH.
Maintain inventory of all chemicals with
chemical and common name
Manufacturer must assess and supply info
about chemical/physical hazards
(flammability, explosive, aerosol, flashpoint)
Ensure labels are not defaced or removed and
post appropriate warning

Cabinet for storage of chemicals

Orderly chemical storage

Storage practices for

flammables and combustibles
Bulk storage of flammable gases or
liquids away from sources of heat.
Ex. ether, acetone, xylene, alcohol

Withdraw an amount from main batch

good only for 2 days
Bulk storage of concentrated acids
should be at or near floor level, properly
identified
Fire extinguishers; fire alarms
CO2: for flammable liquids, chemicals, oil
and grease, electrical equipment
SODA: wood, paper, rag, glowing embers

Fire alarm

Fire
extinguisher
location

Infection hazards
Exposure of personnel to infection can
occur by aerosolization of tissues,
needlestick injury, scalpel/blade
wounds, and mucocutaneous exposure
during specimen processing.
In general, actual incidence of
transmission of infectious agents from
unfixed surgical specimens to
personnel is extremely low.

Infection hazards
Risk of infection depends on

Pathogen or microorganism involved

Type of exposure (wound, aerosol, mouth)
Amount of blood involved
Amount of virus in exposed blood

If exposed to blood, immediately

Wash with soap and water
Flush splashes to nose, mouth, skin with
water
Irrigate eyes with clean water, saline, or
sterile irrigants

Hepatitis B Virus (HBV)

All personnel should be vaccinated.
After needlestick injury, seroconversion
rate is 30% from HBeAg(+) blood and
<6% from HBeAg(--) blood in nonvaccinated individuals.
Mucocutaneous exposure can also occur.

Postexposure prophylaxis (HBV hyperimmune globulin and vaccine)

non-vaccinated individuals or vaccinated
persons with low antibody titers.
Treatment provides about 75% protection
if instituted within 7 days (1 week)

Hepatitis C Virus (HCV)

Risk is approximately 1-8% for HCV
transmission after a needlestick injury.
The risk after skin or mucous membrane
exposure is likely to be very low.

Post-exposure treatment (immune

globulin) not effective
If there is potential exposure, person
should be monitored for infection in
order to start treatment as early as
possible.

Human Immunodeficiency
Virus (HIV)

0.3% of persons seroconvert after a

needlestick exposure, 0.1% after
mucocutaneous exposure, and <0.1%
after skin exposure.
HIV can be cultured from cadavers hours
to days after death

Post-exposure treatment with antiviral

agents can decrease the risk of
seroconversion by 81%
Treatment should start ASAP, as it may be
less effective after 2-3 days.

Tuberculosis (TB)
Can be transmitted not only as
aerosol but also percutaneously
Risk of transmission of TB in
performance of autopsy and frozen
section is documented
Must wear mask when working with
fresh or unfixed specimens that are
suspected or known to be infected
Use of coolant aerosol spray in frozen
section discouraged

Formalin probably kills TB

SARS and CJD

Risk for severe acute respiratory
syndrome (SARS) low for personnel,
except when performing autopsies.
Suspected cases handled as for HBV
All tissues should be promptly fixed and
cryostat decontaminated

Creutzfeldt-Jacob disease (CJD)

Present in formalin-fixed and paraffin
embedded tissues for years
CJD transmission to pathologists and
histotechnologist is documented

CJD-infected specimen
Decontamination procedure
Double-gloving; processing formalin-fixed
tissue on a table covered by plastic sheet
To deactivate infectivity, soak tissue blocks
in conc. formic acid for 1hr, then fresh
10% buffered formalin for at least 48hrs.
All instruments and gloves used must be
decontaminated. Immerse in 2N NaOH for
1hr.
Tissue remnants, cutting debris, used
formalin, plastic sheet should be discarded
in a plastic container to be cremated as
infectious hospital waste.

Infection control in the section

Universal precautions: treat all tissues as
potentially infectious
PPE and puncture-proof used-sharps box
Dissecting instruments in Lysol solution
Water baths: wash, rinse, dry daily
Cutting boards: disinfectant (cover overnight)
Autotechnicon: wash/dry beakers once/wk
Tissue cassettes: remove wax, place in
detergent bath, wash clean, scald, towel dry
Wet tissue: store in 10% formalin in leakproof container. After 4 weeks, incinerate.
Disinfect daily: sink, knobs, handles, phones
No smoking, no eating, no drinking

Infection control in the section

Fresh tissues potentially infective; all
specimens placed in fixative ASAP.
Formalin effectively inactivates viruses
(including HIV and HBV) and reduces
infectivity of mycobacteria.
Frozen section on potentially infectious cases
may be done but should be avoided if
cytologic preparations can be used or intraoperative diagnosis is not needed. Freezing
does not inactivate infectious agents.
Air-dried slides should be considered
potentially infectious. Any smears submitted
for evaluation must be fixed in alcohol.

Decontamination
Common decontamination agent 10%
solution (volume/volume with tap water,
made daily) of household bleach makes a
very effective/economical disinfectant,
inactivating HBV in 10min & HIV in 2min
Prewashing removes concentrated
amounts of protein
All laboratory surfaces must be made of
nonporous material, allowing for easy
cleaning and decontamination

Common Histopath-specific hazards

Fixatives: formalin
Severe eye and skin irritant. Pungent
fumes require good ventilation. Sensitizer
by skin and respiratory contact. Toxic by
ingestion and inhalation. Corrosive.
Carcinogenic. Work in well ventilated
area, wear goggles, gloves, and lab coat.

Sodium azide: reagent preservative

Flush solutions down the drain with lots of
water (tendency for the azide to form
metal azides in the plumbing). These are
also explosive.

Histopathology-specific hazards
Benzidine, benzene, anthracene, and
naphthol containing compounds:
carcinogens, use with caution
Cytology: clean cytocentrifuge daily;
use capped tubes to spin samples
Decalcification:
formalin fixed tissues should be washed
well before decalcifying in HNO3 due to
danger of forming carcinogenic fumes of
bis-chloromethyl ether.

Histopathology-specific hazards
Frozen section:
fresh material may be infectious. Sterilize
cabinet and microtome before cleaning.

Paraffin wax processing:

rotary processors drawback: high rate of

solvent evaporation, with risk of toxic and
potentially explosive fumes in air.

Microtomy: use blade guards

Most common site of injury is the nondominant hand. Reusable but
contaminated equipment should be
decontaminated with bleach.

Radiation Safety
Radioactive specimens ex. sentinel lymph
nodes(SLN) may be received
Dose of 0.4-1.0 milliCurie(mCi) 99m
technetiumsulfur colloid is typically used

Mean radiation dose (MRD) to skin of

hand of surgeon during biopsy is about
10mrem.
MRD to pathology staff exposed to these
specimens much lower than that of surgeon
due to shorter time handling the specimens.
Source: Am J Surg Pathol 24(11):15491551, 2000

Radiation Safety
Half-life of Tc99m is 6hrs, and radiation
levels decrease to background levels
after 10 half-lives (60hrs).
SLN samples and related surgical materials
can be disposed of through ordinary medical
waste disposal methods 60hrs after surgery.

Personnel monitoring devices (film

badges) not necessary for pathology staff
because of the low levels of radioactivity,
rapid decay, and limited exposure time.
Source: Am J Surg Pathol 24(11): 15491551, 2000

Radiation Safety
Other considerations
All personnel handling these specimens,
including couriers, must be aware that the
specimens contain low levels of radioactivity.
The specimen should be sent promptly to the
laboratory in sealed containers labeled with:
Caution Radioactive Material
Protective wear (disposable gloves, surgical
scrubs, plastic aprons) should be worn when
handling the specimens.
Gross examination should be delayed for at
least 6hrs from time of surgery

Radiation Safety
Other considerations
Quarantine primary tumor excision at least
24hrs due to its higher radioactivity level
compared with SLN.
Frozen Section: amount of radioactive
material in specimen shavings limited or low,
no special precautions recommended and no
need for a dedicated cryostat.
Specimen should be held in a secure location
to prevent unauthorized access and
premature disposal.
Labels indicating radioactive materials should
be removed before disposal.

Treatment of samples/reagents
before disposal
Presept tablet (strong hypochlorite)
Efficient disinfectant containing sodium
dichloroisocyanurate (NaDCC) in an
effervescent base
Dissolved in water, it is effective through
the entire biocidal spectrum (all bacteria,
viruses, fungi, algae, and protozoa)
Highly resistant to inactivation by organic
soilage
Compact and stable in storage
Compatible with detergents

Disposition of instruments, trash,

and specimen after dissection
Needles, blades, and other sharp
disposable objects promptly discarded
into appropriate containers.
Trash items soiled with blood or other
potentially infectious materials
discarded into designated biohazard
containers in the cutting area.
Upon completion of the dissection, the
specimen should be stored in a
container with adequate formalin,
securely closed to prevent leakage,
accurately labeled and placed in the
vented storage cabinet.

Garbage disposal and cleaning

the section
The laboratory must have a method for
disposal of hazardous wastes.
Health care facilities processing tissues
often contract this to a waste management
company.

Tissues collected should be stored in

formalin and may be disposed by
incineration or by putting them through
a "tissue grinder" attached to a large
sink (similar to a large garbage disposal
unit).

Garbage disposal and cleaning

the section
Daily cleaning of the histopathology
section should be done.

Wax on the floor should be removed with a

metal spatula.

Garbage should be collected everyday.

The collected garbage in each trashcan

should be sealed and place in a big yellow
bag and labeled the date it was collected.

Garbage should be discarded after 2

days from the date it was collected.
Just in case tissue, request form, or
specimen containers are inadvertently
thrown

Rational waste
segregation

Disposal of tissues
Schedule disposal of surgical tissues
and body fluids.
Only those samples with official report
are to be discarded.
Samples for disposal are removed
from formalin and placed in a doubled
yellow plastic bag with a newspaper
underneath to absorb the formalin.
The plastic bag should be labeled for
disposal and must be endorsed to the
assigned housekeeper.

Disposal of chemicals
Formalin
Formalin stock solution is stored in a cool
and dry place in a tightly capped
container.
Prepared 10% formalin is stored in a
tightly capped container with a faucet for
easy retrieval.
All used formalin (10%) is disposed of
properly in the sink with a continuous
flow of running tap water (at least 5
minutes) depending on the volume of
formalin being disposed of.

Disposal of chemicals
Xylene and toluene
Stock solution of both Xylene and Toluene
are placed in a cool and dry place.
Used Xylene and Toluene are stored
separately in a tightly capped container
labeled as used xylene/toluene for
disposal.
Once the container is full, the chemicals
are disposed of accordingly.

Disposal of chemicals
Alcohols (ethanol and methanol)
Stock solutions are stored in a cool and
dry place away from flammable materials.
All used alcohols are disposed thru the
sink with continuous flow of running tap
water.

Staff training and preparedness

Safety standard operating procedure
(SOP) Manual should define the
hazards and safe working procedures
for the department.
Safety training program should be
part of the continuing education
lectures given periodically as new
recruits come in.
Regular safety inspections (at least
annually).

Staff training and preparedness

Staff must be familiar with the
location and operation of the ff
emergency items in the lab:

First aid kit

Fire extinguisher
Eyewash station and Emergency shower
Spill Kit (minor chemical/biologic spills
<1L)

Evacuation procedures and exits

for disasters and major spills

Hotline numbers for emergency

Chemical spills kit & procedure

Safety information flyers

Emergency route

Documentation
Laboratory safety manual
Incident report logbook:

Investigate and record all accidents to

prevent same occurrence in the future.

Safety training program

Fire extinguishers, spill kits, first aid
Evacuation procedures

Equipment maintenance checks

Ex. calibration, temperature, company

preventive maintenance

MSDS: preferably bound and in

alphabetical order

Thanks (again) for the attention

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QUALITY ASSURANCE IN
HISTOPATHOLOGY LABORATORY