1 P a g e 1 Bloodborne Pathogens FIRE, MEDICAL, CHEMICAL SPILL EMERGENCY: CNU POLICE , Ext Virginia Poison Control Center:
2 P a g e 2 TABLE OF CONTENTS Table of Contents... 2 Revision History Purpose Application and Scope Responsibilities Exposure Determination Information and Training Hepatitis B Vaccination Exposure Protection Engineering Controls Specimen Containers and Handling Regulated Waste Containers Facilities for Flushing Eyes Hand Washing Sinks Communication of Hazards to Employees Administrative Controls Universal Precautions Personal Protective Equipment Housekeeping Procedures Decontamination of Surfaces Refuse Handling Laundry Groundskeeping HIV and Hepatitis B Virus (HBV) Research Laboratories and Production Facilities Exposure Procedures Post-Exposure Vaccination, Evaluation, and Follow-up Recordkeeping Requirements Medical Records Training Records Sharps Injury Log Appendix A Definitions Appendix B Training Certification Appendix C Hepatitis B Immunization Declination Form Appendix D Sharps Injury Log
3 P a g e 3 REVISION HISTORY Version Date Comments 1 12/11/2012 Initial Plan developed 2 07/17/2013 Final 2.1 2/2016 Plan revisions updates to formatting This Plan is reviewed annually and amended as necessary by Environmental Health and Safety to reflect: Applicable regulations that are revised New or modified tasks and procedures which affect occupational exposure performed by employees, and/or new or revised employee positions with occupational exposure Changes in technology that eliminate or reduce exposure to bloodborne pathogens Consideration and implementation of appropriate commercially-available and effective safer medical devices designed to eliminate or minimize occupational exposure. All revisions to this Plan will be shared with the parties identified in this document.
4 P a g e PURPOSE This Bloodborne Pathogens (ECP) was developed pursuant to the Occupational Safety and Health Act (OSHA) Bloodborne Pathogens Standard (29 CFR ), adopted by Virginia Occupational Safety and Health (VOSH). These regulations mandate implementation of specific measures to minimize occupational exposure to blood or other potentially infectious materials. The standards require: Development of a facility exposure control plan Exposure determination Initial and annual Bloodborne Pathogens training Use of universal precautions Appropriate personal protective equipment Provision of hepatitis B vaccine at no cost to employee The written ECP establishes the mechanisms, methods, engineering controls, administrative controls and work practice controls that employees must use to safely work with human blood, blood products and other potentially infectious materials (OPIM). 2.0 APPLICATION AND SCOPE a) This Plan covers all employees who could be "reasonably anticipated" to contact blood and other potentially infectious material (OPIM) as a result of performing job duties that involve potentially infectious material. OPIM includes the following body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid that is visibly contaminated with blood. b) Bloodborne pathogens (BBP) are organisms that are present in the blood and certain other body fluids of infected persons. They are transmitted by blood-to-blood contact, not by casual contact. c) Examples of bloodborne pathogens are the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The occupational routes of transmission of bloodborne pathogens are by 1) needlestick or cut from a contaminated sharp object; 2) splash to the eyes, nose, or mouth; and 3) contact with broken skin. 3.0 RESPONSIBILITIES Responsibilities are included in each component of this plan based on the requirements of the Bloodborne Pathogens Standard.
5 P a g e EXPOSURE DETERMINATION EHS is responsible for completing an exposure determination by identifying all employee job classifications in which occupational exposure to human blood or OPIM may occur. The following University job classifications have been identified as ones in which employees have potential exposure (skin, eye, mouth, other mucous membrane, or parenteral) to bloodborne pathogens. This assessment is made without regard to the use of PPE. Personnel are placed into 1 of 2 categories based on risk of exposure to blood or OPIM. Supervisors are responsible for informing EHS of employees who transfer to a new position with duties that put the worker at risk of exposure or to a position where there is no longer risk of exposure. University Police Officers Athletics Head Trainer and Staff EHS technical staff Designated first aid responders Category 1* Job Classification Plumber Housekeeper Laboratory personnel working with human materials and/or HIV cultures Category 2** Job Classification Lab Personnel Groundskeeper Landscaper Category 2 Tasks Handling human material in research Handling and disposal of contaminated waste Handling and disposal of contaminated waste *Category 1: A list of all job classifications in which all employees in those job classifications have occupational exposure. **Category 2: A list of all job classifications in which some employees have occupational exposure, and a list of all tasks and procedures in which occupational exposure occurs. All other job classifications involve NO intentional exposure to blood or OPIM, although situations can be imagined in which anyone might encounter potential exposure. Therefore, it is appropriate that all employees receive basic awareness training.
6 P a g e INFORMATION AND TRAINING a) Supervisors must ensure that employees register for Bloodborne Pathogens Training within 10 days of initial assignment to tasks where there is the potential for occupational exposure to blood or OPIM. b) At-risk personnel shall complete initial training upon assignment, and annually thereafter. c) Training will be interactive and will cover the following elements: An accessible copy of 29 CFR and an explanation of its contents. CNU Bloodborne Pathogens Modes of transmission of bloodborne pathogens. Epidemiology and symptoms of bloodborne diseases. Tasks and other activities that may expose personnel to blood and/or OPIM. Use and limitations of engineering and work practices controls used in the work area to limit or eliminate exposure to bloodborne pathogens. PPE selection and its limitations. Procedures for using PPE, including location, removal, handling, decontamination and disposal. Information on the hepatitis B vaccine, including the efficacy, safety, method of administration, and benefits of vaccination. Statement that the hepatitis B vaccine is offered to at-risk employees free of charge. Procedure to follow in the event of an exposure to blood or OPIM including decontamination, reporting the incident, and medical follow-up. 6.0 HEPATITIS B VACCINATION According to the OSHA Bloodborne Pathogens Standard (29 CFR ), CNU employees covered under this plan must be offered the hepatitis B vaccine series free of charge within 10 days of initial assignment and at a reasonable place and time. Vaccinations are performed by, or under the supervision of, a physician or other licensed healthcare provider and provided according to the recommendations of the US Public Health Service. a) Following completion of Bloodborne Pathogens Training, EHS will make arrangements for the provision of the Hepatitis B vaccination series (three shots). It is the responsibility of recipients to schedule and obtain the initial and follow-up vaccines. b) Employees may decline the vaccine for any of the following reasons: The employee has received the complete hepatitis B vaccination series. Antibody testing has revealed that the employee is immune to hepatitis B. The hepatitis B vaccine is contraindicated for medical reasons. The employee elects to decline the hepatitis B vaccine for any other reason
7 P a g e 7 c) Employees who decline the vaccine must provide EHS with a signed OSHA-required declination form. Any employee who initially declines the hepatitis B vaccination, but later decides to accept the vaccination while still covered by the standard, shall be provided the vaccination series as described above. d) A titer is recommended for any employee who contacts patients or blood and is at risk of percutaneous injuries. The titer for HBV antigens should be completed 1-2 months after the last of the dose vaccination series has been administered. If, at a future date, the US Public Health Service recommends a routine booster dose of the hepatitis B vaccine, such booster doses shall be made available. e) EHS will maintain records regarding Hepatitis B Vaccinations per 29 CFR EXPOSURE PROTECTION Supervisors shall enforce engineering, administrative, and work practice controls with all personnel. 7.1 Engineering Controls Engineering controls are devices or systems which isolate or remove the bloodborne pathogens hazard from the workplace. To ensure effectiveness, engineering controls must be maintained, examined and/or replaced as needed. Examples of engineering controls are the use of a puncture-resistant, leak proof sharps container, needleless systems or sharps with engineered sharps injury protection, and biosafety cabinets used in biological research Specimen Containers and Handling Specimens of blood or other potentially infectious materials are placed in containers which prevent leakage during collection, transport, handling, storage, or shipping. Specimen containers are labeled as biohazards. If the exterior of the specimen container is contaminated, it must be placed inside a labeled secondary container which prevents leakage Regulated Waste Containers Regulated waste is sometimes also called Medical Waste or Infectious Waste. The OSHA Bloodborne Pathogens Standard requires proper handling, storage, and disposal of regulated waste. Supervisors shall ensure that proper procedures are in place for hazardous/regulated waste management per the EHS Hazardous and Regulated Waste Management Manual, and shall ensure an adequate supply of appropriate containers for regulated waste containment. There are two types of regulated waste containers used for disposal: 1. Sharps container - constructed of puncture-resistant material, leak-proof, and designed for disposal of needles, razors, etc.; labeled with the universal biohazard symbol:
8 P a g e 8 o Contaminated needles must not be bent or recapped by hand. o Contaminated sharps are placed in appropriate containers as soon as feasible. o Sharps containers are located as close as practical to locations where sharps are being used or likely to be encountered. o Sharps are disposed of in labeled, puncture-resistant containers with leakproof sides and bottoms that are located in all areas where patient care is provided. o Maintained upright throughout use o Replaced routinely and not allowed to overfill 2. Biohazard disposal bag - a large plastic bag that is usually red; labeled with the universal biohazard symbol. The Hazardous and Regulated Waste Management Manual outlines the procedures for disposal and removal of regulated waste Facilities for Flushing Eyes A ready source of running water to flush the eyes or mouth is sufficient. A commercial eyewash system is not required Hand Washing Sinks Hands and other skin surfaces shall be immediately and thoroughly washed following contact with blood or other body fluids/substances. Hands shall be washed immediately after gloves are removed. If a person has a significant exposure to another person s blood or body fluids which are potentially infectious (as cited above), follow EHS guidelines pertaining to exposure to blood or bodily fluids. If hand washing is not feasible or facilities are not immediately available, antiseptic hand cleaners and paper towels may be used Communication of Hazards to Employees a) Fluorescent orange or red-orange biohazard warning labels with the universal biohazard symbol must be affixed to containers of: Regulated medical waste; Refrigerators and freezers containing blood or OPIM; Other containers used to store, transport or ship blood or OPIM; and Contaminated equipment b) The labels must be affixed as close as feasible to the container by string, wire, adhesive, or other method which prevents loss or unintentional removal. Red bags or containers may be substituted for labels. For contaminated equipment, the labels must also state which portions of the equipment are contaminated.
9 P a g e 9 c) The following are exempt from the labeling requirement: Containers of blood products that have been released for clinical use; Containers of blood or OPIM that are placed in a labeled container for storage, transport, shipment, or disposal; and Regulated medical waste that has been decontaminated. 7.2 Administrative Controls Administrative controls are work procedures or practices, such as written safety policies, rules, supervision, and training, with the goal of reducing the duration, frequency, and severity of exposure to hazardous materials or work environments. Work practices are methods which alter the way a job or task is performed to reduce the likelihood of occupational exposure to blood or OPIM. Examples of work practice controls include, but are not limited to, not recapping, bending or breaking sharps such as hypodermic needles and using decontamination techniques after gloves are removed and as soon as possible after contact with body fluids. EHS will assist departments in developing administrative and work practice controls to help reduce the potential for exposure to blood and OPIM. The following work practice controls must be incorporated for all at-risk work areas and personnel: All procedures involving blood or OPIM must be performed in a manner that minimizes splashing, spraying, spattering and generation of droplets. Hand washing facilities and eye wash stations must be readily accessible to at-risk personnel. All hand washing facilities must include a source of running potable water, soap and single use towels or a hot air drying machine Antiseptic cleanser must be available for personnel who may not have ready access to a sink (e.g. University Police) Personnel must thoroughly wash their hands with soap and water immediately or as soon as feasible after removing gloves or other PPE. Personnel must wash hands and any other skin or hair with soap and water or flush mucous membrane with water immediately or as soon as feasible following contact with blood or OPIM. When waterless antiseptic hand cleanser is used, hands must be washed with soap and water as soon as feasible. Mouth pipetting is prohibited. Eating, drinking, smoking, application of cosmetics, and handling of contact lenses is prohibited in areas where there is a reasonable likelihood of occupational exposure. Food and drink are not kept in refrigerators, freezers, shelves, cabinets, counter tops or bench tops, or other areas where potentially infectious materials are present Universal Precautions Universal precautions will be observed at CNU. This means to consider blood and OPIM as if infectious, regardless of the perceived status of the material.
10 P a g e Personal Protective Equipment (PPE) PPE is a physical control, such as safety equipment, used to prevent or minimize the exposure to blood or OPIM. It serves to protect an individual in the event that administrative controls or engineering controls are insufficient. PPE is provided to CNU employees at no cost. All employees at-risk of occupational exposure (skin, eye, mouth, mucous membrane, or parental contact with human blood or OPIM) must wear PPE that will act as a barrier to these materials. The type(s) of protective clothing or equipment used in a specific instance will depend on the job being performed. The following protective clothing and equipment will be made available for use depending upon the activity performed: Gloves Gloves are worn when there is a possibility for direct hand contact with human blood or OPIM. There are several types of gloves available, and selection should be based upon the job being performed: Thin latex or nitrile gloves are used for operations involving delicate manipulations. These gloves are designed to fit tightly against the skin. The proper size should be selected to fit the worker's hands. Latex and nitrile gloves are available either powdered or powder-free. If an employee has a skin reaction from the gloves, hypo-allergenic and/or powder-free types must be provided. All such gloves are disposable and are not to be reused. Polyvinyl chloride (PVC) gloves are also disposable and should not be reused. They do not fit tightly against the skin and should not be used for activities requiring delicate manipulations. PVC gloves may be powdered or powder-free, and are available in a variety of sizes. PVC gloves are not recommended for work with human blood or OPIM because they do not always provide a leak-proof barrier. Rubber, neoprene or other thicker reusable gloves (e.g.utility gloves) are more durable and are generally used for more strenuous activities, such as cleaning blood spills. They may be re-used if properly decontaminated following contact with potentially infectious materials. Reusable gloves should be periodically inspected to ensure there are no cracks, holes or breaks in the material; if any are found, they must be discarded. Eye & Face Protection Masks Goggles with solid side shields or chin-length faceshields must be worn when there is a risk of splashing human blood or OPIM. This protective equipment reduces the potential for contact with the mucous membranes of the eyes. The use of protective masks is intended to reduce the risk of splashing human blood onto the mucous membranes of the nose and mouth. If masks are disposable, they must be removed immediately following use and not be reused. Reusable masks and face shields must be properly handled, cleaned and
11 P a g e 11 decontaminated prior to reuse. Protective Clothing Protective clothing must be worn when there is a risk of human blood or OPIM spattering a worker's skin or clothing. There are various types of suits, gowns and aprons available for this purpose. The type of protective clothing selected will depend upon the task and degree of exposure anticipated. Protective clothing should be resistant to fluids, and may be disposable or reusable. Reusable clothing must be properly laundered prior to reuse. Resuscitation Masks Personnel who perform cardiopulmonary resuscitation (CPR) should have resuscitation masks on hand for use in an emergency. Most resuscitation masks are disposable and should be handled as contaminated waste following use. The resuscitation mask allows for effective CPR without mouth-to-mouth contact. Most masks are also fitted with a one way valve which prevents the flow of materials from victim to rescuer. All employees using PPE must observe the following precautions: Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised. Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth Remove PPE after it becomes contaminated, and before leaving the work area. Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface. Used PPE may be disposed of in plastic bags, then incinerated or autoclaved; never wash or decontaminate disposal gloves for reuse. Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration. Wash hands immediately or as soon as feasible after removal of gloves or other PPE. 7.4 Housekeeping Procedures Supervisors shall ensure that the work area is maintained in a clean a sanitary condition Decontamination of Surfaces Use a disinfectant labeled "tuberculocidal" or 10% bleach for decontamination of surfaces. If a bleach solution is used, it must be diluted fresh daily. Precautions must be taken by employees to prevent exposure during cleanup and disinfection of surfaces contaminated with human blood or
12 P a g e 12 OPIM. The level of personal protection should be appropriate for the anticipated exposure. Any procedure involving cleanup of human blood or OPIM should be done in a way that minimizes splashing, spraying, or spattering. Small Spills (< 1 ft 2 ) Wear the appropriate PPE before beginning cleaning activities. A face shield or mask/goggles should be worn if splashing might occur, or if directed by the supervisor, and when decontaminating materials at or above waist level. Place contaminated sharp objects into sharps containers. Spread paper towels over the contaminated surface(s) and liberally apply disinfectant (10% bleach solution or tuberculocidal disinfectant) to the paper towels. Employees may also apply the disinfectant to the contaminated surface(s) with a spray bottle adjusted to deliver a fine mist. The disinfectant should remain in contact with the spilled material for the time period specified by the manufacturer before continuing with decontamination procedures. Pick up the paper towels, and wipe the surface with disinfectant-dampened paper towels until all visible traces of the contaminant are removed. If it is necessary to use a scrubbing device (e.g., scrubbing pad) to clean the contaminated surface, wear a faceshield or mask/goggles. After removal of all visible material, re-wipe the surface with clean paper towels and disinfectant, and allow surface to dry. Place cleanup materials that have touched the contaminated surface (including disposable gloves) into a biohazard disposal bag, and place bag in labeled rigid biohazard containers. Remove PPE in a manner that prevents skin contact with the potentially-contaminated outer surfaces and disinfect or discard as appropriate. Following disinfection, reusable equipment may be handled as noninfectious. Larger Spills Larger spills usually require more vigorous methods of cleanup, and therefore more PPE. If strenuous hand activity is anticipated (e.g., mopping), use approved utility gloves. If cleaning efforts are likely to cause splashing of clothing, or if directed by the supervisor, fluid-resistant coveralls or aprons should be worn. Disposable clothing should be discarded into biohazard disposal bags. Disinfect all reusable equipment with disinfectant. If an employee's clothing becomes contaminated with human blood or OPIM, remove it as soon as possible, place in a biohazard disposal bag, and deliver to the supervisor for proper laundering. Employees may elect to have a change of clothing available at their offices.
13 P a g e Refuse Handling 1) Refuse receptacles that are reasonably likely to be contaminated with blood or other potentially infectious materials are inspected and decontaminated on a regularly scheduled basis. 2) Refuse receptacles are decontaminated as soon as feasible after they become visibly contaminated. 3) Contaminated, broken glassware is cleaned up using mechanical means such as tongs or dust pan and brush rather than picked up with the hands Laundry The identification of contaminated clothing or bed linen is based upon the visible presence of human blood or OPIM. "Dirty" clothing or bed linen which is not visibly contaminated may be handled and laundered by employees not identified as having occupational exposure to Bloodborne Pathogens. Care must be taken, however, to ensure that these employees receive sufficient training to recognize potential contamination so they may defer this work to trained and protected workers. a) Contaminated laundry or bed linen shall be handled as follows: 1) Use PPE to minimize potential for exposure (includes gloves, face shield and/or mask and goggles if necessary) (e.g., when removing contaminated clothing from a biohazard disposal bag which contains visible free liquid) 2) Handle as little as possible with a minimum of agitation, 3) Properly bag and do not sort or rinse at its point of origin, 4) Place in appropriately-labeled and fluid-resistant container; Biohazard disposal bags are suitable for this purpose. The containers must be kept closed during transport and until clothing is removed for laundering. 5) Wash with detergent and water at a temperature of not less than 160 o F for at least 25 minutes. b) Contaminated PPE should be removed and handled as follows: 1) Remove protective clothing in a way that prevents skin contact with contaminated surfaces. 2) Place any disposable items that have come into contact with the contaminated clothing or bed linen (including disposable gloves and the empty biohazard disposal bag) into a biohazard disposal bag for proper disposal. 3) If reusable utility gloves are used, discard as regulated waste, or disinfect with disinfectant before leaving the site. 4) If surfaces of face shields or goggles have become visibly contaminated, disinfect with disinfectant or place in regulated waste containers.
14 P a g e Groundskeeping Groundskeeping activities include removal of blood, OPIM and contaminated wastes from grounds. Wastes may include sharps (needles, scalpels, razors, etc.), bandages, prophylactics used for sexual intercourse, or other substances or objects that may be contaminated with human blood or OPIM. These materials should be removed and the grounds disinfected following the work practices and engineering controls outlined in the preceding section. Decontamination of outside surfaces (e.g., sidewalks) requires the same level of personal protection as described in the previous section. It is often not possible to completely remove all visible traces of a potentially infectious material without causing significant property destruction. In these cases, apply an approved disinfectant in a manner and quantity that allows for complete disinfection. 8.0 HIV AND HEPATITIS B VIRUS (HBV) RESEARCH LABORATORIES AND PRODUCTION FACILITIES Specific information on procedures to be followed in any research laboratories and production facilities engaged in the culture, production, concentration, experimentation and/or manipulation of HIV and HBV will be available in the CNU Laboratory Safety Manual. Access to these areas is limited to authorized persons who have been advised of the potential hazards, and who meet specific entry requirements. These areas are identified with a hazard warning sign incorporating the universal biohazard symbol. 9.0 EXPOSURE PROCEDURES a) In the event of an exposure incident, the following are specific procedures that shall be followed: 1) Immediately remove any contaminated PPE and clothing and dispose of it in a designated receptacle. 2) Immediately flood the exposed area with water, and clean any exposed skin or hair, including any wound, with soap and water for 15 minutes. The area should be washed thoroughly but not scrubbed to avoid any further risk of exposure. 3) If exposure occurs to the eyes, eye should be flushed for 15 minutes using an eye wash station. 4) Apply first aid as needed. 5) Isolate the sample for testing, if feasible. 6) Disinfect working surface where exposure occurred if contaminated (seek assistance if needed).
15 P a g e 15 7) Notify the supervisor as soon as possible after the exposure incident; the supervisor shall provide information to Human Resources regarding the route of exposure and circumstances surrounding the incident. 8) Seek immediate medical care within 2 hours of exposure. 9) The employee is expected to comply with recommended medical treatment. 10) As soon as feasible, complete the Accident Report Form and any other applicable documentation and send it to the Human Resources Department. 11) Human Resources shall refer the employee for post-exposure evaluation to include a confidential medical evaluation, counseling, and prophylaxis by a Worker s Compensation panel physician. 12) The employee or supervisor should also notify EHS of the exposure by telephone at (757) , or at as soon as possible POST-EXPOSURE VACCINATION, EVALUATION AND FOLLOW-UP a) When an employee reports an exposure incident as a result of occupational exposure, Worker s Compensation provides for a post-exposure Hepatitis B vaccination, confidential medical evaluation, counseling, and exposure prophylaxis. Post-exposure follow-up will include: Identification and documentation of the source individual, when possible. Consent for HIV, HBV, and HCV blood testing of the source individual obtained, if the source individual is willing for their blood to be tested. If the source individual s status is known, testing is not necessary. Consent, refusal, and blood test results of the source are documented. The exposed employee s blood shall be collected for HIV and HBV testing, if consent is obtained. The employee has the right to refuse either or both tests. If they consent to baseline blood collection, the sample(s) will be preserved for at least 90 of the exposure incident. If the employee elects to have the baseline sample tested, such testing will be done as soon as possible. Testing frequency will be determined by the evaluating physician, but should be at the time of the incident, within 6 weeks, and at 3-month intervals up to 12 months. The exposed employee will be informed of the results of the source individual testing The exposed employee will be informed about the applicable laws and regulations concerning disclosure of the identified infectious state of the source individual. The exposed employee will be offered post-exposure prophylaxis, as recommended by the U.S. Public Health Service and prescribed by the treating physician. The employee has the right to decline treatment of any kind. The exposed employee will be offered counseling and medical evaluation of any reported illnesses at no cost to the exposed employee.
16 P a g e 16 b) EHS is responsible for providing, at a minimum, the following information for Worker s Compensation for evaluating an employee following an occupational exposure to blood or OPIM: Documentation of the employee s hepatitis B vaccination status. Agent specific information, if applicable. Results of source individual testing, if available. c) Human Resources shall provide the Worker s Compensation panel physician with appropriate documentation including the following: A copy of the Bloodborne Pathogens standard (29 CFR ) Documentation of route(s) of exposure, and circumstances under which exposure occurred. Results of the source individual s blood testing, if available; and All medical records relevant to the appropriate treatment of the employee. d) Human Resources shall obtain and provide the employee with a copy of the evaluating Worker s Compensation medical provider s written opinion within 15 days of completion of the evaluation. The written opinion will only include the following information: Date of the evaluation Facility name, address, contact name, and telephone number Name and title of the treating healthcare professional s written opinion documenting the following: That the healthcare professional informed the exposed personnel of testing results, if obtained. Post exposure prophylaxis information including any medications administered at the facility and any prescriptions given to personnel That counseling by the healthcare professional occurred regarding any medical conditions resulting from exposure to blood and/or OPIM which require further evaluation or treatment. Any recommended treatment and follow-up. Note: Other findings or diagnosis shall remain confidential and shall not be included in the written report. e) Human Resources shall arrange for post-exposure treatment as needed with the Worker s Compensation treating physician.
17 P a g e RECORDKEEPING REQUIREMENTS All employee records shall be made available to the employee in accordance with 29 CFR All employee records shall be made available to the Assistant Secretary of Labor for OSHA and the director of the National Institute for Occupational Safety and Health (NIOSH), or their representatives, upon request Medical Records Medical records shall be maintained in accordance with 29 CFR These records shall be kept confidential and maintained separate from the employee s Personnel file. The contents will not be disclosed or reported to any person within or outside the workplace without the employee s express written consent, except as required by law or regulation. Records must be maintained for the duration of employment plus 30 years and shall include the following: Maintained by EHS: o Name and Banner # number of employee o A copy of the employee s hepatitis B vaccination records including dates of vaccination, titer results (if available), declination forms and attachments o A copy of the information provided to the Worker s Compensation medical provider, including a description of the employee s duties as they relate to the exposure incident, documentation of the route(s) of exposure, and circumstances of the exposure (as may be detailed in an accident report). Maintained by Human Resources: o The employee s name and Social Security number; o In the event of an exposure incident, a copy of the information provided to the Workers Compensation medical provider, including a description of the employee s duties as they relate to an exposure incident, documentation of the route(s) of exposure, and circumstances of the exposure o A copy of all results of post-exposure examinations, medical testing (including post-vaccination antibody testing), and follow-up procedures as a result of an exposure incident; and o The employer s copy of the healthcare professional s written opinion; OR o A signed declination form Training Records EHS is responsible for maintaining Bloodborne Pathogens Training records. Training records shall be maintained for at least three years from the date of training, and shall include the following information: Date of training; Outline of the materials presented;
18 P a g e 18 Name of person conducting the training; and Names and of all persons in attendance Sharps Injury Log For cases that involve percutaneous injury from contaminated sharps, EHS is responsible for maintaining a Sharps Injury Log. Information shall be entered on the log so as to protect the confidentiality of the injured employee. At a minimum, log entries shall document the following: The type and brand of device involved in the incident; The department or work area where the incident occurred; and An explanation of how the incident occurred. Note: Sharps Injury Log is kept in addition to the OSHA 300 Log.
19 APPENDIX A. DEFINITIONS Bloodborne Pathogens P a g e 19 Blood: means human blood, human blood components, and products made from human blood Bloodborne Pathogens: means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Clinical Laboratory: means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials. Contaminated: means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. Decontamination: The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Disinfect: To inactive virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g. bacterial endospore) on inanimate objects. Engineering controls: Controls that isolate or remove the bloodborne pathogen hazard from the workplace (e.g., sharps disposal containers, self-sheathing needles, and needleless systems). Exposure incident: A specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee s duties. Handwashing facilities: A facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines. Licensed healthcare professional: A person whose legally permitted scope of practice allows him or her to independently perform the activities related to post-exposure evaluation and follow-up specified in 29 CFR Occupational Exposure: any reasonable anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee s duties. This definition excludes incidental exposures that may take place on the job and that are neither reasonable nor routinely expected to occur in the normal course of employment. Other Potentially Infectious Materials: 1) The following fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, amniotic fluid, and any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; 2) Any unfixed tissue or organ (other than intact skin)from a human (living or dead); and 3) HIV- containing cell or tissue cultures, organ
20 P a g e 20 cultures, and HIV- or HBV containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. Parenteral: Piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions. Percutaneous: through the skin. Personal protective equipment: Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. Personnel: Personnel include faculty (professional, administrative, and research), staff (administrative, professional, classified, wage, and student wage), affiliates (visiting faculty, volunteers, visiting research associates), and paid students (graduate students, undergraduate students, laboratory assistants, etc.) who may be potentially exposed to blood or OPIM. This does not refer to students enrolled in instructional courses. Regulated medical waste: (as defined in 9VAC ) Includes (1) discarded cultures, stocks, specimens, vaccines, and associated items likely to contain agents that are likely to be pathogenic to healthy humans; discarded etiologic agents; wastes from the production of biological materials; and antibiotics likely to have been contaminated by agents that are likely to be pathogenic to healthy humans; (2) wastes consisting of human blood or human body fluids or items contaminated with human blood or human body fluids; all human anatomical wastes and all wastes that are human tissues, organs, or body parts; (3) sharps likely to be contaminated with agents that are pathogenic to healthy humans; all needles, syringes with attached needles, suture needles, and scalpels, including all sharps generated through veterinary practice; (4) animal carcasses, body parts, bedding, and all other wastes likely to have been contaminated as a result of animals being intentionally infected with agents likely to be pathogenic to healthy humans; (5) any residue or contaminated soil, water, or other debris resulting from the cleanup of a spill of any regulated medical waste; (6) any solid waste contaminated by or mixed with regulated medical waste. Research laboratory: A laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities. Sharps with engineered sharps injury protections: A non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medication or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. Source individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally
21 P a g e 21 disabled; trauma victims; human remains; and individuals who donate or sell blood or blood components. Sterilize: The use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores. Titer: A titer is a measurement of the amount or concentration of a substance in a solution. It usually refers to the amount of medicine or antibodies found in a patient s blood. Universal precautions: An approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Work practice controls: Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).
22 P a g e 22 APPENDIX B. BLOODBORNE PATHOGENS TRAINING CERTIFICATION
23 BLOODBORNE PATHOGENS TRAINING CERTIFICATION All employees who have occupational exposure to bloodborne pathogens receive training. Training will be conducted in a manner appropriate to the educational level, literacy, and language of those employees receiving training. Training materials are available through EHS. Training will include information on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements: a copy and explanation of the standard an explanation of our ECP and how to obtain a copy an explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident an explanation of the use and limitations of engineering controls, work practices, and PPE an explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE (provided by the supervisor) an explanation of the basis for PPE selection information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident an explanation of the signs and labels and/or color coding required by the standard and used at this facility an opportunity for interactive questions and answers with the person conducting the training session.
24 BLOODBORNE PATHOGENS TRAINING CERTIFICATION Instructor Name and Signature: Training Date: Employee Name Employee ID Employee Signature ** Print additional pages as needed.
25 APPENDIX C. HEPATITIS B IMMUNIZATION DECLINATION FORM
26 HEPATITIS B IMMUNIZATION DECLINATION FORM I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. (Signature) (Date) (Employee name print clearly) (Banner #) Reason for declination: ( ) Prior completion of Hepatitis B vaccination series ( ) Immunity has been established by a documented serologic antibody test (titer). ( ) Choose to decline at this time Distribution: Original to Environmental Health and Safety Office, Forbes 1047 Copy to individual
27 APPENDIX D. SHARPS INJURY LOG
28 SHARPS INJURY LOG Bloodborne Pathogens standard states that the employer shall establish and maintain a Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps. The information in the Sharps Injury Log shall be recorded and maintained in such manner as to protect the confidentiality of the injured worker. Case No. Type, Brand, Model of Device Department or Work Area Describe how the incident occurred (procedure or action performed: disposal, injection, etc.)