Animal Use Protocols

Animal use protocol review is an important aspect of every animal care and use program in research and represents the initial step toward obtaining approval for conducting animal-based research. The U.S. requirements for review of animal activities are implemented by federal agencies, including the U.S. Department of Agriculture/Animal and Plant Health Inspection Service (USDA/APHIS), which is responsible for ensuring conformance with the AWA and AWAR, and the National Institutes of Health (NIH) Office of Laboratory Animal Welfare (OLAW), which is responsible for ensuring implementation of PHS Policy. The standards document used by OLAW is the Guide for the Care and Use of Laboratory Animals (i.e., Guide), published by the Institute for Laboratory Animal Resources, National Research Council (NRC 2011), and it presents expectations for the approval of animal use by the IACUC/OB in terms of protocol review. The Guide is an internationally recognized document, and numerous countries require review of animal use activities in accordance with the standards presented therein. As such, AAALAC International utilizes the Guide as a primary standards documents, along with the Guide for the Care and Use of Agricultural Animals in Research and Teaching (Ag Guide) (FASS 2010) and ETS 123 (Council of Europe 1986).

The IACUC/OB should consider information provided in the animal use protocol and evaluate legitimacy of the proposed study based on regulatory requirements. Animal use information presented to the IACUC/OB is typically on forms developed by the institution, and in the past, paper documents were used for this purpose. However, more recently, electronic systems are commonly used for protocol review, as these can provide a more manageable alternative by allowing for easy storage and retrieval of these important documents. The animal use protocol should include the rationale for performing the research project, as well as a description of the research in lay language that an average newspaper reader would understand. For species covered by the U.S. AWAR and in many other countries, investigators must also document that they have considered alternatives to pain and distress by performing a search of relevant databases, documenting the keywords used in the search and the databases searched, and the dates covered by the search. The results of the search are typically incorporated into consideration of the replacement, reduction, and refinement (three Rs) of animal use. A description of how the search results may impact development of the research plan may also be required, and the researcher should account for the number of animals to be used for the research. This should be justified statistically whenever possible. Other items that should be documented in the protocol include:

• Verification that the research proposed does not unnecessarily duplicate research already performed. The necessity to provide additional proof of the validity of previous results should be scientifically justified (USDA 2015).
• Appropriate use of anesthetics and analgesics. Use of these agents must be addressed, and withholding them must be justified for scientific reasons (USDA 2015). Proper use of anesthetics and analgesics is an ethical and scientific imperative (NRC 2011).
• Housing standards that will be used, according to species, as defined in the AWAR (USDA 2015) and in the Guide (NRC 2011). Deviations from these standards should be justified in the protocol.
• Surgical procedures that will be used. An animal should not undergo more than one major survival surgical procedure unless there is scientific justification for doing so.
• Euthanasia methods that will be used. U.S. institutions and many others worldwide refer to the American Veterinary Medical Association (AVMA) Guidelines for the Euthanasia of Animals (AVMA 2013) for guidance on methods of euthanasia. Deviations from the recommendations in the AVMA Guidelines should be scientifically justified in the animal use protocol.
• Personnel qualifications. All individuals involved in the use of animals must be qualified to perform the animal-related tasks to which they are assigned, and staff should be provided instruction and training on procedures to be performed. Training and/or experience with the animal species and techniques should be documented, and this information may be retained in the protocol. Additionally, many countries, including the United States (NRC 2011; USDA 2015), require that research personnel receive training in regard to relevant legislation, IACUC/OB function, the ethics of animal use, the three Rs principle, reporting of animal welfare concerns, and occupational health and safety, in addition to animal handling, surgery techniques, and anesthesia and analgesia. Accessibility of training records may be important for review by the IACUC/OB or government regulators, and electronic systems may be useful in this regard.

IACUC/OB Meeting Minutes

Documentation of IACUC/OB meeting activities should be maintained in the form of minutes. The AWAR (USDA 2015) and PHS Policy (NIH 2015) contain identical requirements for meeting minutes at U.S. institutions, and these are typical for other countries also. Namely, meeting minutes should include records of attendance, IACUC/OB activities, and descriptions of IACUC/OB deliberations such that major issues and outcomes are provided in enough detail for an outsider to ascertain the nature of the discussions and the conclusions reached. Importantly, meeting minutes should not contain details that might place the institution or any individual at risk, or which could compromise privacy or proprietary information (Public Health Service 2013). These expectations are applicable to discussions regarding policy or SOP development, inspection reports, incidents of noncompliance, and reports of animal welfare concern, in addition to discussions regarding animal use activities (i.e., protocol review and approval).

Retention Requirements

Regulatory requirements for retaining documents relevant to animal use will vary internationally. For example, the Directive 2010/63/EU (European Parliament and the Council of the European Union 2010) indicates that inspection records shall be kept for 5 years, but in the United States, it is mandated that protocols, meeting minutes, and records of deliberations be retained for 3 years after completion of the animal activity (NIH 2015; USDA 2015). For U.S. institutions, this includes retention of a copy of the approved Animal Welfare Assurance, the protocol application and associated significant changes, semiannual reports to the institutional official (IO), and records of the outcome of site visits performed by AAALAC International or another accrediting agency. Regardless of the national requirements, all such records should be retained as a hard copy or electronically in a central location for ease of access when needed.

IACUC/OB Policies

Development and adoption of formal written policies by the IACUC/OB can serve to set program standards for investigators, administrators, and the institution. By creating policies before difficult issues actually arise, the committee gives itself time for careful thought and consideration of complex questions without the pressure associated with an immediate crisis. Policies can also help the IACUC/OB achieve consistency while attending to the myriad responsibilities related to protocol review, inspections, and addressing animal-related concerns. Although formal IACUC/OB policies are potentially of benefit, international requirements for their development can vary, and there is no regulatory requirement in the United States that animal program policies be developed. Nevertheless, many institutions, both globally and in the United States, have adopted formal IACUC/OB policies on topics that typically impact animal use programs, such as euthanasia standards, environmental enrichment requirements, and cage density constraints, to name just a few. The timing of periodic review of policies by the IACUC/OB varies, but many institutions revise these documents at least every 3 years or whenever regulatory requirements change. Policies can be maintained on paper or electronically, but regardless of the medium, it is critically important that investigators have access to the most recent version. At larger institutions, it is recommended that electronic dissemination via e-mail or web page be used to ensure that the latest version of any policy is available to all laboratories.

Facility Inspection and Program Review

Regular facility inspections and review of the animal care program by the IACUC/OB can help ensure compliance with recommended standards. In performing these tasks, the IACUC/OB may identify deficiencies or program weaknesses that should be addressed to ensure that a high level of quality animal care is provided. Requirements for performing facility inspections and reviewing the animal care program can vary from one country to the next. For example, the Directive 2010/63/EU (European Parliament and the Council of the European Union 2010) mandates that member states shall ensure that the competent authorities carry out regular inspections of all animal users, with the frequency of inspections based on a risk analysis for each institution. In comparison, the Guide (NRC 2011) states that facility inspections and program review should occur at least annually, or more often if necessary. Given the international diversity in conducting this type of review, the reader should refer to specific regulatory requirements for the country of interest. The information presented here focuses on U.S. regulatory requirements.

The AWAR (USDA 2015) and PHS Policy (NIH 2015) both require that the IACUC/OB inspect all animal facilities every 6 months, document its findings by indicating if an item is significant or minor, and develop a timeline for correction. Information gathered during inspections should be recorded, and some inspectors have started entering the information onto tablets or laptop computers that are carried with them. In the United States, if there is a significant deficiency identified during program review or inspections involving AWAR-covered species, a date for correction of the deficiency must be identified and completed within 15 days of the correction date. A written notice to the USDA is required if correction of a significant deficiency does not occur within the 15-day window. The results of both the facility inspection and the program review should be documented, signed by a majority of the committee members, and sent to the IO. Minority views of any IACUC/OB member related to the inspection and program review should be included, along with any changes to the animal use program and any departures from the Guide or PHS Policy, or the AWAR.

Animal Welfare Concerns and Noncompliance

Many countries have regulatory requirements for responding to animal welfare concerns and noncompliance, and the reader is referred to Chapter 8 for more detailed discussion of global regulations. In the United States, the AWAR (USDA 2015) indicate that the IACUC/OB must review and as necessary investigate any public complaints or noncompliance reports from personnel related to the use of animals at research facilities. Adequate methods for receiving complaints confidentially are expected to be in place. The Guide (NRC 2011) indicates that mechanisms for reporting concerns should be documented and posted in the facility. The posting should have multiple points of contact and should include a mechanism for anonymous reporting, and indication of compliance with whistle-blower policies and protection from reprisals. The response to animal-related concerns or investigations of noncompliant activities should be well documented, and software systems designed to track such activities are available (Capterra 2016). Retention of associated documents should be defined by institutional policy or regulatory requirements.

Postapproval Monitoring

Postapproval monitoring (PAM) programs vary from institution to institution, and the type and intensity of a PAM program often are dependent on institutional size and complexity (Haywood and Greene 2008). Certain responsibilities of the IACUC/OB, including periodic facility inspections, program review, and continuing protocol review, should be considered as part of a PAM program, and the documentation required for these activities has been discussed. More formal PAM programs will require additional documentation to ensure that all relevant parties (i.e., PI, laboratory staff, and IACUC) are made aware of observations and outcomes (Dale 2008). Regardless of the intensity of the PAM program, documentation of observations is evidence of a well-established program of care that is focused on animal well-being.

General

Laboratory animal programs should have a written program of veterinary care outlining the provision of adequate medical care for all animals, including delivery of both routine and emergency services. Institutions that are applying for accreditation by AAALAC must complete a program description that describes all aspects of the veterinary care program. Other documents that may be required include a PHS-approved Animal Welfare Assurance statement when funding is received from the PHS or other government agencies.

Animal Resource and Facility Standard Operating Procedures

Animal resource and facility SOPs are documents that present step-by-step instructions and responsibilities for tasks to be performed by individuals working in laboratory animal care and use programs. Specific SOPs should be identified by each program and may include categories such as personnel, husbandry, animal health and well-being, canine exercise programs, primate psychological well-being programs, facility maintenance, equipment operation, and personnel safety. Animal resource and facility SOPs should be written in a thorough and standardized way so that all personnel can follow and execute the activities consistently. Written SOPs are essential in many circumstances, but even when they are not required, they are a useful tool to ensure consistency within the program.

Staff Education and Training

Staff education and training are critical to ensure quality animal care in any laboratory animal use program. Basic methods of documenting education and training will be presented here. However, Chapter 12 of this volume presents the necessary elements of a thorough and inclusive education and training program that meets regulatory requirements.

Husbandry Assignments and Completion of Activities

Completion of assigned animal husbandry duties should be documented. These activities may be conducted by one animal care person or by many individuals, depending on the size of the program. A simple written daily log of activities may be appropriate in small programs, but large programs with multiple animal care personnel often develop more robust documentation systems.

Documentation of daily assignment schedules and completion of activities is a great resource for both animal care personnel and those at the managerial level. Many organizations utilize electronically managed programs, such as a spreadsheet to distribute workload. A well-maintained electronic spreadsheet or management program can be a valuable tool to oversee husbandry assignments when dealing with fluctuating animal populations and husbandry staff. The information that is maintained usually includes assignable tasks with time allocations for each chore. Programs can be set up to calculate times for all assigned work, including, but not limited to, changing animal cages, checking animal health, feeding, cleaning, stocking supplies, and housing newly received animals.

Completion of husbandry tasks, as well as daily observations of animals for health and well-being, assurance of access to feed and water, and verification of a safe and appropriate environment, should be documented. Completion of cleaning tasks outlined in animal resource and facility SOPs should also be documented. A simple calendar sign-off sheet maintained in the animal housing area may suffice for documentation of completed basic husbandry tasks, room environmental parameters, and verification of animal well-being. Portable or wall-mounted electronic documentation devices are now more commonly used at many institutions.

Acquisition and Disposition of Animals

Records regarding the acquisition and disposition of all animal species should be maintained. The USDA also requires specific documentation regarding the acquisition, transportation. and disposition of cats and dogs (USDA 2015). This information must be maintained for a reasonable period of time, and most institutions retain these records for a minimum of 3 years following the final disposition of the animal.

Identification, Cage Cards, and Census and Billing

All animals held for research must have appropriate identification, which starts with their acquisition and receipt. Animal records can vary from limited information on a cage card for rodents, birds, and fish, to detailed computerized records for individual animals. Means of identification include room, rack, pen, stall, and cage cards with written, bar-coded, or radio frequency identification (RFID) information. Identification cards should include the source of the animal, strain or stock, names and contact information for the responsible investigators, pertinent dates (e.g., arrival date and birth date), and protocol number when applicable. Genotype information, when applicable, should also be included, and should be consistent.

Large animals such as dogs, cats, nonhuman primates, and farm animals typically have an identification tag attached to their collar or a legible tattoo. Some large animals within a primary enclosure (e.g., penned cattle) may be identified by coat color and pattern differences. Records containing basic descriptive information are essential for the management of colonies of large long-lived species and should be maintained for each animal (NRC 1979; Dyke 1993; Suckow and Doerning 2007). These records often include species, animal identifier, sire and/or dam identifier, sex, birth or acquisition date, source, exit date, and final disposition. Such animal records are essential for genetic management and historical assessments of colonies. Records of rearing and housing histories, mating records, and behavioral profiles are useful for the management of many species, especially nonhuman primates (NRC 1979). Relevant recorded information should be provided when animals are transferred between institutions.

Documenting and tracking animal census is important for historical assessment of populations and is used for appropriate billing. This can be conducted using a traditional hand count of animals. More sophisticated electronic programs are available that use bar codes or chips for scanning into a tracking program. RFID systems are now being used for fast input of information for all animals housed within an entire room.

Environmental Enrichment

A formal, written plan for environmental enrichment is standard practice at most facilities for all species, with the primary aim of enhancing animal well-being. The enrichment plan should describe the structural elements of primary enclosures that may enhance the well-being of animals, along with the nonstructural provisions that promote species-typical activity patterns. Records should be maintained for tracking the actual enrichment provided for each species and for individual animals, including any rotation of specific devices. The environmental enrichment plan should also describe the strategy for social housing of all social species and should describe the steps that will be taken with isolated or individually housed animals to compensate for the absence of conspecifics.

For dogs, facilities should have an appropriate plan to provide them with the opportunity for exercise. The plan should include written standard procedures to be followed in providing the opportunity for exercise and must be approved by the attending veterinarian. Exercise provided or justification for not providing the exercise must be documented to meet requirements of the AWA (USDA 2015).

Emergency (Disaster) Plan

A comprehensive emergency plan is an expectation of the AWA and the Guide and is intended to protect the health and safety of humans and animals. Facilities should develop an appropriate plan to provide for the humane handling, treatment, transportation, housing, and care of animals in the event of an emergency or disaster. The facility should identify emergency situations that would trigger the need for implementation of a contingency plan. Examples of emergencies include electrical outages, faulty heating, ventilation, and air-conditioning (HVAC) systems, fires, animal escapes, and natural disasters that the facility is most likely to experience. The plan should outline specific tasks and procedures for emergency animal evacuation, shelter in place, provision of food and water, sanitation, ventilation, bedding, and veterinary care. The plan should identify a chain of command and who (by name or by position title) will be responsible for fulfilling responsibilities of emergency tasks. The plan also should address how response and recovery will be handled in terms of materials, resources, and training.

Emergency training of all personnel should be conducted and documented on a regular basis. It is advisable to review emergency plans at least annually, and any changes should be communicated to employees through documented training within 30 days.

Animal Health Surveillance

Maintaining an established health status for animals and colonies, as well as keeping unwanted pathogens out of facilities, is a primary concern for any animal care program. It is important to document known pathogens and verify new pathogens as they emerge. An important first step in accomplishing this is to document which pathogens are to be excluded for each species and every housing area. All incoming animals should have health data reviewed before admission into the facility or transfer to other locations, both internal and external. Animals routed through quarantine or isolation typically have further evaluation and health screening that is documented. Health surveillance documentation may be kept as a part of the individual, herd, or specific group of animals within a central filing system or electronic program. Electronic health surveillance and biosecurity programs are very useful and may be used to generate reports for review and action. Ongoing health data information should be collected, reviewed, and maintained centrally, and this may be done using electronic health surveillance programs or other custom computer software. The frequency and type of pathogen testing must be determined and included in the program. Ongoing test results should be archived in the program and reviewed regularly.

Animal Health Records

Animal health records are considered critical for documenting animal well-being and tracking animal care and use at a facility (NRC 2011). The American College of Laboratory Animal Medicine (ACLAM) has issued a public statement indicating that medical records are considered to be a key element of a program of adequate veterinary care for animals used in research, teaching, and testing (Field et al. 2007). Individual health records should be maintained for animals that receive regular, individual health evaluations as deemed appropriate by the institution. Documentation may range from detailed records for each individual animal to limited information recorded in group or herd records. Many facilities use electronic record keeping, while others continue to use handwritten paper records. Typically, dogs, cats, nonhuman primates, marine mammals, and other larger species have their own individual health record, while other species, such as rodents, birds, zebrafish, and other small animals, may have records that document health issues within a selected group, room, or herd of animals.

Health record information should include information associated with the management of clinical disease, diagnostic or therapeutic procedures performed, and preventative medical procedures. Health records may also be useful for recording husbandry information, dietary issues, and necropsy findings where applicable.

Notations in the health record should be made by individuals who have administered treatment, or made direct observations or evaluations of the animals or their diagnostic results. Individual health records should follow the animal throughout its life. A copy of the health record should be transferred with the animal if it is relocated. Individual or group health records can be maintained by the program indefinitely for historical purposes. Otherwise, these documents can be maintained for a reasonable period of time, but typically for a minimum of at least 3 years beyond the final disposition of each animal.

Environmental Health and Safety

It is essential that institutions have in place effective programs for controlling hazards and minimizing occupational risks of injury and illness in the workplace. Programs may have a functional environmental health and radiation safety (EHRS) office available to oversee the institution, while others may have other technical resources available with expertise to oversee specific activities within the program. All critical areas that are overseen by EHRS must function so as to minimize risks, and oversight of these activities should be documented. Documentation should include administrative procedures, facility design and operation, exposure control methods, engineering controls, work practices, personal protective equipment, education and training, equipment performance, information management, emergency procedures, and program evaluation.

Every person who works with animals should be provided an opportunity to enroll and participate in an occupational health and safety program. This should include students, visiting scientists, volunteers, maintenance and custodial personnel, vendors, and other nonemployees. A tracking mechanism should be in place to document enrollment. Documentation of occupational exposures, safety training, medical surveillance, and work-related injury and illness is important and is useful for evaluating the effectiveness of the occupational health and safety program for the institution. This documentation is confidential and should only be accessible to oversight personnel.

Written work practices should be in place in the form of SOPs and policies to help prevent accidents, exposures, and injuries. Special practices should be in writing and followed for specific hazards, such as chemicals, radiation, or infectious agents. These specific hazards should have written procedures (typically posted on the entrance where used) outlining the unique hazards and steps that should be taken to prevent exposure and ensure containment. All staff working with these types of hazardous agents should receive specific training, and this should be documented.

Specialized equipment and work areas should be clearly posted with safety precautions, and staff should be continuously trained concerning safe work practices. Some areas requiring special attention and documentation for use of potentially dangerous equipment include cage washers, sterilization equipment, heat sources, pallet jacks, forklifts, and transport vehicles.

Environmental Monitoring

The animal resource facility environment is an essential component of animal well-being, quality research, and production of laboratory animals, as well as providing conditions that promote the health and safety of personnel who work in these facilities. Active monitoring of the environmental parameters of an animal facility should be in place and the information must be retrievable. Whenever animals are exposed to environmental changes or any unplanned events, the events should be documented and shared with the affected research staff, veterinarians, and the IACUC/OB.

The parameters of the microenvironment immediately surrounding the animals should be monitored and documented. This typically includes temperature and humidity, although concentrations of gases (e.g., ammonia) and particulate matter within the primary enclosure may also be measured using specialized equipment. A baseline of the parameters within the microenvironment is essential to know and document before husbandry practices such as cage type, bedding and enrichment choice, number of animals allowed per enclosure, and cage change frequency are selected. Once the baseline has been established, ongoing checking and documentation of the microenvironment is essential to ensure environmental consistency.

The macroenvironment surrounding the primary enclosure should be documented continuously whenever possible, but at a minimum, daily observations should be recorded. Manual systems and devices such as high and low thermometers, hygrometers, light timers, water supply systems, data loggers, and light meters are useful in this regard. Many institutions have electronic programs that continuously monitor these parameters with built-in alarming and remote notification to key personnel who respond 24/7 when preset parameters are breached. Most electronic programs store collected information that can be reviewed by oversight bodies and research staff for verification of environmental parameters. Nevertheless, even the most sophisticated monitoring program should periodically be checked to validate accuracy.

Verification of air quality, pressure differentials, and ventilation should be documented periodically to ensure that filters and systems are performing as intended, valves are functioning, air quality is as designed, and air exchange rates are within the desired parameters. Periodic air balancing and pressure differential reports should be documented. Any problems discovered should be addressed and the resolutions recorded.

Noise and vibration produced by animals and husbandry activities are inherent in the operation of an animal facility. Routine practices should be in place to reduce noise exposure to animals and humans alike. Unfortunately, unplanned events related to construction, accidents, and natural events will happen. Any event, planned or unplanned, that has the potential to affect animal well-being should be documented and reviewed. Actions put into place to reduce the potential for future negative impacts should also be documented.

Equipment Function

All equipment within the animal facility should be kept in good operating condition. Most large pieces of equipment should have well-documented preventative maintenance programs, including dates of routine maintenance or repair. Documentation should include any testing results verifying proper equipment function. The frequency of functional testing of equipment should be decided by each facility. Equipment in the preventative maintenance and functional performance testing program typically include cage and bottle washers, autoclaves, anesthetic vaporizers, room sterilization equipment, individually ventilated cage systems, biological safety cabinets, fume hoods, laminar flow animal transfer stations, automated water systems, humidifiers, and environmental monitoring systems.

Pest Control

Pest control programs should be well documented. This includes documentation of how structural penetrations are sealed, how vermin entry is prevented, and methods of monitoring and protecting outside areas from vermin nesting or congregation. Additional documentation should include monitoring that is in place to trap unwanted vermin and what is done if insects or evidence of wild animal entry is found. If any traps or chemicals are employed, these should be described in the pest control program with information related to the protection of research animals when using physical or chemical deterrents. The pest control program should indicate that researchers will be notified when vermin control measures are to be implemented.

Security and Access Control

Security of the laboratory animal facility is essential to the welfare of the animals and to research studies that are being conducted. A central paper or electronic file should be kept identifying each individual who receives access to animal facilities. The rooms, areas, and other information concerning access should be kept in these files. Ideally, a method for reviewing access records will be in place with the ability to terminate access when appropriate. Such control may not be practical, however, for decentralized or agricultural facilities.

Water Quality Monitoring

Water is an essential component of the health and well-being for both terrestrial and aquatic animals. Documentation must be in place describing the components of any water system, and this should include a description of the water source, treatment or purification process, and how water is provided to the animals. Quality control should include monitoring for contaminants and other parameters, including pH, alkalinity, hardness, and other parameters listed in the Guide (NRC 2011). Routine test results should be documented and reviewed periodically. If automatic water delivery systems are used, a description or SOP for maintenance, testing, and sanitization is advisable.

Sanitation Monitoring

Sanitation monitoring should be documented on a regularly scheduled basis as determined by each facility. Items that may be included in the sanitation monitoring program are cages, housing racks, room surfaces, transport equipment, enrichment devices, and research or behavioral testing equipment or other hard-surface devices used within the animal facility. Monitoring information should be collected routinely and documented, and reviewed by knowledgeable staff. Documentation of contamination correction plans should be retained for future reference.

Controlled Drugs

Drug security and control are the responsibility of each facility that receives, maintains, or distributes any controlled drugs. Most countries have established their own enforcement agencies similar to the U.S. Department of Justice Drug Enforcement Administration. Drugs, substances, and certain chemicals used to make drugs are classified into five distinct categories or schedules depending on the drug’s acceptable medical use, and abuse or dependency potential. Schedule I drugs are considered the most dangerous, with a high potential for abuse. As the drug schedule changes”“Schedule II, Schedule III, and so forth”“so does the abuse potential; Schedule V drugs have the least potential for abuse.

Detailed records are required, and documentation of receipt and dispensing of controlled drugs must be maintained. A controlled substance logbook is typically kept with the name of the drug, identification number, and date the drug was received. When a controlled substance is dispensed, the date, amount used, patient or project, and identification of the person who dispensed the drug should be recorded in the controlled drug log. Records retention may vary by country, but in the United States, all records pertaining to controlled substances must be kept for 2 years and be made available for inspection by duly authorized officials of the Drug Enforcement Administration (CFR 2016a). In the case of loss of controlled substances, the regional Drug Enforcement Administration and local police department must be notified. A theft report form (DEA-106) must be completed and sent to the nearest office of the Drug Enforcement Administration.

Inspections and Site Visits

In the United States, whenever animals are held that are covered under the AWA, institutions are inspected without notification on a regular basis by a USDA/APHIS inspector. Inspectors will review all documentation associated with these animals to ensure that the facility, husbandry, veterinary care, and IACUC/OB practices are in compliance with the AWAR (USDA 2015). It is essential that all documentation related to the animal care and use program be current, accurate, and available. In the United Kingdom and most of Europe, a Named Animal Care and Welfare Officer (NACWO) is appointed and charged with oversite and reporting back to the Home Office (Council of Europe 1986; European Parliament and the Council of the European Union 2010).

During any USDA/APHIS inspection, it is important to provide relevant and required records. Active records kept in animal rooms, surgery, and support spaces must be made available, and historic files concerning the care and use of all covered animals must be accessible. Typically, animal care and use files are maintained for at least 3 years after the completion of the activity and inspection reports from USDA/APHIS, and all related correspondence should be maintained for at least 3 years. Whenever the USDA/APHIS administrator notifies a research facility in writing that specified records shall be retained pending completion of an investigation or proceeding under the AWA, the research facility shall hold those records until their disposition is authorized in writing by the administrator.

AAALAC International is a private, nonprofit organization that promotes the humane treatment of animals in science through a voluntary assessment and accreditation program. Research programs that participate in the AAALAC accreditation process demonstrate that they meet the minimum standards required by law, and are also going the extra step to achieve excellence in animal care and use. An important document related to the AAALAC accreditation process is the program description, which provides a description of the animal care and use program in specific detail. AAALAC site visitors will review all aspects of an animal care and use program (typically every 3 years), and they will verify that all operations are as described in the program description. Key representatives of the animal program will be interviewed, and facilities will be toured while practices and procedures are observed. Also, documentation related to animal care and use will be reviewed to ensure compliance with regulatory requirements and high standards of animal care. Facilities should document the highlights of the site visit and record any comments presented at the exit briefing. Follow-up activities and correspondence will be documented according to the AAALAC accreditation process (AAALAC International 2016).

Organization and Personnel

Equipment

Written SOPs that define the methods, materials, and schedules used in inspection, cleaning, maintenance, testing, calibration, and/or standardization of equipment are required. Specific personnel (generally identified by job title) who are responsible for performing each operation must be indicated. SOPs should also specify actions to be taken in the event of failure or malfunction of the equipment.

Written records of equipment operations and maintenance must be maintained. These records must contain the date of the operation and whether the maintenance operations were routine and followed the written SOPs. Nonroutine repairs performed as a result of equipment failure and malfunction require written records that document the nature of the defect, how and when the defect was discovered, and any remedial action taken.

Animal Care

SOPs are required for the housing, feeding, handling, and care of animals. Any clinical treatment must be documented and these records retained. Feed and water must be analyzed periodically and the raw data must be maintained. Finally, the use of pest control measures must be documented. FDA inspectors may ask to see a written SOP for pest control, along with documentation of implementation of these procedures.

Initial Registration and Other Forms

The Application for Registration for Possession, Use and Transfer of Select Agents and Toxins (APHIS/CDC Form 1) must be completed and sent to the DSAT (human select agents), to AgSAS (animal or plant select agents), or to either agency if overlap agents (i.e., those that are hazardous to both humans and animals) will be used. The appropriate sections of Form 1 are to be submitted anytime there is a change at the institution. Any correspondence associated with an application or an amendment should be retained. Other APHIS/CDC forms and the reasons for their use are:

• Form 2: To request approval to transfer select agents from one registered entity to another registered entity. Shipping invoices and related materials should be included with Form 2. Note that approval is not required to transfer toxins in quantities below a specified amount listed in the regulations, although these may only be transferred after documenting that the recipient has a legitimate need to use and possess the toxin.
• Form 3: To be submitted within 7 calendar days upon discovery of a theft, loss, or release of a select agent and toxin.
• Form 4: To report identification of a select agent or toxin isolated from a clinical specimen or environmental sample (Form 4A), or from a proficiency (comparative) sample test (Form 4B).
• Form 5: To request an exemption from the select agent regulations for an investigational product.
• FD 961: To obtain a security risk assessment (SRA) for every individual listed on the registration form who requires access to select agents; resubmitted for each person every 3 years.

Biosafety Plan

A written biosafety plan commensurate with the risk of the select agents that are possessed must be developed and implemented (CDC and USDA/APHIS 2014a). The plan must include an occupational health program for individuals with access to Tier 1 agents (i.e., a subset of select agents that pose a severe threat to public health and safety) and to severe acute respiratory syndrome (SARS). Additional information regarding the occupational health program requirements may be found at “Occupational Health Program Guidance Document for Working with Tier 1 Select Agents and Toxins” (CDC and USDA/APHIS 2013a). The biosafety plan must be specific to each laboratory where the select agents are used. Alternatively, an institutional plan may be developed with an attached plan for each laboratory. The plan must provide instructions on the risks and ways to mitigate them.

The elements of the biosafety plan can only be determined by performing an institution-specific risk assessment, although guidance for what may be included has been provided in the Responsible Official Resource Manual (CDC and USDA/APHIS 2013b). The presence of animals at a facility necessitates a biosafety plan for their care and handling, and the components of the plan will depend on the animal species, agents used, procedures conducted, and facilities. SOPs may be used, and if so, these should be referenced and where they can be accessed in the biosafety plan noted.

Electronic accessibility of the biosafety plan, via web page or otherwise, is becoming more common, as this format enhances accessibility and editorial convenience. Staff should be kept apprised of changes when they are made to the electronic document. Written biosafety plans should be subject to document tracking to ensure that when changes are made, all plans are updated accordingly.

Security Plan

A security plan, based on a site-specific security risk assessment, is required for every registered entity. Each security plan is unique; however, the following components must be included in all plans:

• A description of procedures for controlling the long-term select agent inventory
• Procedures for ensuring information security (e.g., inventory access logs, passwords, and entry logs)
• A description of how access to animals exposed (or possibly exposed) to select agents and their safeguarding is controlled, along with escaped animal procedures
• Security procedures when the laboratory must be cleaned or repaired, including information regarding granting and recording access and escort provisions for maintenance personnel, and securing select agents during cleaning or repair
• Procedures for identifying and removing unauthorized individuals
• A description of access procedures (e.g., identify who authorizes and provides keys or access cards or codes, and who removes access and collects keys or cards), along with the response procedures when keys, cards, or codes are lost
• Response procedures following theft or loss of select agents, or when inventory records are altered
• A description of requirements (e.g., security drills and exercises) that will ensure that all personnel with select agent access are aware of security policies and procedures

The security plan should undergo annual review or whenever changes, such as facility renovation or addition of new projects, occur.

Incident Response Plan

A written incident response plan is required with the intent of defining measures that would be taken to mitigate the impact of natural and man-made threats. The plan must be based on a site-specific risk assessment, and it should be developed in harmony with institution- or community-wide plans. Notably, for institutions using animals, the plan must include how animals infected with select agents will be handled during emergency situations, and this must include a description of the response to the release of infected animals into the laboratory, building, or community. Also, if the institution works with animals and it possesses select agent plant pathogens, the impact of the release of the plant pathogens on animals and animal products must be considered. Other required parts of the incident response plan include a full description of the response to:

• Theft, loss, release, or inventory discrepancy for a select agent
• Security breaches
• Severe weather and natural disasters given the geographic location
• Workplace violence, bomb threats, or suspicious packages
• Fire, gas leak, explosion, and power outage

Contact information (home or cell phone, work phone, etc.) for key individuals should be included in the plan, including those for the RO and alternate RO, biosafety officer, animal care and veterinary staff, building manager and facilities management, and physical security official for the building. Contact information for local public safety entities (e.g., police, fire department, and hazardous materials management), along with that for the regional Federal Bureau of Investigation Weapons of Mass Destruction office, should also be listed. Other information that should be in the plan in case of an incident includes a description of each responder’s role in the response, information on procedures for rescue and provision of medical care, a list of personal protective equipment and its location, security and evacuation procedures, a description of emergency medical treatment and first aid, and a description of decontamination procedures for impacted areas.

For institutions with Tier 1 agents (i.e., a subset of select agents that pose a severe threat to public health and safety), the incident response plan must also describe the response to a failure of intrusion detection systems such as locks, cameras, or alarms. Additionally, the plan must contain a description of how federal, state, or local law enforcement will be notified of possible criminal activity related to the institution, its personnel, or its select agents. Examples include unusual interest by outsiders in an institution’s select agent work, and unauthorized removal of select agents from designated areas.

Training

The RO has the responsibility to ensure that training is conducted and documented (CDC and USDA/APHIS 2014a). Training should be appropriate for the work that an individual is performing; for example, a laboratory technician who conducts animal research with plague bacteria will require extensive biosafety training to ensure that he or she knows how to work in a safe manner with this agent. Security training regarding how to protect select agents from theft or loss, and incident response training on how to react to emergencies also should be provided. Note there is a special training requirement for institutions with Tier 1 select agents in that insider threat awareness briefings, which relate to identification and reporting of suspicious behaviors, must be provided annually to individuals with an SRA (CDC and USDA/APHIS 2014a).

Initial and annual refresher training must be provided and documented for each individual who has access to select agents, that is, for those individuals with a security risk assessment. The RO must ensure that each training record includes:

• Name of the individual
• Date of training
• Description of the training
• Means used to verify that the employee understood the training (e.g., by testing to ascertain the employee’s comprehension, or by asking the employee to sign a verification that he or she understood the training)

Individuals who do not have an SRA (e.g., IACUC/OB members during semiannual inspections) may go into select agent areas with an escort. However, there must be a training record that these individuals have received instructions and signed that they received and understood the instructions prior to escorted entry. Recurring visitors (i.e., individuals who enter a select agent area on a regular basis) must receive training once per year, and there must be documentation that they received and understood the training.

It is the RO’s responsibility to ensure that all training records are maintained for at least 3 years, even if the individual leaves the institution before the end of that time. There is no required way to document training, although an individual file for each trainee may help ensure accurate oversight. Paper records are acceptable, as are computer-based systems, which are available commercially.

Other Documentation

Further details on the documentation listed below may be found in the Responsible Official Resource Manual (CDC and USDA/APHIS 2013b).

• Access records: The RO must ensure that there is a record of who has access to rooms where select agents are used and stored. This should include a record of who has been assigned codes, keys, combinations, or other security mechanisms that are needed for access.
• Audits
  • Internal: Annual internal audits are to be conducted, and a copy of these, including documentation of the deficiencies identified and their resolution, are to be maintained.
  • External: This includes inspections, reviews, certifications, or audits by other agencies, accreditation organizations, or groups. There is no regulatory requirement to maintain these documents; however, they could be useful in responding to FSAP inquiries.
• IBC minutes: FSAP inspectors may ask to review IBC minutes (although there is no requirement under the select agent regulations for this committee).
• List of select agents and toxins: The RO should maintain a record of the select agents for which the institution is registered (these will be identified in the initial registration and amendments), where the select agents are located, and a current inventory for each. Electronic inventory systems are available that can facilitate this requirement.
• List of personnel with an SRA: For each individual, the list should include:
  • Name
  • Date of submission request for SRA
  • Date of SRA approval
  • Date when access to select agents was allowed
  • SRA expiration date (3 years after approval date)
• Health-related entry requirements: These include personal records of immunizations, respiratory evaluations, baseline sera, or health evaluations required for individuals working with select agents. This information is often confidential and is kept by the occupational health service.
• FSAP inspection reports: These reports, including the response to deficiencies and all follow-up documentation, should be maintained by the RO.
• Drills and exercises: These interchangeable terms refer to activities conducted by an institution that ensure that the biosafety, incident response, and security plans are adequate. Documentation of such activities, although not required, provides evidence that the institution has engaged in these drills or exercises.
• Commissioning and verification: Commissioning is a process that ensures that all systems in a facility perform as designed. The original commissioning document for animal biosafety levels (ABSLs) 3 and 4 facilities and subsequent annual verification documentation should be maintained.
• Equipment records: Maintenance records for biological safety cabinets, autoclaves, digesters, liquid effluent decontamination systems, high-efficiency particulate air (HEPA) filters, exhaust fans, and other lab equipment should be maintained. Also, sterilization verification should be kept for autoclaves, and records of decontamination verification should be maintained for digesters and liquid effluent decontamination systems.
• Internal transfer records: Transfer of select agents within an institution (e.g., from one laboratory to another) should be maintained. An internal transfer form may be developed for this purpose (note that APHIS/CDC Form 2 is not required for internal transfers).
• Restricted experiments: These are experiments that require review and approval by FSAP before they may be conducted. Specific information regarding these types of experiments may be found in Section 13 of the select agent regulations (CDC and USDA/APHIS 2014a) and in the Responsible Official Resource Manual (CDC and USDA/APHIS 2013b). All documentation, including the letter requesting the FSAP review, supportive documents, and related correspondence, should be maintained.