Chem-Bio Talk.ppt Biosafety health and environment
asraf22
44 views
68 slides
Oct 11, 2024
Slide 1 of 68
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
About This Presentation
Biosafety health and environment
Slide Content
1
Introduction
•Safety: Safety is the protection against unintentional/non-
deliberate release of toxic chemical/biological hazards
(chemical/agents) into the environment and to mitigate the
impact if such events occur (Prevention of accidents)
•Chem-Bio safety comprises of disciplines:
•Employees safety
•Public safety
•Environment safety
•Safety: Safety is the protection against unintentional/non-
deliberate release of toxic chemical/biological hazards
(chemical/agents) into the environment and to mitigate the
impact if such events occur (Prevention of accidents)
•Chem-Bio safety comprises of disciplines:
•Employees safety
•Public safety
•Environment safety
3
Introduction
•Security: Security is the protection against the risk of intentional/delibrate
misuse of a chemical/biological hazards (Chem-Bio agents) – intent to
cause harm and to mitigate the impact if such events occur (Prevention of
attack)
•It comprises of:
–Physical security of site
– Personnel management
– Information security & management of activities
– Allocation of chemical security responsibilities
– Development of emergency plans & trainings
Goal: Ensure that you don’t accidently help a criminal
or a terrorist get dangerous chemicals
Introduction
•Security: Security is the protection against the risk of intentional/delibrate
misuse of a chemical/biological hazards (Chem-Bio agents) – intent to
cause harm and to mitigate the impact if such events occur (Prevention of
attack)
•It comprises of:
–Physical security of site
– Personnel management
– Information security & management of activities
– Allocation of chemical security responsibilities
– Development of emergency plans & trainings
Goal: Ensure that you don’t accidently help a criminal
or a terrorist get dangerous chemicals
Difference Between Chemical Safety and Security
•Safety
–Label everything so people
can recognize hazardous
chemicals.
–Let community and especially
emergency responders know
what chemical dangers are
there.
–Share knowledge about
chemical hazards so people
know to be alert.
•Security
–Labels help identify targets
for theft or attack.
–Sharing locations of
chemicals can publicize
targets for theft or attack.
–Sharing knowledge of
chemical hazards could
inspire harmful behavior
•Safety
–Label everything so people
can recognize hazardous
chemicals.
–Let community and especially
emergency responders know
what chemical dangers are
there.
–Share knowledge about
chemical hazards so people
know to be alert.
•Security
–Labels help identify targets
for theft or attack.
–Sharing locations of
chemicals can publicize
targets for theft or attack.
–Sharing knowledge of
chemical hazards could
inspire harmful behavior
5
Bio-safety vs Bio-security
Bio-safety protects “people from germs”
Bio-security protects “germs from people”
Safety
Security
Bio-safety vs Bio-security
Bio-safety protects “people from germs”
Bio-security protects “germs from people”
Safety
Security
Why Chem-Bio Safety
•Chem-Bio agents that are used every day in labs and
factories can be hazardous
•can be harmful to the health of the workers
•They can be also a threat to the safety of the workers, the
community and to the environment
•Laboratory-associated infections (LAIs)
•Chemical-associated diseases (CADs)
•Chem-Bio agents that are used every day in labs and
factories can be hazardous
•can be harmful to the health of the workers
•They can be also a threat to the safety of the workers, the
community and to the environment
•Laboratory-associated infections (LAIs)
•Chemical-associated diseases (CADs)
•Chem-Bio agents:
–Dual-use
•Chemical weapons
•Biological weapons
•Sabotage
–Impacts of sabotage
•Deaths, injuries
•Economic losses and environmental
impact 7
Why Chem-Bio Security
–Dual-use
•Chemical weapons
•Biological weapons
•Sabotage
–Impacts of sabotage
•Deaths, injuries
•Economic losses and environmental
impact 7
Why Chem-Bio Security
8
Approach to Chem-Bio Safety and Security
•Regulations, Frameworks & Risk management system (RMS)
•To assess the potential Chem-Bio Safety & Security risks
•To Implement processes to manage those risks
•To ensure ongoing performance of those processes
•RMS required to adequately prevent, detect, or respond to a
Chem-Bio accident or Chem-Bio security incidents.
Approach to Chem-Bio Safety and Security
•Regulations, Frameworks & Risk management system (RMS)
•To assess the potential Chem-Bio Safety & Security risks
•To Implement processes to manage those risks
•To ensure ongoing performance of those processes
•RMS required to adequately prevent, detect, or respond to a
Chem-Bio accident or Chem-Bio security incidents.
Chem-Bio Safety & Security: Regulations &
Frameworks
“Cleanliness half of faith” (Hadith)
“Trust in God, but tie your camel.”
International treaties, National level regulations
and best practices that support
1. Chemical safety and security
2. Biological safety and security
Frameworks
“Cleanliness half of faith” (Hadith)
“Trust in God, but tie your camel.”
International treaties, National level regulations
and best practices that support
1. Chemical safety and security
2. Biological safety and security
11
1. Regulations & Frameworks for
Chemical Safety & Security
•There exist international treaties, national level regulations, and industry best practices that
support chemical safety and security management
–UN Security Council Resolution 1540
–The Basel Convention
–The Stockholm Convention
–The Rotterdam Convention
–The Globalized Harmonized System (GHS)
–Strategic Approach to International Chemicals Management (SAICM)
–Registration, Evaluation, Authorization (REACH)
–International Organization for Standardization (ISO)
–Chemical Weapon Convention (CWC)
1. Regulations & Frameworks for
Chemical Safety & Security
•There exist international treaties, national level regulations, and industry best practices that
support chemical safety and security management
–UN Security Council Resolution 1540
–The Basel Convention
–The Stockholm Convention
–The Rotterdam Convention
–The Globalized Harmonized System (GHS)
–Strategic Approach to International Chemicals Management (SAICM)
–Registration, Evaluation, Authorization (REACH)
–International Organization for Standardization (ISO)
–Chemical Weapon Convention (CWC)
International Health Regulations (IHR), WHO
CDC
NIH
EU
BWC
2. Frameworks & Regulations for
Biosafety & Security
CDC
NIH
EU
BWC
2. Frameworks & Regulations for
Biosafety & Security
CWC
•The Convention on the Prohibition of the
Development, Production, Stockpiling and
Use of Chemical Weapons and on their
Destruction
•Most Successful treaty so far, 95%
•The Convention on the Prohibition of the
Development, Production, Stockpiling and
Use of Chemical Weapons and on their
Destruction
•Most Successful treaty so far, 95%
•Chemical Weapons Convention (CWC) opened for signature
on 13 January 1993 in Paris.
•Preparatory Commission was set up in The Hague to prepare
for Entry-into-Force (180 days after the 65th State ratified the
CWC).
•Entry-into Force on 29 April 1997.
Steps towards chemical
disarmament
14
on 13 January 1993 in Paris.
•Preparatory Commission was set up in The Hague to prepare
for Entry-into-Force (180 days after the 65th State ratified the
CWC).
•Entry-into Force on 29 April 1997.
Steps towards chemical
disarmament
14
•Preamble
•24 Articles
•3 Annexes
Scheduled Chemicals (64)
Verification
Confidentiality
15
Structure of CWC
•24 Articles
•3 Annexes
Scheduled Chemicals (64)
Verification
Confidentiality
15
Structure of CWC
An international treaty which excludes completely the development, production,
stockpiling, use and transfer of CW
Four Pillars of the
Convention
Disarmament - Destruction of chemical
weapons stockpiles and their associated
production facilities
16
Non-Proliferation - Verification of non -
production of CWs
Assistance and Protection against CWs
International Cooperation for peaceful use
and development of chemistry
stockpiling, use and transfer of CW
Four Pillars of the
Convention
Disarmament - Destruction of chemical
weapons stockpiles and their associated
production facilities
16
Non-Proliferation - Verification of non -
production of CWs
Assistance and Protection against CWs
International Cooperation for peaceful use
and development of chemistry
Establishment of the OPCW
(The Hague, The Netherlands)
17
Article VIII of the CWC
•To achieve the object and
purpose of the CWC
•To ensure the
implementation of the
provisions of the CWC
•To provide a forum for
consultation and cooperation
among the States Parties
OPCW
•Founded in 1997 as an implementing
body of the CWC
•Main bodies:
➢Conference of States Parties (193)
➢Executive Council (41)
➢Technical Secretariat (500)
(The Hague, The Netherlands)
17
Article VIII of the CWC
•To achieve the object and
purpose of the CWC
•To ensure the
implementation of the
provisions of the CWC
•To provide a forum for
consultation and cooperation
among the States Parties
OPCW
•Founded in 1997 as an implementing
body of the CWC
•Main bodies:
➢Conference of States Parties (193)
➢Executive Council (41)
➢Technical Secretariat (500)
CWC
Sched 1
Sched 3
Sched 2
DOCDOC
Sched 1
Sched 3
Sched 2
DOCDOC
Schedule 1 Chemicals
•It has been developed, produced,
stockpiled or used as a chemical
weapon ...;
•It poses otherwise a high risk to the object
and purpose of this Convention by virtue
of its high potential for use in activities
prohibited under this Convention … ;
•It has little or no use for permitted
purposes
•It has been developed, produced,
stockpiled or used as a chemical
weapon ...;
•It poses otherwise a high risk to the object
and purpose of this Convention by virtue
of its high potential for use in activities
prohibited under this Convention … ;
•It has little or no use for permitted
purposes
Schedule 1 Chemicals
•12 entries – families or individual chemicals
•Schedule 1A: toxic chemicals - Includes well
known chemical weapons agents such as
–Sarin, Soman, VX
–Sulfur and nitrogen mustards
•S1A also includes toxins Ricin and Saxitoxin
•Schedule 1B - key precursors
•12 entries – families or individual chemicals
•Schedule 1A: toxic chemicals - Includes well
known chemical weapons agents such as
–Sarin, Soman, VX
–Sulfur and nitrogen mustards
•S1A also includes toxins Ricin and Saxitoxin
•Schedule 1B - key precursors
Uses of Schedule 1 Chemicals
•No large scale uses
•Ricin
–Anticancer research
•Saxitoxin
–Diagnostic kits for Paralytic Shellfish Poisoning
•Nitrogen Mustard
–Small quantities for skin cancer treatment
•Sarin – Sulfur Mustard – VX
–Small quantities used for developing protection
and detection methods
•No large scale uses
•Ricin
–Anticancer research
•Saxitoxin
–Diagnostic kits for Paralytic Shellfish Poisoning
•Nitrogen Mustard
–Small quantities for skin cancer treatment
•Sarin – Sulfur Mustard – VX
–Small quantities used for developing protection
and detection methods
Schedule 2 Chemicals
•... it possesses such lethal or incapacitating
toxicity as well as other properties that could
enable it to be used as a chemical weapon;
•It poses a significant risk ... by virtue of its
importance in the production of a chemical
listed in Schedule 1 or Schedule 2, part A;
•It is not produced in large commercial
quantities for purposes not prohibited under
this Convention.
•... it possesses such lethal or incapacitating
toxicity as well as other properties that could
enable it to be used as a chemical weapon;
•It poses a significant risk ... by virtue of its
importance in the production of a chemical
listed in Schedule 1 or Schedule 2, part A;
•It is not produced in large commercial
quantities for purposes not prohibited under
this Convention.
Carrier for Dyes in Textile & Printing Industry
Co-solvent in Water-based Pen Inks
Manufacture of Some Types of Plastics,
Resins and Adhesives
Lubricant Additive
Examples of Uses of a Specific
Schedule 2 Chemical
Co-solvent in Water-based Pen Inks
Manufacture of Some Types of Plastics,
Resins and Adhesives
Lubricant Additive
Examples of Uses of a Specific
Schedule 2 Chemical
Examples of Sch 2 Commercial Uses
BZ
PFIB
Amiton
Dialkylphosphoramidic
Dihalides Family
Schedule 2B4 Family
Was a commercial pesticide withdrawn
due to toxicity
Waste Constituent
Flame retardants, Anti-Foam agents,
Gasoline/Oil Additives
Viscosity depressants, Textiles, Drugs,
Polyamide Fibers, Fireproofing agents
Pharmaceuticals, Medical Research
None
Dialkyl N,N-dialkyl-
Phosphoramidates Family
24
BZ
PFIB
Amiton
Dialkylphosphoramidic
Dihalides Family
Schedule 2B4 Family
Was a commercial pesticide withdrawn
due to toxicity
Waste Constituent
Flame retardants, Anti-Foam agents,
Gasoline/Oil Additives
Viscosity depressants, Textiles, Drugs,
Polyamide Fibers, Fireproofing agents
Pharmaceuticals, Medical Research
None
Dialkyl N,N-dialkyl-
Phosphoramidates Family
24
Schedule 3 Chemicals
•It has been produced, stockpiled or used as a
chemical weapon;
•… it possesses such lethal or incapacitating
toxicity as well as other properties that might
enable it to be used as a chemical weapon;
•It poses a risk by virtue of its … importance in the
production of one or more chemicals listed in
Schedule 1 or Schedule 2B;
•It may be produced in large commercial quantities
for purposes not prohibited under this Convention.
•It has been produced, stockpiled or used as a
chemical weapon;
•… it possesses such lethal or incapacitating
toxicity as well as other properties that might
enable it to be used as a chemical weapon;
•It poses a risk by virtue of its … importance in the
production of one or more chemicals listed in
Schedule 1 or Schedule 2B;
•It may be produced in large commercial quantities
for purposes not prohibited under this Convention.
Triethanolamine
Desulfurisation in Petroleum Refining
Intermediate in Manufacture of Surface Active
Agents, Textile Specialties, Waxes, Polishes,
Herbicides, Petroleum Emulsifiers, Cement
Additives, Cutting Oils
Making Emulsions with Mineral & Vegetable
Oils, Paraffin & Waxes
Solvent for Dyes
Examples of Uses of a Specific
Schedule 3 Chemical
Desulfurisation in Petroleum Refining
Intermediate in Manufacture of Surface Active
Agents, Textile Specialties, Waxes, Polishes,
Herbicides, Petroleum Emulsifiers, Cement
Additives, Cutting Oils
Making Emulsions with Mineral & Vegetable
Oils, Paraffin & Waxes
Solvent for Dyes
Examples of Uses of a Specific
Schedule 3 Chemical
Examples of Sch 3 Commercial Uses
Sulfur monochloride
Diethyl phosphite
Catalyst, Antifungals, Insecticides,
Lube oil additives, Color preventative
Sulfur dichloride
Thionyl chloride
Vulcanizing rubber, Lube oil additives,
Antioxidants, Crosslinking, Solvent,
Catalyst
Chlorinating agent, Antibiotics, Pesticide,
Lube oil additives, Antioxidants,
Funguicide
Acid chlorides, Herbicides, Insecticides,
Fumigants, Thermoplastics, Surfactants,
Drugs, Vitamins, Dyes, Catalyst, Batteries,
Chlorinating agent, Photography
Sulfur monochloride
Diethyl phosphite
Catalyst, Antifungals, Insecticides,
Lube oil additives, Color preventative
Sulfur dichloride
Thionyl chloride
Vulcanizing rubber, Lube oil additives,
Antioxidants, Crosslinking, Solvent,
Catalyst
Chlorinating agent, Antibiotics, Pesticide,
Lube oil additives, Antioxidants,
Funguicide
Acid chlorides, Herbicides, Insecticides,
Fumigants, Thermoplastics, Surfactants,
Drugs, Vitamins, Dyes, Catalyst, Batteries,
Chlorinating agent, Photography
Risk of Chemical Theft & Sabotage
•Unlimited access to:
–Chemical storage areas
–Analytical laboratories
–Chemical waste sites
–Construction sites
•No controls or security checks on
chemical procurement
•Shipping and receiving areas not
protected
28
•Unlimited access to:
–Chemical storage areas
–Analytical laboratories
–Chemical waste sites
–Construction sites
•No controls or security checks on
chemical procurement
•Shipping and receiving areas not
protected
28
Chemical Weapon Agents
•Nerve Agents
–GA (Tabun)
–GB (Sarin)
–GD (Soman)
–GF
–VX (methylphosphonothioic acid)
•Blister Agents
–HD - sulphur mustard (Yperite)
–HN - nitrogen mustard
–L - Lewisite
–CX - phosgene oximine
•Choking Agents
–CG phosgene
–DP diphosgene
–Cl chlorine
–PS chloropicrin
•Nerve Agents
–GA (Tabun)
–GB (Sarin)
–GD (Soman)
–GF
–VX (methylphosphonothioic acid)
•Blister Agents
–HD - sulphur mustard (Yperite)
–HN - nitrogen mustard
–L - Lewisite
–CX - phosgene oximine
•Choking Agents
–CG phosgene
–DP diphosgene
–Cl chlorine
–PS chloropicrin
The Second Battle of Ypres
World War 1
April, 1915
first large-scale military use of chemical
weapons
World War 1
April, 1915
first large-scale military use of chemical
weapons
Line of cylinders release gas at Ypres
•Germany used 168 tons of chlorine gas
against French Algerian and, later,
Canadian troops
•16,000 troops exposed, about 6,000 die
of
asphyxiation.
•German press release state that use is in
response to prior French use of gas
•Allied troops panic as trenches become
saturated with heavier-than-air gas
against French Algerian and, later,
Canadian troops
•16,000 troops exposed, about 6,000 die
of
asphyxiation.
•German press release state that use is in
response to prior French use of gas
•Allied troops panic as trenches become
saturated with heavier-than-air gas
Halabja poison gas attack
March 15-19, 1988
Military use of chemical weapons
Against Iraqi Kurds during the
Iran-Iraq war
March 15-19, 1988
Military use of chemical weapons
Against Iraqi Kurds during the
Iran-Iraq war
Tokyo Sarin Attack
March 20, 1995
terrorists place containers of the nerve gas
sarin in five trains on 3 of Tokyo's 10
underground railway lines.
March 20, 1995
terrorists place containers of the nerve gas
sarin in five trains on 3 of Tokyo's 10
underground railway lines.
Rescue Efforts after Tokyo Attack
Shoko Asahara, founder of the religious cult
Aleph, found guilty of ordering attack in a
trial that ended on February 27, 2004
Aleph, found guilty of ordering attack in a
trial that ended on February 27, 2004
Attack of Nerve Agents, UK, Syria
Biological Weapons Convention (BWC)
Biological Weapons Convention, BWC, 1972
BWC prohibits the development, production
and possession of BW
Biological Weapons Convention, BWC, 1972
BWC prohibits the development, production
and possession of BW
Classification of Pathogens & Safety
Levels
Risk Group 1: not associated with disease in healthy human adults,
BSL-1
Risk Group 2: cause mild disease for which medical
countermeasures are available, BSL-2
Risk Group 3: cause serious or deadly disease for which
medical countermeasures may be available, have low potential to
spread in the community or environment, BSL-3
Risk
Group 4: cause serious or deadly disease for which medical
countermeasures are unlikely to be available, and which have high
potential to spread in the community or environment, BSL-4
Levels
Risk Group 1: not associated with disease in healthy human adults,
BSL-1
Risk Group 2: cause mild disease for which medical
countermeasures are available, BSL-2
Risk Group 3: cause serious or deadly disease for which
medical countermeasures may be available, have low potential to
spread in the community or environment, BSL-3
Risk
Group 4: cause serious or deadly disease for which medical
countermeasures are unlikely to be available, and which have high
potential to spread in the community or environment, BSL-4
No
.
Agent Name
and Disease
Containment Recommendations
1Bacillus
anthracis:
Disease: Anthrax
BSL-
2: Clinical materials and diagnostic ‐
quantities of infectious cultures.
BSL-
3: Production quantities, high ‐
concentrations of cultures, aerosol
production.
2Bordetella
pertussis
Disease:
BSL-
2: Known or potentially infectious ‐
clinical material and cultures.
BSL-
3: Production operations.‐
3Brucella species
Disease:
BSL-
2: Routine clinical specimens of ‐
human or animal origin.
BSL-
3: All manipulations of cultures of ‐
pathogenic Brucella spp.
4Burkholderia
mallei
Disease:
BSL-
2: Primary isolations from patient ‐
fluids or tissues in a BSC.
BSL-
3: Infectious aerosols, droplets, ‐
centrifugation, handling infected animals.
5Burkholderia
pseudomallei
BSL-
2: Clinical specimens of melioidosis ‐and B. pseudomallei cultures, in BSC.
BSL-
3: Aerosols or droplets, production ‐
quantities.
6Chlamydia spp.
Disease:
BSL-
2: Clinical specimens‐
BSL-
3: Any activity with aerosol ‐
production, or concentrations.
7Clostridium
tetnus & C.
botulinum
Disease:
Tetanus
ABSL-
2: Diagnostic studies and titration ‐
of toxin.
BSL-
3: Aerosol or droplet production, ‐
routine handling of larger quantities.
8Francisella
tularensis
Disease:
BSL-
2: Clinical materials of human or ‐
animal origin
BSL-
3: Cultures at high concentrations.‐
9Mycobacterium
tuberculosis , M.
leprae Disease:
TB, meningitus
BSL-
2: Non-aerosol-producing ‐ ‐ ‐
manipulations of clinical specimens.
BSL-
3: Cultures of any of the subspecies ‐
of the M. tuberculosis complex.
10Neisseria
gonorrhoeae, N.
meningitidis
Disease:
BSL-
2: Clinical materials or cultures. ‐
BSL-
3: High risk of aerosol or droplet ‐
production, high concentrations.
12
Salmonella Typhi
Disease:
BSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
13
Shigella
dysenteriae type
1
Disease:
ABSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
14
Staphylococcal
enterotoxins (SE)
Disease:
BSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
15
Yersinia pestis
Disease: Plague
BSL-
2 Clinical materials and cultures; ‐
necropsies in a BSC.
BSL-
3: Droplet, aerosol production, large ‐
scale production or high concentrations.
16
Mycoplasma
Disease:
BSL-
2 Clinical materials and cultures; ‐
necropsies in a BSC.
BSL-
3: Droplet, aerosol production, large ‐
scale production or high concentrations.
17
Coxiella burnetii,
Q fever
BSL-
2: laboratory procedures, serological ‐
examinations, staining of impression
smears.
BSL-
3: Inoculation, incubation, ‐
harvesting of embryonated eggs or cell
cultures, infected tissues.
18 Rickettsia spp. Disease: typhus BSL-
2: Clinical laboratory procedures‐
BSL-
3: All other manipulations, inoculation, incubation etc.‐
.
Agent Name
and Disease
Containment Recommendations
1Bacillus
anthracis:
Disease: Anthrax
BSL-
2: Clinical materials and diagnostic ‐
quantities of infectious cultures.
BSL-
3: Production quantities, high ‐
concentrations of cultures, aerosol
production.
2Bordetella
pertussis
Disease:
BSL-
2: Known or potentially infectious ‐
clinical material and cultures.
BSL-
3: Production operations.‐
3Brucella species
Disease:
BSL-
2: Routine clinical specimens of ‐
human or animal origin.
BSL-
3: All manipulations of cultures of ‐
pathogenic Brucella spp.
4Burkholderia
mallei
Disease:
BSL-
2: Primary isolations from patient ‐
fluids or tissues in a BSC.
BSL-
3: Infectious aerosols, droplets, ‐
centrifugation, handling infected animals.
5Burkholderia
pseudomallei
BSL-
2: Clinical specimens of melioidosis ‐and B. pseudomallei cultures, in BSC.
BSL-
3: Aerosols or droplets, production ‐
quantities.
6Chlamydia spp.
Disease:
BSL-
2: Clinical specimens‐
BSL-
3: Any activity with aerosol ‐
production, or concentrations.
7Clostridium
tetnus & C.
botulinum
Disease:
Tetanus
ABSL-
2: Diagnostic studies and titration ‐
of toxin.
BSL-
3: Aerosol or droplet production, ‐
routine handling of larger quantities.
8Francisella
tularensis
Disease:
BSL-
2: Clinical materials of human or ‐
animal origin
BSL-
3: Cultures at high concentrations.‐
9Mycobacterium
tuberculosis , M.
leprae Disease:
TB, meningitus
BSL-
2: Non-aerosol-producing ‐ ‐ ‐
manipulations of clinical specimens.
BSL-
3: Cultures of any of the subspecies ‐
of the M. tuberculosis complex.
10Neisseria
gonorrhoeae, N.
meningitidis
Disease:
BSL-
2: Clinical materials or cultures. ‐
BSL-
3: High risk of aerosol or droplet ‐
production, high concentrations.
12
Salmonella Typhi
Disease:
BSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
13
Shigella
dysenteriae type
1
Disease:
ABSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
14
Staphylococcal
enterotoxins (SE)
Disease:
BSL-
2: Strict compliance.‐
ABSL-
3 conditions may be considered for ‐
protocols involving aerosols.
15
Yersinia pestis
Disease: Plague
BSL-
2 Clinical materials and cultures; ‐
necropsies in a BSC.
BSL-
3: Droplet, aerosol production, large ‐
scale production or high concentrations.
16
Mycoplasma
Disease:
BSL-
2 Clinical materials and cultures; ‐
necropsies in a BSC.
BSL-
3: Droplet, aerosol production, large ‐
scale production or high concentrations.
17
Coxiella burnetii,
Q fever
BSL-
2: laboratory procedures, serological ‐
examinations, staining of impression
smears.
BSL-
3: Inoculation, incubation, ‐
harvesting of embryonated eggs or cell
cultures, infected tissues.
18 Rickettsia spp. Disease: typhus BSL-
2: Clinical laboratory procedures‐
BSL-
3: All other manipulations, inoculation, incubation etc.‐
1AdenovirusesBSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
2Congo Virus,
Disease:
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
3Dengue Virus,
Disease:
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
4Ebola Virus BSL-
4/ABSL-4: All live variola virus work is to be ‐ ‐
done only within WHO approved facilities
5Hantaviruses,
Disease: Hanta
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
6Hepatitis
viruses: HBV,
HCV, HDV
BSL-
2: for all activities utilizing known or potentially ‐
infectious body fluids and tissues.
BSL-
3 Activities with potential for droplet or aerosol ‐
production and high concentrations.
7Herpesvirus
simiae
BSL-
2: cells, blood, or serum from macaques and ‐
manipulation of tissues.
BSL-
3 practices are recommended for handling ‐
materials from which B virus is being cultured
BSL-
4 facilities are recommended for propagation of ‐
virus obtained from diagnostic samples.
8Human Herpes
Virus
BSL-
2 recommended for activities utilizing known or ‐
potentially infectious.
BSL-
3 should be considered when producing, ‐
purifying, and concentrating human herpesviruses.
9Influenza:
human influenza
strains (e.g.,
H1/H3/B),
human influenza
strains (e.g.,
H1/H3/B), Swine
flu
BSL-
2 for diagnostic, research and production ‐
activities utilizing contemporary, circulating human
influenza strains (e.g., H1/H3/B) and low pathogenicity
human influenza strains (e.g., H1/H3/B), and equine and
swine influenza viruses.
BSL-
3 practices, procedures and facilities are ‐
recommended with rigorous adherence to additional
respiratory protection and clothing change protocols.
1
0
Lymphocytic
Choriomeningitis
Virus
BSL-
2: Body fluids, cell culture passage of laboratory ‐
adapted strains.
BSL-
3: Aerosol production, production quantities, ‐
high concentrations of infectious materials.
1
1
Mumps &
Measle viruses
BSL-
2: Body fluids, cell culture passage of laboratory ‐
adapted strains.
BSL-
3: Aerosol production, production quantities, ‐
high concentrations of infectious materials.
1
2
Poxviruses BSL-
2 and ABSL-2 plus vaccination, are ‐ ‐
recommended for work with most other poxviruses.
BSL-
3: work with monkeypox virus is performed by ‐
vaccinated personnel.
BSL-
4/ABSL-4: All live variola virus work is to be ‐ ‐
done only within WHO approved facilities; (one is the
HHS in Atlanta, one in Russia).
1
3
Polio Virus BSL-
2 and/or ABSL-2: Infectious materials or ‐ ‐
animals.
BSL-
3: Potential for droplet or aerosol production, ‐
production quantities or high concentrations.
1
4
Rabies Virus
(and related
lyssaviruses)
BSL-
2 and/or ABSL-2: Infectious materials or ‐ ‐
animals.
BSL-
3: Potential for droplet or aerosol production, ‐
production quantities or high concentrations.
1
5
Retroviruses,
(HIV & SIV)
BSL-
2 practices, containment equipment, and facilities ‐
are recommended for clinical specimens.
BSL-
3 practices for activities for production of ‐
research laboratory-
scale quantities of HIV or SIV.‐
1
6
Severe acute
respiratory
syndrome
(SARS)
coronavirus
BSL-
2: Pathologic examination, processing of ‐
inactivated tissues, molecular analysis of extracted
nucleic acid preparations, routine staining and
microscopic analysis of fixed smears.
BSL-
3: SARS-CoV propagation in cell culture, initial ‐ ‐
characterization of viral agents recovered in cultures of
SARS specimens.
1
7
West Nile Virus
(WNV) BSL-
2: human diagnostic specimens. ‐
BSL-
3: Manipulations of WNV cultures, animal, vector ‐
studies.
1
8
Zika Virus BSL-
3: Diagnostic, clinical materials, infectious ‐
cultures, infected animals or arthropods.
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
2Congo Virus,
Disease:
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
3Dengue Virus,
Disease:
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
4Ebola Virus BSL-
4/ABSL-4: All live variola virus work is to be ‐ ‐
done only within WHO approved facilities
5Hantaviruses,
Disease: Hanta
Hemorrhagic
Fever
BSL-
2: Sera, handling of human body fluids when ‐
potential exists for splatter or aerosol.
BSL-
3: Cell-culture virus propagation and purification ‐ ‐
should be carried out in BSL-
3 facility‐
6Hepatitis
viruses: HBV,
HCV, HDV
BSL-
2: for all activities utilizing known or potentially ‐
infectious body fluids and tissues.
BSL-
3 Activities with potential for droplet or aerosol ‐
production and high concentrations.
7Herpesvirus
simiae
BSL-
2: cells, blood, or serum from macaques and ‐
manipulation of tissues.
BSL-
3 practices are recommended for handling ‐
materials from which B virus is being cultured
BSL-
4 facilities are recommended for propagation of ‐
virus obtained from diagnostic samples.
8Human Herpes
Virus
BSL-
2 recommended for activities utilizing known or ‐
potentially infectious.
BSL-
3 should be considered when producing, ‐
purifying, and concentrating human herpesviruses.
9Influenza:
human influenza
strains (e.g.,
H1/H3/B),
human influenza
strains (e.g.,
H1/H3/B), Swine
flu
BSL-
2 for diagnostic, research and production ‐
activities utilizing contemporary, circulating human
influenza strains (e.g., H1/H3/B) and low pathogenicity
human influenza strains (e.g., H1/H3/B), and equine and
swine influenza viruses.
BSL-
3 practices, procedures and facilities are ‐
recommended with rigorous adherence to additional
respiratory protection and clothing change protocols.
1
0
Lymphocytic
Choriomeningitis
Virus
BSL-
2: Body fluids, cell culture passage of laboratory ‐
adapted strains.
BSL-
3: Aerosol production, production quantities, ‐
high concentrations of infectious materials.
1
1
Mumps &
Measle viruses
BSL-
2: Body fluids, cell culture passage of laboratory ‐
adapted strains.
BSL-
3: Aerosol production, production quantities, ‐
high concentrations of infectious materials.
1
2
Poxviruses BSL-
2 and ABSL-2 plus vaccination, are ‐ ‐
recommended for work with most other poxviruses.
BSL-
3: work with monkeypox virus is performed by ‐
vaccinated personnel.
BSL-
4/ABSL-4: All live variola virus work is to be ‐ ‐
done only within WHO approved facilities; (one is the
HHS in Atlanta, one in Russia).
1
3
Polio Virus BSL-
2 and/or ABSL-2: Infectious materials or ‐ ‐
animals.
BSL-
3: Potential for droplet or aerosol production, ‐
production quantities or high concentrations.
1
4
Rabies Virus
(and related
lyssaviruses)
BSL-
2 and/or ABSL-2: Infectious materials or ‐ ‐
animals.
BSL-
3: Potential for droplet or aerosol production, ‐
production quantities or high concentrations.
1
5
Retroviruses,
(HIV & SIV)
BSL-
2 practices, containment equipment, and facilities ‐
are recommended for clinical specimens.
BSL-
3 practices for activities for production of ‐
research laboratory-
scale quantities of HIV or SIV.‐
1
6
Severe acute
respiratory
syndrome
(SARS)
coronavirus
BSL-
2: Pathologic examination, processing of ‐
inactivated tissues, molecular analysis of extracted
nucleic acid preparations, routine staining and
microscopic analysis of fixed smears.
BSL-
3: SARS-CoV propagation in cell culture, initial ‐ ‐
characterization of viral agents recovered in cultures of
SARS specimens.
1
7
West Nile Virus
(WNV) BSL-
2: human diagnostic specimens. ‐
BSL-
3: Manipulations of WNV cultures, animal, vector ‐
studies.
1
8
Zika Virus BSL-
3: Diagnostic, clinical materials, infectious ‐
cultures, infected animals or arthropods.
Biological Weapon Agents
•Anthrax
•Botulinum Toxins
•Brucellosis
•Cholera
•Clostridium Perfringens Toxins
•Congo-Crimean Hemorrhagic Fever
•Ebola Haemorrhagic Fever
•Melioidosis*
•Plague
•Q Fever
•Rift Valley Fever
•Saxitoxin
•Smallpox
•Staphylococcal Enterotoxin B
•Trichothecene Mycotoxins
•Tularemia
•Venezuelan Equine Encephalitis
•Anthrax
•Botulinum Toxins
•Brucellosis
•Cholera
•Clostridium Perfringens Toxins
•Congo-Crimean Hemorrhagic Fever
•Ebola Haemorrhagic Fever
•Melioidosis*
•Plague
•Q Fever
•Rift Valley Fever
•Saxitoxin
•Smallpox
•Staphylococcal Enterotoxin B
•Trichothecene Mycotoxins
•Tularemia
•Venezuelan Equine Encephalitis
US Anthrax Attack
September 18 – October 9, 2001
Anthrax spores found in this Princeton NJ mailbox
September 18 – October 9, 2001
Anthrax spores found in this Princeton NJ mailbox
Letters containing
Anthrax spores to 5 US
Newspapers
and 2 US Senators
Anthrax spores to 5 US
Newspapers
and 2 US Senators
Anthrax bacteria
•Several thousand people exposed and take antibiotics
•22 people developed anthrax infections
–11 inhalation anthrax
–11 subcutaneous anthrax (less lethal)
•5 died of inhalation anthrax
–2 postal workers
–3 from unknown sources, possibly cross-contamination of mail
•total damage (incl. cleanup) exceeded $1 billion
•22 people developed anthrax infections
–11 inhalation anthrax
–11 subcutaneous anthrax (less lethal)
•5 died of inhalation anthrax
–2 postal workers
–3 from unknown sources, possibly cross-contamination of mail
•total damage (incl. cleanup) exceeded $1 billion
Cronavirus
“Viral pneumonia”
“Viral pneumonia”
Scientific Classification
•Group IV: Positive Sense
Single Stranded RNA
•Order: Nidovirales (“Nested” (“Nested”
viruses)viruses)
•Family: Coronaviridae
•Genus: Coronavirus
•Species: SARS coronavirus
(SARS –CoV, Urbani strain)
•Hosts: Vertebrates
©
M
c
G
r
a
w
-
H
ill,
I
n
c
.
2
0
0
5
C
o
u
r
t
e
s
y
o
f
D
r
.
A
la
n
C
a
n
n
.
•Group IV: Positive Sense
Single Stranded RNA
•Order: Nidovirales (“Nested” (“Nested”
viruses)viruses)
•Family: Coronaviridae
•Genus: Coronavirus
•Species: SARS coronavirus
(SARS –CoV, Urbani strain)
•Hosts: Vertebrates
©
M
c
G
r
a
w
-
H
ill,
I
n
c
.
2
0
0
5
C
o
u
r
t
e
s
y
o
f
D
r
.
A
la
n
C
a
n
n
.
Coronavirus Morphology &
Pathogenesis
“The envelope carries three
glycoproteins:
• S - Spike protein: receptor binding,
cell fusion, major antigen
• E - Envelope protein: small,
envelope-associated protein
• M - Membrane protein:
transmembrane - budding &
envelope formation In a few types,
there is a third glycoprotein:
• HE - Haemagglutinin-esterase
The genome is associated with a
basic phosphoprotein, N.”
Pathogenesis
“The envelope carries three
glycoproteins:
• S - Spike protein: receptor binding,
cell fusion, major antigen
• E - Envelope protein: small,
envelope-associated protein
• M - Membrane protein:
transmembrane - budding &
envelope formation In a few types,
there is a third glycoprotein:
• HE - Haemagglutinin-esterase
The genome is associated with a
basic phosphoprotein, N.”
Coronavirus Pathogenesis
cont…,
C
o
u
r
t
e
s
y
o
f
D
r
.
A
la
n
C
a
n
n
.
• enters via endocytosis & membrane
fusion
• + sense genome is translated to produce
viral polymerase
• Viral polymerase produces full length –
sense strand (poorly understood step)
• - sense strand used as a template to
produce mRNA (monocistronic), “nested
set” of transcripts
• assembled in the golgi apparatus and
transport using secretory nature and
released.
•REPLICATION OCCURS IN
CYTOPLASM
cont…,
C
o
u
r
t
e
s
y
o
f
D
r
.
A
la
n
C
a
n
n
.
• enters via endocytosis & membrane
fusion
• + sense genome is translated to produce
viral polymerase
• Viral polymerase produces full length –
sense strand (poorly understood step)
• - sense strand used as a template to
produce mRNA (monocistronic), “nested
set” of transcripts
• assembled in the golgi apparatus and
transport using secretory nature and
released.
•REPLICATION OCCURS IN
CYTOPLASM
Symptoms and Diagnostic Tests
•Initial Symptoms:
–fever of 100.4
о
F or higher, headaces, body aches, and malaise.
•Week Later:
–dry cough, difficulty breathing and severe diarrhea are seen in patients.
•Recovery: starts after 5 to 6 days
• Early Diagnosis:
patient is given antibiotics, antiviral, and steroids used for atypical pneumonia.
Patient is are quarantined in specially ventilated rooms.
Laboratory tests:
RT-PCR (reverse transcription-polymerase chain reaction) assay
Detection of 2019-nCoV RNA
EIA (enzyme immunoassay)
Detection of serum antibody to 2019-nCoV RNA
Enzyme-linked immunosorbent assays (ELISA)
Detects antibodies against the virus produced in response to infection
•Initial Symptoms:
–fever of 100.4
о
F or higher, headaces, body aches, and malaise.
•Week Later:
–dry cough, difficulty breathing and severe diarrhea are seen in patients.
•Recovery: starts after 5 to 6 days
• Early Diagnosis:
patient is given antibiotics, antiviral, and steroids used for atypical pneumonia.
Patient is are quarantined in specially ventilated rooms.
Laboratory tests:
RT-PCR (reverse transcription-polymerase chain reaction) assay
Detection of 2019-nCoV RNA
EIA (enzyme immunoassay)
Detection of serum antibody to 2019-nCoV RNA
Enzyme-linked immunosorbent assays (ELISA)
Detects antibodies against the virus produced in response to infection
Treatment and Prevention
No standard treatment yet
Patients receive combination therapy
HIV/FLU therapy (Arbidol)
Prevention
Isolation
Sterilization of area occupied by 2019-nCoV patients
Caution and extra precautionary measure taken by medical workers and
doctors.
Vaccines
In progress
No standard treatment yet
Patients receive combination therapy
HIV/FLU therapy (Arbidol)
Prevention
Isolation
Sterilization of area occupied by 2019-nCoV patients
Caution and extra precautionary measure taken by medical workers and
doctors.
Vaccines
In progress
Epidemiology
•Animal and environmental reservoirs
•Onset of illness
–Incubation period: 4 to 6 days
–Infectious period is very dangerous if not treated right away leads to death of
infected person/animal
•Transmission
–Close contact – droplet, fomites, direct contact
–Airborne
–Fecal-oral
•Animal and environmental reservoirs
•Onset of illness
–Incubation period: 4 to 6 days
–Infectious period is very dangerous if not treated right away leads to death of
infected person/animal
•Transmission
–Close contact – droplet, fomites, direct contact
–Airborne
–Fecal-oral
Develop contingency plans
Use standard statistical risk
analysis to prioritize preparedness
Strengthen public health infrastructure
Identify beforehand sources of
Additional assistance
Draw upon international assistance
And support
Implement the Conventions
Use standard statistical risk
analysis to prioritize preparedness
Strengthen public health infrastructure
Identify beforehand sources of
Additional assistance
Draw upon international assistance
And support
Implement the Conventions
Overarching principles: a warm-
up
• Always follow standard practices for clothing and protective equipment.
What are these?
•Before you do anything, evaluate potential hazards – and then plan
your actions.
–What are some possible hazards with your research?
–How can you find the hazards associated with chemicals?
–Are any special hazards (electrical, laser, biosafety) present?
Are any engineering controls needed ?
What might these be?
•What types of personal protective equipment are needed?
•Be prepared for an emergency:
–Where is the nearest (exit/eyewash/fire extinguisher/shower)?
–What should I do in the event of a fire? flood? chemical spill?
5
9
up
• Always follow standard practices for clothing and protective equipment.
What are these?
•Before you do anything, evaluate potential hazards – and then plan
your actions.
–What are some possible hazards with your research?
–How can you find the hazards associated with chemicals?
–Are any special hazards (electrical, laser, biosafety) present?
Are any engineering controls needed ?
What might these be?
•What types of personal protective equipment are needed?
•Be prepared for an emergency:
–Where is the nearest (exit/eyewash/fire extinguisher/shower)?
–What should I do in the event of a fire? flood? chemical spill?
5
9
What kinds of risk might you
encounter?
•Chemical (flammable, corrosive, health, reactivity)-next page
–Could include explosion
–What about byproducts of the reaction?
•Pressure
–Gas cylinders
–Reaction pressure (related: release of toxic gases)
•Fire (Smoke/chemical inhalation; burns)
•Electrical (death; serious burns)
•UV or Laser (eye damage)
•Cut or laceration; crushing (loss of blood; loss of limb)
•Slip/fall
•In general, imagine what could possibly go wrong?
•If you have any doubts, contact UNL EHS.
6
0
encounter?
•Chemical (flammable, corrosive, health, reactivity)-next page
–Could include explosion
–What about byproducts of the reaction?
•Pressure
–Gas cylinders
–Reaction pressure (related: release of toxic gases)
•Fire (Smoke/chemical inhalation; burns)
•Electrical (death; serious burns)
•UV or Laser (eye damage)
•Cut or laceration; crushing (loss of blood; loss of limb)
•Slip/fall
•In general, imagine what could possibly go wrong?
•If you have any doubts, contact UNL EHS.
6
0
GHS for
Chemical
Hazard
Assessment
6
1
Chemical
Hazard
Assessment
6
1
Clothing, Behavior, and Personal Protective
Equipment (PPE)
•Clothing:
–NO open-toed shoes/sandals.
–Approved lab coats required except where specifically exempted (ask if you are not
sure).
–Tie back long hair. Avoid loose hair, scarves, neckties, and loose clothing around
machinery (e.g., motors, belt drives, lathes)
6
2
•Working alone- Not allowed for new investigators or
undergraduate researchers; not encouraged for anyone).
•Food/drink: Not allowed in any areas in which reagents are
stored/used/dispensed.
•Gloves are discussed later.
Eye protection: goggles or safety
glasses required unless specifically
exempted (ask if you are not sure).
Equipment (PPE)
•Clothing:
–NO open-toed shoes/sandals.
–Approved lab coats required except where specifically exempted (ask if you are not
sure).
–Tie back long hair. Avoid loose hair, scarves, neckties, and loose clothing around
machinery (e.g., motors, belt drives, lathes)
6
2
•Working alone- Not allowed for new investigators or
undergraduate researchers; not encouraged for anyone).
•Food/drink: Not allowed in any areas in which reagents are
stored/used/dispensed.
•Gloves are discussed later.
Eye protection: goggles or safety
glasses required unless specifically
exempted (ask if you are not sure).
Roles and Responsibility
•Laboratory Waste Management
•Laboratory Personal Protective
Equipment (PPE) Guidance
•Risk Assessments
•Lab Specific Training
•Online Training
•Lab Process and Equipment
Evaluation
•Lab closeout and
decontamination
•24-hr Emergency Response
•Injury Reporting and
Accident Investigation
•Indoor Air Quality (IAQ)
Investigations
•Shipping and Transporting
•Respiratory Protection
•Laboratory Ergonomics
•Spill Response and Training
•Noise Mitigation
General Lab Safety
Services Important to You
•Laboratory Personal Protective
Equipment (PPE) Guidance
•Risk Assessments
•Lab Specific Training
•Online Training
•Lab Process and Equipment
Evaluation
•Lab closeout and
decontamination
•24-hr Emergency Response
•Injury Reporting and
Accident Investigation
•Indoor Air Quality (IAQ)
Investigations
•Shipping and Transporting
•Respiratory Protection
•Laboratory Ergonomics
•Spill Response and Training
•Noise Mitigation
General Lab Safety
Services Important to You
•Chemical Storage
Guidance
•Hazard
Communication
•Exposure Monitoring
•Fume hood
Certifications
•Controlled
Substances & Listed
Chemicals
•Toxic Gases,
Compressed Gases &
Cryogenics
•Aerosol Monitoring
Systems
•Anesthetic Gas &
Vapor Minimization
Chemical Safety
Services Important to You
Guidance
•Hazard
Communication
•Exposure Monitoring
•Fume hood
Certifications
•Controlled
Substances & Listed
Chemicals
•Toxic Gases,
Compressed Gases &
Cryogenics
•Aerosol Monitoring
Systems
•Anesthetic Gas &
Vapor Minimization
Chemical Safety
Services Important to You
Biological Safety Other
•Safe Biological Work Practices
•Biological Waste Practices
•Biological Project Registrations
•Bloodborne Pathogens &
Exposure Control Plan
•Laboratory Disinfectants &
Sterilants
•Select Agents and Select
Agent Toxins
•Synthetic Biology
•Radiation Protection
•Hazardous Waste
Management
•Fire/Life Safety
•Emergency Preparedness
Services Important to You
•Safe Biological Work Practices
•Biological Waste Practices
•Biological Project Registrations
•Bloodborne Pathogens &
Exposure Control Plan
•Laboratory Disinfectants &
Sterilants
•Select Agents and Select
Agent Toxins
•Synthetic Biology
•Radiation Protection
•Hazardous Waste
Management
•Fire/Life Safety
•Emergency Preparedness
Services Important to You
•Common findings:
–Biosafety Cabinets certification
–Improper chemical storage
–Hazardous waste management
–Chemicals not on or removed from chemical
inventory
–Chemical not tagged
–Emergency Response Guide up-to-date
–Paperwork properly completed
Inspections
–Biosafety Cabinets certification
–Improper chemical storage
–Hazardous waste management
–Chemicals not on or removed from chemical
inventory
–Chemical not tagged
–Emergency Response Guide up-to-date
–Paperwork properly completed
Inspections
Categories
HealthcareDownload
Download Slideshow Get the original presentation fileQuick Actions
Statistics
- Views 44
- Slides 68
- Age 436 days
Related Slideshows
36
Clinical approach Dyspnoea A simple and practical approach.pptx
ShajahanPS
39 views
238
Cancer Awareness therapy for public by Dr Kanhu Charan Patro
kanhucpatro
38 views
41
Prof Satyadas Memorial oration Kozhikode.pptx
ShajahanPS
34 views
26
Viral Conjunctivitis and it;s managment.pptx
ZaidAzhar
46 views
30
Essential Thrombocythemia 15 Years of Experience at the Hematology Department, Algies, Algeria.pdf
sbelakehal
41 views
10
Hypertension sign symptoms cmdt style with regime
androiddabest
42 views