The purpose of this SOP is to establish the process for processing and reviewing research or education protocols that involve the use of live, vertebrate animals and amendments to previously approved projects.
General Requirements
Per PHS Policy IV.B.6-8 and UNCW policy, the IACUC shall review research and teaching protocols involving the use of live, vertebrate animals to determine that the proposed research project is in accordance with PHS Policy and is consistent with the Guide for the Care and Use of Laboratory Animals unless acceptable justification for a departure is presented, and conforms with the UNCW Assurance. The IACUC may approve, require modifications in (to secure approval), or withhold approval of activities related to the care and use of animals according to PHS Policy IV.C.1-3.
Scope
This SOP pertains to studies involving the use of animals as defined below.
Applicable Definitions
Animal – any live, vertebrate animal used or intended for use in research, research training (including teaching), experimentation, or biological testing or for related purposes. Only animals approved by the UNCW IACUC are permitted in animal housing or experimentation areas. This definition excludes:
1) Free-living wild animals observed in their natural habitat during field studies, provided the field study activity is not likely to materially alter or influence the activity of the study animal or other species in the study area and does not have the potential to cause harm (does not involve trapping, capturing, physical/chemical restraint, handling and/or invasive procedures). A field study will materially alter or influence the activity of a study animal if the methods to detect the animal reduce the animal’s chance at survival, the ability to reproduce and/or impacts their migration.
2) Animals used for display purposes only, such as fish tanks/exhibition aquaria where the animals are not research subjects.
3) Pets, meaning domestic or tamed animals owned by an individual, whether UNCW employee, student, or community member, kept for that individual’s companionship or personal enjoyment, provided they are not used as research subjects.
4) Animals that meet the definition of service or emotional support animals per UNCW policy 05.360 Service Animals, Emotional Support Animals, and Pets.
Assurance – an agreement with the Office of Laboratory Animal Welfare (OLAW) to operate an animal care program in accordance with certain policies and principles. UNCW's OLAW Assurance # is D16-00502(A3871-01).
Attending Veterinarian (AV) – the AV has direct program authority and responsibility for the Institution’s animal care and use program including access to all animals. The AV reports to the IACUC chair and directly to the institutional official (IO) if any violations of the AWA are discovered.
Backup Veterinarian – if the AV is unavailable, the Backup AV provides veterinarian services and has direct program authority and responsibility for the Institution’s animal care and use program including access to all animals.
Designated Member Review (DMR) – a review method where written descriptions of activities involving live vertebrate animals are made available to all IACUC members, and members may request review at a convened meeting for any reason. If no member of the committee requests review at a convened meeting, the IACUC chair designates one or more reviewers who are qualified to conduct the review and have the authority to approve, require modifications (to secure approval), or request full committee review of the activities. Designated reviewers do not have the authority to deny approval. The DMR process in no way implies that the quality of the review is less stringent than a protocol reviewed by the full committee.
IACUC staff – Research Integrity Office director or research compliance specialist assigned to oversee the UNCW IACUC program.
Pet – a domestic or tamed animal owned by an individual, whether UNCW employee, student, or community member, kept for that individual’s companionship or personal enjoyment.
Principal Investigator (PI) – the member of a research team who is ultimately responsible for the project. The PI may not be a student. If a student is the primary researcher on a project, the student’s faculty advisor may serve as the PI.
Quorum – a majority of members of the IACUC.
The Three Rs – a widely accepted concept referring to three ways of reducing distress to research animals and encouraging the use of alternatives. The Three Rs, reduction, refinement and replacement, are defined as:
1) Replacement - substituting other systems for whole animal use. Examples include human and animal cell, tissue, and organ cultures; chemical systems; blood products; computer simulations; and plastic organ models.
2) Reduction - decreasing the number of animals to the minimum needed to yield accurate test results.
3) Refinement - using modern medicine to minimize or eliminate pain and distress and employing housing and husbandry techniques to enrich the captive environment to reduce boredom and promote natural behavior.
Protocol Processing Procedures for Initial and Replacement Submissions
Upon receipt of a protocol to use live, vertebrate animals for research or education, IACUC staff are responsible for the following:
1) assigning a protocol number;
2) entering protocol information in the IACUC database;
3) saving an electronic copy of the submission in appropriate folder; and
4) conducting an initial administrative review to ensure all relevant questions on the form have been completed, any necessary appendices have been included, and basic compliance requirements have been met, such as training requirements and the health evaluation requirements described in SOP 7.1 Health Surveillance and Risk Assessment for Vertebrate Animal Exposure (a.k.a. Health Screening Questionnaire).
IACUC staff complete relevant sections of the Veterinary Consultation form and transmit a copy of each submitted protocol to the AV and/or back-up AV. The AV and/or back-up AV conduct a veterinary consultation of the study and send comments and recommendations to the PI. The PI may revise and resubmit the protocol based on the AV's comments.
The PI must return the revised protocol to IACUC staff by or before the second submission deadline posted on the IACUC website.
IACUC staff organizes meeting materials in accordance with SOP 6.1 IACUC Meetings and Minutes.
Protocol Review Procedures for Initial and Replacement Submissions
Full IACUC Review
Submissions are normally placed on regularly scheduled convened meeting agendas, and PIs are expected to plan in advance so that no special approval arrangements are necessary to accommodate the researcher's needs.
Full board meetings are conducted in accordance with SOP 6.1 IACUC Meetings and Minutes.
The IACUC will conduct its review of submissions in accordance with PHS Policy IV.C and will specifically consider the Three Rs (see Definitions), personnel qualifications, and personnel safety.
Protocol revisions required by a convened quorum of members or a designated member reviewer that are not submitted within 90 days from the date the principal investigator is notified of the required revisions, may be subject to a follow-up review at the next scheduled convened meeting or referral by the designated reviewer to full committee review.
Designated Member Review (DMR)
If designated review is authorized by the members, the IACUC chair or designee appoints a member, a team of members, or him/herself to conduct the review. The designated reviewer or review team (reviewer) has the authority to approve or require modifications to the protocol. When the reviewer decides to approve a protocol, the reviewer notifies the IACUC staff and the IACUC staff prepares an approval memo for the IACUC chair’s or designee’s signature.
When the reviewer determines that modifications are needed in order for the PI to secure approval, the reviewer may contact the PI by phone, e-mail or in person to discuss the protocol and the modifications required. In all instances, the reviewer must notify the IACUC staff of the information being requested from the PI. The modifications are communicated in writing to the PI by the IACUC staff and that communication/exchange becomes part of the electronic protocol file for the proposed study.
When the revised protocol is submitted and the PI’s responses to the required modifications are found to be acceptable, approval procedures stated above are followed.
The reviewer does not have the authority to deny an application for animal use. If the reviewer is unable to approve a protocol with or without changes, the reviewer must withhold approval and request full review of the protocol.
When the reviewer decides to withhold approval of the protocol, the reviewer e-mails justification for his/her decision to the IACUC staff. IACUC staff prepares a memo for the IACUC chair’s or designee’s signature and includes the justification in the memo. The memo may also include the date of the next IACUC meeting, if known, and other instructions to the PI. IACUC staff send the memo to the PI.
An electronic copy of the approved/signed protocol is placed in the IACUC files.
Procedures for Processing and Reviewing Modifications to Approved Protocols
PIs are responsible for submitting requests to change any aspect of an approved protocol, including changes to personnel, funding sources, types or numbers of animals used, etc. in accordance with SOP 7.2 Protocol Development, Submission and Modification Requirements.
PIs must submit these requests in writing to iacuc@uncw.edu.
Upon receiving a request to modify a study, IACUC staff review the information provided, determine if additional information is needed in order to properly direct the request, and acknowledge receipt of the request to the PI and if necessary, request clarifications.
Minor changes may be handled administratively by IACUC staff. These changes are documented in the electronic protocol file and include:
1) correcting typographical errors;
2) correcting grammar;
3) updating contact information;
4) changing personnel, other than the PI, if it can be documented that all such personnel are appropriately identified, adequately trained and qualified, enrolled in applicable occupational health and safety programs, and meet other criteria as required by the IACUC;
5) adding or removing experimental rooms or housing areas in buildings already approved by the IACUC for those purposes; and/or
6) proposing an increase in the total number of animals needed for animal groups that will experience Pain Category B, provided appropriate justification is provided.
Moderate changes require review by either the IACUC chair or an IACUC member appointed by the chair in order to receive approval. Once approved, these changes are documented in the electronic protocol file. Examples of moderate changes include but are not limited to:
1) harvesting additional tissues if it requires additional procedures and/or substantially lengthens anesthesia or captivity length;
2) taking additional measurements;
3) altering the operant schedule (e.g. fixed ratio to variable interval);
4) altering a surgical approach;
5) using a different gender animal;
6) making a minor change in species (rat to mouse); and/or
7) proposing an increase in the total number of animals needed for animal groups that will experience Pain Categories C or D, or proposing a 10% increase or less of animal groups that will experience Pain Category E, provided the animal group does not include endangered or threatened species at state or federal level, and appropriate justification is given.
Significant changes in ongoing research projects are those that either have, or have the potential to have, a negative impact on animal welfare, or those that indicate a substantial difference in the conduct of the study. Significant changes require the PI to submit a revised protocol and, as determined by the IACUC chair or designee, may require review by the full committee for designated member review or review at a convened meeting, depending on the nature of the request. Once approved, the revised protocol becomes part of the original protocol electronic file. Examples of significant changes include but are not limited to:
1) changing the objective of a study;
2) changing from non-survival to survival surgery;
3) changing the degree of invasiveness of a procedure or discomfort to an animal;
4) making a substantive change in species;
5) changing the principal investigator of the study;
6) changing the anesthetic agent(s) or the use or withholding of analgesics;
7) changing the approved method of euthanasia;
8) changing the duration, frequency, or number of procedures performed on an animal; and/or
9) proposing more than a 10% increase in the total number of animals needed for animal groups that will experience Pain Category E or that include threatened or endangered species at the state or federal level.
Procedures for Continuing Review of On-Going Research Projects
The IACUC will conduct continuing review of each previously approved, on-going activity at appropriate intervals as determined by the IACUC, including a complete de novo review at least once every 3 years according to PHS Policy IV.C.1.-5. Continuing review is conducted at least annually. The IACUC may determine that some protocols require continuing review more often than annually, based on the type of animals used or procedures involved.
Principal Investigator Notification
The IACUC must notify the PI in writing as soon as possible of the results of the review.
The purpose of this SOP is to outline the steps for evaluating and investigating a report of noncompliance or concern for animal welfare in a live, vertebrate animal research study or educational activity.
General Information
Researchers conducting research, training or educational activities with live, vertebrate animals are required to conduct the activity in a humane, ethical and responsible manner, in accordance with the methods and procedures approved by the UNCW Institutional Animal Care and Use Committee (IACUC). Failing to follow the approved methods and procedures is a violation of UNCW IACUC policy.
Scope
The SOP pertains to all live, vertebrate animal research, teaching and training activities conducted by UNCW faculty, staff and students, or external researchers collaborating with UNCW faculty, staff or students on research approved by the UNCW IACUC.
Applicable Definitions
Allegation of Noncompliance – an unproven assertion of noncompliance.
Attending Veterinarian (AV) – the AV has direct program authority and responsibility for the Institution’s animal care and use program including access to all animals. The AV reports to the IACUC chair and directly to the institutional official (IO) if any violations of the AWA are discovered.
Continuing Noncompliance – repeated instances of noncompliance by the same investigator. “Repeated instances” can mean a noncompliant activity occurring multiple times within the same study, or a noncompliant activity occurring once in multiple studies. Such repetition if unaddressed may affect the humane care and use of live, vertebrate animals.
Institutional Official (IO) – the individual who bears ultimate responsibility for the Animal Welfare Assurance Program and is responsible for resource planning and ensuring alignment of program goals with the university’s mission.
Minor Noncompliance – noncompliance that does not increase risk to animals, such as an administrative inconsistency from the methods and procedures approved by the IACUC. Examples of minor noncompliance include but are not limited to:
Failing to submit annual review information within a reasonable time following the due date.
Failure to notify the IACUC when appropriately trained personnel were added to the research team;
Using a location not listed on the approved protocol for approved activities.
Noncompliance – failure to comply with federal regulations, state laws, or UNCW policies or SOPs related to the humane care and use of live, vertebrate animals, and/or the requirements or determinations of the IACUC, or provisions of the approved research, education or training study.
Principal Investigator (PI) – the member of a research team who is ultimately responsible for the project. The PI may not be a student. If a student is the primary researcher on a project, the student’s faculty advisor may serve as the PI.
Research Misconduct – fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results. It does not include honest error or differences of opinion. Noncompliance of IACUC policies and/or SOPs generally does not constitute research misconduct.
Serious Noncompliance – instances of noncompliance that pose an actual or potential increased risk to the wellbeing of live, vertebrate animals or UNCW research team members working on animal research. Examples of serious noncompliance include but are not limited to:
Conducting research, education or training activities involving live, vertebrate animals without UNCW IACUC review and approval;
Continuing use of animals after study approval has lapsed;
Changing the PI of the study without IACUC approval;
Allowing untrained or inappropriately trained individuals to work with animals;
Not providing anesthetics or analgesics as required by the approved protocol;
Performing unapproved surgical procedures;
Using an unapproved euthanasia method;
Other major deviations from approved methods and procedures that may place animals or research team members at risk; and/or
A combination of continuing and/or minor incidents of noncompliance or concerns of inhumane treatment of animals.
Whistleblower – a person who informs on an individual or an organization engaged in an unethical or illegal activity.
General Procedures
Retaliation and/or discrimination against any individual who acts as a whistleblower by reporting a concern regarding animal welfare is strictly prohibited and actionable. Retaliation and/or discrimination may result in a disciplinary action up to and including dismissal from employment or expulsion from the university, in accordance with procedures established by university policies.
Any individual who identifies a concern regarding animal welfare or who identifies a possible incident of noncompliance should report the matter to IACUC staff, the IACUC chair, or the IO. The Research Integrity Office (RIO) also maintains a reporting system on its website to accept anonymous complaints or concerns.
The recipient of the concern, if not the RIO director, will notify the RIO director of the concern at the earliest opportunity.
If the IACUC chair has a conflicting interest in the matter, the RIO director will ask the IO to designate an IACUC member without a conflicting interest to oversee the IACUC’s response to the concern.
If the report is made by a complainant whose identity is known, and the complainant wishes to maintain confidentiality of his/her identity, the RIO director will not divulge the complainant’s name unless it is ultimately found that the complainant provided inaccurate information in bad faith. If so, the RIO director will share the complainant’s identity to appropriate authorities such as the IO and/or General Counsel’s office for possible disciplinary or legal action.
At the conclusion of the review or investigation, the RIO director will communicate the IACUC’s findings to the reporting individual, if their identity is known.
Within one day of being notified of the concern, the IACUC chair or designee will determine the appropriate initial response based on whether the concern:
Places animal welfare or safety at risk If the concern describes conditions that threaten animal welfare, the IACUC chair or designee will immediately:
Notify the AV and request a site visit. If the site visit reveals a deviation from regulation, policy or protocol that poses a serious threat to animal welfare, the IACUC chair/designee and/or AV have authority to temporarily halt research activities until the full committee convenes to determine appropriate action.
Notify the IO
Places staff safety at risk:
If the concern describes conditions that create unsafe conditions for research team members, the IACUC chair or designee will immediately:
Notify the UNCW Environmental Health & Safety office and request a site visit.
Notify the IO
Involves research misconduct
If the concern describes research misconduct, the IACUC chair/designee will advise the RIO director to refer the matter to appropriate institutional officials in accordance with UNCW’s Research Misconduct policy.
Involves noncompliance with IACUC policy that does not impact animal welfare.
Upon determining the appropriate initial response, the chair/designee will instruct IACUC staff to send an inquiry to the PI of the study on behalf of the chair/designee to notify the PI that a concern regarding animal welfare and/or possible noncompliance has been identified, and instruct the PI to respond to the concern within two days.
IACUC staff will retain a copy of the notification in electronic format.
IACUC staff will place the concern on the next regularly scheduled convened IACUC meeting for evaluation and will provide the committee with a summary of the concern and the PI’s response. If the PI fails to respond, IACUC staff will advise the committee of the PI’s failure to respond.
If necessary, based on the nature of the concern, the IACUC chair may call a special meeting to review the matter.
Only a quorum of convened IACUC members may determine if a concern or complaint warrants a full investigation.
Minor Noncompliance
When the IACUC determines that a concern or complaint constitutes an incidence of minor noncompliance, the IACUC may direct the chair/designee, a subcommittee, or IACUC staff to instruct the PI to develop a corrective action plan to address the problem, establish the due date of the corrective action plan, and who will review it to determine if it is acceptable.
Serious Noncompliance
If the IACUC determines that an incident of noncompliance is serious, or if the IACUC finds a significant number or repeated minor infractions the IACUC can vote to require any of the following actions or combination of actions:
Take no action – When the IACUC votes to take no action, the PI, his/her immediate supervisor, and the IO will be notified in writing. IACUC staff will file a report in electronic format.
Open an in-depth investigation - When the IACUC votes to open an in-depth investigation, the IACUC will designate two or more members of the committee who do not have conflicting interests in the study and are not in the role of chair/designee to conduct the investigation under the coordination of the RIO director.
Suspend the protocol – When the IACUC votes to suspend the protocol, the RIO director will notify the PI, his/her immediate supervisor, and the IO in writing on behalf of the IACUC of the date the suspension must commence. When a protocol is suspended, no new animals can be collected. The researcher may also be required to safely return animals to the collection location if collected from the field, or if possible, transfer animals to another approved study conducted by a researcher not involved with the incident of noncompliance. The IACUC may instruct the PI to provide the IACUC with a plan to phase out the use of animals, which must be accepted by the IACUC, and must contact the IACUC when all animals have been phased out. The study may resume only when the IACUC votes to lift the suspension of the protocol.
Terminate the protocol – When the IACUC votes to terminate the protocol, the RIO director will notify the PI, the PI’s immediate supervisor, and the IO in writing on behalf of the IACUC of the date the termination must commence. When a protocol is terminated, all research activities related to the protocol must cease. The IACUC may direct the PI as to how to terminate the protocol. Typically, the PI may not collect new animals and must submit a plan to the IACUC describing how existing animals will be cared for until they are able to be transferred to other approved studies conducted by researchers not involved in the incident of noncompliance, safely returned to the collection site if collected from the field, or other humane method of ceasing use of the animals. The study may not resume until the IACUC votes to lift the termination of the protocol or to allow some parts of the study to continue.
Prevent the researcher/PI from conducting research at UNCW - In extreme cases, the IACUC may decide to no longer permit a researcher to conduct research at UNCW. When the IACUC votes to prevent a researcher from conducting research, the RIO director notifies the PI, the PI’s immediate supervisor, and the IO in writing on behalf of the IACUC. When the IACUC votes to prevent a researcher from conducting research at UNCW, all relevant research activities must cease.
In addition to or in lieu of the above-mentioned actions, the IACUC can vote to require the researcher to complete additional training in the humane care and use of animals, require more frequent than annual review of protocols, place a researcher on temporary probation from conducting animal research, require the researcher to destroy data already collected, or take any similar disciplinary action appropriate to the magnitude of the noncompliance.
The IACUC or IO may take any of the above actions when it is determined a research protocol is not being conducted according to federal or local regulations or UNCW policies and procedures, has deviated from its approved protocol, or raises concerns about the risks to animals or research team members.
Procedures for Conducting an In-Depth Investigation
When the IACUC determines that an in-depth investigation is required to obtain detailed information regarding the conduct of a live, vertebrate animal study, the investigation team may:
Conduct interviews of knowledgeable sources, including but not limited to the principal investigator (PI), research team members, and animal housing staff;
Request from the PI a written response to questions;
Observe the methods and processes used; and
Collect and review any related documentation, including but not limited to correspondence, feeding and husbandry logs, or other study materials.
The investigation team shall ensure that the investigation is conducted in a timely manner, is thorough, and the procedures used are limited to those that are deemed reasonable and necessary in order to produce relevant, reliable and sufficient detail that will enable the IACUC chair/designee or full board to determine further actions needed, if any.
They should establish and communicate deadlines for interviews, responses, and document collection, and make available extensions for good cause.
Upon conclusion of the investigation, the investigation team shall prepare a written report to the IACUC detailing the investigation process, the investigation findings, and the investigative team’s recommendations for further actions to be taken, which may include, but are not limited to:
Require no further action;
Accept and approve a proposed corrective action plan provided by the PI or the Institution;
Require that the PI modify the protocol to minimize risk, such as modifying the feeding or husbandry procedures or revising other methods and procedures;
Require the interval at which continuing review is conducted to be modified to less than one year as appropriate to the degree of risk;
Require observation of the research;
Require submission of status reports on a defined set schedule to the IACUC;
Require additional education and training for the PI and/or other research team members;
Require that random audits be performed of studies conducted by the PI to ensure study procedures are followed as approved by the IACUC;
Replace the PI of the study with an experienced animal researcher with a clean research compliance record, selected by the IACUC;
Issue a letter of reprimand to the PI and/or other research team member(s) and copying as appropriate the department chair, faculty advisor (if noncompliant individual was a student), dean, provost, institutional official, or other administrator;
Require the PI to destroy or decommission data collected by noncompliant methods or during a lapse in IACUC approval;
Refer the PI or all of the research team to another University entity (i.e., IO, Sponsored Programs and Research Compliance, Institutional Risk Management, Human Resources);
Refer the matter to the appropriate UNCW office(s) that handle(s) research misconduct and/or whistleblowing activities;
Suspend any or all components of the research (i.e., new animal collection, specific experiments, and data analysis) until a corrective action plan can be developed and implemented or until additional review can occur;
Terminate the research; and/or
Revoke the privilege of the PI and/or members of the research team to conduct live, vertebrate animal research or education activities.
The IACUC will review the investigation report at the next scheduled full board meeting and will consider the recommendations made by the investigation team. If the investigation is completed in-between regularly scheduled IACUC meetings, the IACUC may decide if an additional meeting should be scheduled to consider the recommendations.
The IACUC chair/designee will issue a final determination letter to the PI to convey the final decisions of the board. The letter shall also describe the PI’s appeal rights.
Appeals and Reporting Procedures
Appeal
The PI may appeal any action by the IACUC in writing to the IO within 10 business days of receiving notification of the decision. The IACUC’s decision will stand until the appeal can be properly evaluated. The IO’s decision is final. The only grounds for requesting an appeal are if the researcher believes that the IACUC’s decision is due to inadequate, or inaccurate information, or noncompliance with university policy, state law or federal regulation. Mere disagreement with the IACUC’s decision does not constitute grounds for an appeal.
The RIO director will report the IO’s decision to the IACUC at the next scheduled meeting and will record the decision in the meeting minutes.
Reporting to Federal Agencies
As required by applicable law, regulation or UNCW policies, the IO shall report, in writing, the finding of serious or continuing noncompliance and the action(s) taken by UNCW to address such noncompliance to regulatory agencies, the study sponsor, and UNCW officials as appropriate.
In accordance with UNCW’s Assurance to the Office of Laboratory Animal Welfare (OLAW), Part VI.B., the IACUC must report to OLAW when the following occurs on animal research supported by a Public Health Service agency or the National Science Foundation:
Any serious or continuing noncompliance with the PHS Policy
Any serious deviations from the provisions of the Guide
Any suspension of an activity by the IACUC.