COLORADO STATE UNIVERSITY BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN 2013-2014 Clrad State University Envirnmental Health Services
CONTENTS INTRODUCTION... 3 PROGRAM ADMINISTRATION AND RESPONSIBILITIES... 3 Envirnmental Health Services... 3 Departments... 4 Supervisrs... 4 Individual Persnnel... 4 DEFINITIONS... 5 Occupatinal Expsure... 5 Bldbrne Pathgens... 5 Other Ptentially Infectius Material (OPIM)... 5 EMPLOYEE EXPOSURE DETERMINATION... 6 METHODS OF IMPLEMENTATION AND CONTROL... 6 Expsure Cntrl Plan... 6 Engineering Cntrls... 6 Universal Precautins and Safe Wrk Practices... 7 Persnal Prtective Equipment... 7 Sharps Plicy... 9 Labels... 9 Husekeeping... 10 Laundry... 10 Additinal Cnsideratins fr Researchers Handling Human Bld, OPIM, Bldbrne Pathgens, r Human Derived Tissue Cultures:... 11 Additinal requirements that MAY exceed thse fr research labratries nt invlved in the abve activities include:... 11 HEPATITIS B VACCINATION... 12 POST-EXPOSURE EVALUATION AND FOLLOW-UP... 12 Medical Evaluatin and Fllw up... 13 Prcedures fr Evaluating the Circumstances Surrunding an Expsure Incident... 13 EMPLOYEE TRAINING... 14 Initial Training and Annual Retraining... 14 RECORDKEEPING... 15 Training Recrds... 15 Medical Recrds... 16 Sharps Injury Lg... 16 APPENDIX I - Bldbrne Pathgens Site-Specific Training Checklist... 17 PAGE 2
COLORADO STATE UNIVERSITY EXPOSURE CONTROL PLAN (V130712) INTRODUCTION Clrad State University is cmmitted t prviding a safe and healthy wrk envirnment fr all staff, students and visitrs. In pursuit f this gal, the fllwing Expsure Cntrl Plan (ECP) is prvided t eliminate r minimize ccupatinal expsure t bldbrne pathgens in accrdance with OSHA standard 29 CFR 1910.1030, Occupatinal Expsure t Bldbrne Pathgens. Occupatinal expsure is defined as reasnably anticipated skin, eye, mucus membrane, r parenteral cntact with human bld r ther ptentially infectius materials (OPIM) that may result frm the perfrmance f an emplyee s duties. The ECP is a key dcument t assist CSU in implementing and ensuring cmpliance with the standard, thereby prtecting ur emplyees. This ECP includes: Determinatin f emplyee expsure Implementatin f varius methds f expsure cntrl including: Universal precautins Engineering and wrk practice cntrls Persnal prtective equipment Husekeeping Hepatitis B vaccinatin Pst-expsure evaluatin and fllw-up Cmmunicatin f hazards t emplyees Training Recrdkeeping Prcedures fr evaluating circumstances surrunding expsure incidents Implementatin methds fr these elements f the standard are discussed in the subsequent pages f the ECP. PROGRAM ADMINISTRATION AND RESPONSIBILITIES Clrad State University and all persnnel have the respnsibility t be infrmed f hazards and preventive practices assciated with Bldbrne Pathgens. Specific respnsibilities include: Envirnmental Health Services Envirnmental Health Services (EHS) is respnsible fr the management and administratin f the ECP thrugh the Occupatinal Health Prgram (OHP) and Bisafety Office (BSO). Activities delegated t EHS include: Overseeing implementatin f the ECP Develping, in cperatin with administratrs and departmental authrities, any additinal plicies and practices needed t supprt the implementatin f the ECP Revising, updating, and imprving the ECP regularly, and whenever necessary t include new r mdified tasks and prcedures Training will be crdinated by EHS. Expsure cntrl trainers (ECT) will be designated by EHS and trained t prvide infrmatin and training t all emplyees wh have an anticipated risk f expsure t bldbrne pathgens Wrking with principal investigatrs r supervisrs in the evaluatin f emplyee expsure ptential Maintaining apprpriate training recrds PAGE 3
Ensuring the develpment f suitable educatin/training prgrams fr emplyees and ECT s Peridically review and update training prgrams Departments Each department that has persnnel at risk f cming in cntact with a BBP will adpt this ECP and establish a prgram f cmpliance. This departmental prgram will include prcesses fr: Ensuring cmpliance with the cntents f the ECP The identificatin f departmental persnnel gverned by the ECP Meeting training requirements Ensuring prper recrd maintenance Supervisrs Supervisry persnnel (managers, directrs, supervisrs, r principal investigatrs) are respnsible fr making apprpriate wrkplace risk assessments and identifying jb psitins and persnnel wh may have expsure t human bld, bldbrne pathgens, r ther ptentially infectius materials during the perfrmance f their assigned duties. The expsure determinatin will be made withut regard fr the use f persnal prtective equipment. Cntact EHS fr Bldbrne Pathgen Risk Assessment. Supervisry persnnel are additinally respnsible fr: Ensuring all staff under their directin meet the apprpriate requirements prir t assignment t duties by which ccupatinal expsures culd ccur: Are prperly trained befre wrking with bld r ther ptentially infectius materials, per training sectin belw and the suggested checklist template in Appendix I. Have declared their vaccinatin preference, and have initiated vaccinatin (if vaccinatin is desired), per vaccinatin sectin belw Maintaining recrds f all site-specific training and Declaratin f Vaccinatin Preference with emplyee recrds, and submitting a cpy t EHS. Ensuring that guidelines established in this manual are strictly fllwed by all persns under their jurisdictin. Maintenance f all necessary persnal prtective equipment (PPE), engineering cntrls (e.g., sharps cntainers), labels and clean up materials as required. Ensuring that adequate supplies f the afrementined equipment are available in apprpriate sizes. Individual Persnnel Individuals wh are determined t have ccupatinal expsure t human bld r ther ptentially infectius material must cmply with the prcedures and requirements presented in this manual and in persnnel training. Individual persnnel must accept shared respnsibility fr acting in a safe manner. Individuals: Shuld cnsult with their supervisrs regarding the safe handling and prper dispsal f human bld r ther ptentially infectius materials (OPIMs) used in their specific wrk areas Are respnsible fr fllwing CSU safety guidelines, including Universal Precautins and standard micrbilgical practices (See CSU Bisafety Manual: http://www.ehs.clstate.edu/wbisafety/hme.aspx) Must cmplete required training and annual re-training and request infrmatin and training when unsure Reprt jb-related BBP expsure t OHP Wear all necessary PPE PAGE 4
DEFINITIONS Occupatinal Expsure Occupatinal expsure is defined as reasnably anticipated skin, eye, mucus membrane, r parenteral cntact with human bld r ptentially infectius material (OPIM) that may result frm the perfrmance f an emplyee s duties. An expsure incident wuld invlve cntact with bld r ther ptentially infectius bdy fluid thrugh: Percutaneus (needlestick, puncture r cut thrugh the skin) Mucus membrane (cntact with eyes, muth, nasal passage) Nn-intact skin (cntact thrugh cuts, abrasins in the skin) Inhalatin (inhaling aersls) Bldbrne Pathgens Bldbrne pathgens are micrrganisms fund in human bld that can infect and cause disease when persns are expsed t bld that cntain the micrrganisms. While there are many bldbrne pathgens, the 3 specifically cvered in this ECP are: Human Immundeficiency Virus (HIV) causes Acquired Immundeficiency Syndrme (AIDS) Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) Other Ptentially Infectius Material (OPIM) Materials that can cntain bldbrne pathgens. OPMs include: Human bld and bld prducts Semen r vaginal secretins Internal human bdy fluids, including cerebrspinal fluid, and fluids frm jints, chest cavity, heart sac r abdmen Breast milk (nly if ingested) Unfixed human tissues r rgans (bth living and dead) Human cell lines nt dcumented t be free f bldbrne pathgens Bld, tissues, r cell lines frm animals experimentally infected with bldbrne pathgens Cultures r any liquid cntaining bldbrne pathgens (this includes culture media) Equipment cntaminated with human bld r OPIMs Any bdy fluid visibly cntaminated with human bld Any bdy fluid that is difficult t differentiate frm ther fluids The fllwing are nt cnsidered t be OPIMs unless they are visibly cntaminated with bld, r it is difficult r impssible t distinguish: Tears Sweat Saliva (except during dental prcedures) Vmit Feces Urine Nse fluids Intact human skin (frm living r dead surce) PAGE 5
EMPLOYEE EXPOSURE DETERMINATION CSU persnnel wh have duties that include expsure r reasnably anticipated risk f expsure t bld r ther ptentially infectius material are included in the Expsure Cntrl Plan. Each jb classificatin in this categry includes: Emergency Respnders, plice fficers, and persnnel administering first aid Persnnel whse regular jb duties include clean-up f bld spills r ther ptentially infectius material (e.g. designated husekeeping, select custdial, campus recreatin, and maintenance persnnel, etc.) Persnnel wrking with r cnducting research n human bld, ther ptentially infectius materials, unfixed human tissues and rgans, and/r cultures derived frm human cells r tissues Persnnel cnducting research n HIV and/r Hepatitis viruses Each department shuld determine which tasks pse a risk t emplyees and are encuraged t develp specific expsure cntrl methds t wrk in cnjunctin with the CSU Expsure Cntrl Plan. Cntact EHS fr assistance. METHODS OF IMPLEMENTATION AND CONTROL Expsure Cntrl Plan Emplyees cvered by the bldbrne pathgen standard receive an explanatin f this ECP during their initial training sessin. This plan is als reviewed in the annual refresher training. All emplyees can review this plan at any time during their wrk shift by ging nline (http://www.ehs.clstate.edu/wbisafety/pdf/expsure_cntrl_plan.pdf) r by cntacting EHS at 970-491- 3102. If requested, the emplyee will be prvided with a cpy f the ECP free f charge and within 15 days f the request. EHS is respnsible fr crdinating reviews and updating the ECP annually, r mre frequently if necessary, t reflect any new r mdified tasks and prcedures that affect ccupatinal expsure and t reflect new r revised emplyee psitins with ccupatinal expsure. The bldbrne pathgen expsure cntrl at Clrad State University emplys 4 majr strategies: Engineering cntrls Universal precautins and safe wrk practices Persnal prtective equipment Administrative cntrls - training Engineering Cntrls Engineering cntrls are used t prevent r minimize expsure t bldbrne pathgens. Engineering cntrls are devices that reduce expsure risk by remving r islating the wrker frm the hazards. Specific engineering cntrls include: Eyewashes Bisafety cabinets Ventilatin Sharps engineered fr safer use Sharps cntainers PAGE 6
The University identifies the need fr changes in engineering cntrls thrugh review f OSHA recmmendatins, emplyee interviews and cmmittee discussins. New prducts are evaluated regularly thrugh literature and supplier infrmatin. Departments are respnsible fr ensuring that recmmended engineering cntrls are implemented. Universal Precautins and Safe Wrk Practices Universal Precautins All emplyees will utilize universal precautins, which are an apprach t prevent the ccupatinal expsure t human bld r OPIM. Accrding t the cncept f universal precautins, all human bld, tissue, and certain human bdy fluids are treated as if knwn t be infectius fr HIV, HBV, HCV and ther bldbrne pathgens. Safe Wrk Practices Safe wrk practices are designed t reduce the likelihd f ccupatinal expsure, and include the fllwing: When wrking in an area where human bld r OPIM are present, persnnel must adhere t the fllwing safe wrk practices: N eating, drinking, r chewing tbacc r gum N applying csmetics r handling cntact lenses N strage f fd in refrigeratrs, freezers, cabinets, r any ther area that may be cntaminated with human bld r OPIM Glves (and ther PPE, as needed) must be wrn when there is a ptential t cme in cntact with human bld r OPIM. Glves must be changed after becming trn r cntaminated Hands must be washed after glve remval Additinally, when wrking with human bld, OPIM, r when cnducting research n HIV, HBV, HCV, and/r ther human bldbrne pathgens, persnnel MUST: Use a certified bisafety cabinet where feasible Cnduct all prcedures invlving bld r OPIM in such a manner t minimize splashing, spraying, splattering and generating drplets. Use leak-prf and nn-breakable cntainers t hld bld r OPIM Affix bihazard labels as apprpriate t cntainers f bld r OPIM that have nt been sterilized Keep waste cntainers near the wrk area Never verfill waste cntainers Examine equipment which may becme cntaminated with bld r OPIM prir t servicing r shipping, and decntaminate as necessary Use extreme cautin when wrking with sharp bjects such as needles, razr blades, scalpels, r brken glass and prperly dispse f sharps in an apprpriate sharps cntainer. Persnal Prtective Equipment Required PPE shuld be prvided t CSU emplyees at n cst t emplyees. Training in the use f the apprpriate PPE fr specific tasks r prcedures is t be prvided by the supervisrs. Supervisrs can cntact Envirnmental Health Services fr assistance. Types f PPE available t emplyees are as fllws: PAGE 7
Safety glasses r face mask with eye shield Glves (Latex r nitrile) Eye prtectin Masks Prtective clthing- if there is a risk f splattering nt expsed skin r clthing. Examples include lab cat, gwn, aprn, r sleeve prtectrs. PPE shuld als be lcated in the Bldbrne pathgen spill kits and may be btained thrugh supervisrs r principle investigatrs. All emplyees using PPE must: Wear apprpriate glves when it is reasnably anticipated that there may be hand cntact with bld r OPIM, and when handling r tuching cntaminated items r surfaces. Replace glves if trn, punctured, r cntaminated, r if the ability t functin as a barrier is cmprmised. Never wash r decntaminate dispsable glves fr reuse. Utility glves may be decntaminated fr reuse if their integrity is nt cmprmised; discard utility glves if they shw signs f cracking, peeling, tearing, puncturing r deteriratin. Wash hands immediately r as sn as feasible after remving glves r ther PPE. Always wear apprpriate face and eye prtectin when splashes, sprays, splatters r drplets f bld r OPIM pse a hazard t the eyes, nse r muth. Always wear full bdy prtectin (including lab cat/gwn, glves, eye prtectin) during prcedures and activities likely t generate splashes, sprays, splatters r drplets f bld r OPIM. Remve PPE after it becmes cntaminated and befre leaving the wrk area. Remve, immediately r as sn as feasible, any garment cntaminated with freign bld r OPIM, in such a way as t avid cntact with the uter surface. PAGE 8
Sharps Plicy Sharps must be handled and dispsed f in accrdance with the CSU Sharps Plicy (http://www.ehs.clstate.edu/wbisafety/hme.aspx). Extreme cautin must be used when wrking with sharp bjects such as needles, scalpels, razr blades, r brken glass and prperly dispse f the sharps in apprpriate sharps cntainers. Needles shall be dispsed f in labeled sharps cntainers accrding t the CSU Sharps Plicy. Sharps cntainers are inspected and maintained r replaced by designated individuals as needed r whenever necessary t prevent verfilling. Needles shuld nt be re-sheathed. Sme applicatins may require re-sheathing. In thse cases, the use f re-sheathing needles r mechanical re-capping devices are strngly recmmended. If these alternatives are nt feasible, then the ne-handed scp methd fr re-sheathing shuld be emplyed: Needles and ther sharps shuld be handled as little as pssible. Handling sharps fr transprt, cleanup r dispsal must be dne using a mechanical device r tl (frceps, pliers, brm and dust pan) Breaking r shearing needles is prhibited. Cntrls shuld be used t prevent needlestick injuries, and include specially engineered sharps injury prtectin (e.g. leur-lck syringes, permanent needle and syringe cmbinatin, self-sheathing needles, needle-less systems, etc.). University emplyees wh encunter imprperly dispsed needles shall ntify Envirnmental Health Services/ BSO f the lcatin f the needle(s). The apprpriate authrities (e.g., lab manager, principle investigatr) must als be ntified. Department/building prctrs r custdial staff shuld be cntacted t dispse f prperly decntaminated sharps r glassware. Labels The fllwing labeling methds are used at CSU: Bihazard label fr all equipment used with r t stre infectius material (sharps cntainer, bihazardus trash): PAGE 9
Bihazard bag fr spill clean-up materials that have nt been disinfected. The bag must be bright range r red, and must have the bihazard symbl. Supervisrs and PIs are respnsible fr ensuring that the bihazard label and symbl is affixed n range r red bags as required if regulated waste r cntaminated equipment is brught int r taken ut f the facility. Emplyees are t ntify EHS if they discver regulated waste cntainers, refrigeratrs cntaining bld r OPIM, cntaminated equipment, etc., withut prper labels. Husekeeping Facilities Maintenance and ther CSU custdial r maintenance staff must wrk tgether with each Department t ensure that the fllwing cnditins are met: Decntaminatin must be perfrmed with disinfectants registered fr destructin f HBV, HCV, and HIV. Equipment and surfaces must be clean and decntaminated after cntact with bld r OPIM. Bins/pails (e.g. wash basins) need t be cleaned and decntaminated as sn as feasible after visible cntaminatin. Spills f bld r OPIM shuld be cleaned up as sn as pssible by persnnel specifically trained fr bldbrne pathgen spill respnse. Regulated waste needs t be placed in cntainers which are clsable, cnstructed t cntain all cntents and prevent leakage, apprpriately labeled r clr cded and clsed prir t remval t prevent spillage r prtrusin f cntents during handling. Brken glassware must be picked up using mechanical means (e.g. tngs, dustpan and brush) and dispsed f in an apprpriate sharps cntainer. Cntaminated sharps are discarded as sn as pssible int cntainers that are clsable, punctureresistant, leak prf n sides and bttms, and apprpriately labeled r clr cded. Sharps dispsal cntainers are available thrugh supervisrs and must be lcated where sharps are being used. When dispsing f bihazardus waste: Supervisrs must instruct emplyees in the prper dispsal and prcedures when using bihazard bags. Bihazard bags MUST be autclaved befre they can be dispsed f in the regular trash. Waste cntainers must be in an upright psitin and replaced rutinely. Cntainers with bld r OPIM must be clsed after use, fr dispsal r fr transfer t an autclave. Laundry It is each department s respnsibility t prvide laundering services fr the fllwing cntaminated articles: Bar and kitchen twels. Sprts twels. Lab cats and scrubs prvided by departments. If the use f persnal scrubs and/r lab cats is permitted, then prtcls r means f laundering must be prvided by the department. Persnal clthing knwn r believed t be cntaminated with bldbrne pathgens. Such clthing shuld nt leave campus withut decntaminatin. Twels prvided in shwering facilities. Laundering prvided by departments needs t be perfrmed by a designated laundry service n a regular basis. PAGE 10
Prir t laundering, the fllwing laundering requirements must be met: Inspect laundry t verify that it is free f sharps. Handle cntaminated laundry as little as pssible, with minimal agitatin. Place wet cntaminated laundry in leak-prf, labeled r clr cded cntainers befre transprt. Garbage bags r bags prvided by the laundering service shuld be used fr this purpse. Use the fllwing PPE when handling and/r srting cntaminated laundry: Glves Eye/face prtectin Additinal Cnsideratins fr Researchers Handling Human Bld, OPIM, Bldbrne Pathgens, r Human Derived Tissue Cultures: PIs and departments must prvide additinal apprpriate administrative cntrls, prtective equipment, infrmatin and training as apprpriate fr all emplyees engaged in: Culture, cncentratin r research f HIV, HBV, r HCV and/r ther bldbrne pathgens. Wrk with human r animal cell lines ptentially infected with bldbrne pathgens. Nte: Certain cell lines may be exempt frm this requirement. PIs must cnsult with EHS/BSO t determine specific exemptins. Manipulatin f human bld r OPIM. Manipulatin f animal bld r tissue cultures experimentally infected with HIV, HBV, r HCV. Additinal requirements that MAY exceed thse fr research labratries nt invlved in the abve activities include: Security: Clsed, lcked when nt attended, labratry drs and limited lab access. Apprpriately labeled labratry access drs. Wrk Practices and Administratin Site-specific training must dcument that persnnel have: Taken the nline BSL1/BSL2 training (https://wsnet.clstate.edu/cwis86/wtrainreg/onlineclass/bslunit1-2/train.aspx. Read the CSU Bisafety Manual (http://www.ehs.clstate.edu/wbisafety/hme.aspx) Been infrmed f the risks assciated with their jb. All spills must be cntained r cleaned up immediately by trained persnnel. All spills and accidents must be reprted immediately t the supervisr and OHP/BSO. All waste frm the wrk area and animal rms must be decntaminated apprpriately. Transprtatin f cntaminated materials fr decntaminatin must be perfrmed in clsed, leak-prf, labeled cntainers. Engineering Cntrls: Certified bisafety cabinets Centrifuge cntainment devices t prevent aersls Autclave r ther effective decntaminating methd fr decntaminatin f waste HEPA filters fr vacuum lines Use f leak-prf and apprpriately labeled cntainers fr transprting cntaminated materials Handwashing sink Eyewash statin Sharps: Safety needles/syringes will be used whenever pssible PAGE 11
Extreme cautin is t be used whenever perfrming prcedures with sharps Needles/syringes shuld nt be recapped, bent, r remved frm syringe after use Sharps will be placed in sharps cntainer immediately after use and autclaved prir t dispsal r reusing Persnal Prtective Equipment Lab cats/gwns r ther apprpriate clthing must be wrn at all times in the labratry and animal handling facility Glves must be wrn when manipulating ptentially infected materials r animals Prtective clthing must nt be wrn utside f the wrk area HEPATITIS B VACCINATION The Hepatitis B vaccinatin series is available at n cst t all emplyees identified in the expsure determinatin sectin f this plan. Vaccinatin is encuraged unless: 1) dcumentatin exists that the emplyee has previusly received the series; 2) antibdy testing reveals that the emplyee is immune; r 3) medical evaluatin shws the vaccinatin is cntraindicated. Infrmatin will be prvided t emplyees during training abut hepatitis B vaccinatins, addressing safety, benefits, efficacy, methds f administratin and availability. Each emplyee must indicate whether they wish t be vaccinated r nt by signing a Declaratin f Vaccinatin Preference frm. Emplyees wh decline vaccinatin may request and btain the vaccinatin at a later date at n cst. The Declaratin f Vaccinatin Preference must be filed with EHS and requested vaccinatins shuld begin at least 10 days prir t initiatin f duties by which ccupatinal expsure culd ccur. The Declaratin f Vaccinatin Preference can be btained: Frm the Occupatinal Health Prgram Crdinatr (OHPC) (970-420-8172; jni.triantis@clstate.edu) Online at http://www.ehs.clstate.edu/wohsp/pdf/declaratin_f_vaccinatin_preference_posted.pdf\. Vaccinatin fr the ECP must be prvided by the designated CSU Occupatinal Health Prvider. POST-EXPOSURE EVALUATION AND FOLLOW-UP Every individual handling material with ptential BBP has the respnsibility t reprt any expsure t their supervisr and t CSU EHS. Medical infrmatin will be held cnfidential and will nt be released withut permissin f the emplyee. Immediate Actins t be Taken After an Expsure Stp all activity. Rinse membranes with water (r eyewash slutin) fr a minimum f 3-5 minutes as sn as pssible fllwing an expsure incident. Cleanse all expsed skin with sap and water as sn as pssible fllwing an expsure incident. Avid intrducing abrasins in skin d nt scrub r use abrasives. Rinse fr a minimum f 3-5 minutes. PAGE 12
Recrd the name and phne number f the surce individual (if knwn), and the lcatin and time f the incident. Ntify yur supervisr and EHS (491-0270). All expsures must be reprted t the supervisr and OHP/ BSO, even if n treatment is required. The supervisr will wrk with EHS fr reprting and fllw up. Seek medical evaluatin immediately: During business hurs (between 8 AM and 5 PM, Mnday thrugh Friday): Attentin must be sught at a CSU Authrized Treating Physician. See http://www.ehs.clstate.edu/wwrkcmp/hme.aspx fr a list f Authrized Treating Physicians. After business hurs (between 5 PM and 8 AM, and n weekends): Urgent Care r Emergency Rm Facilities shuld be utilized. Fllw up must be perfrmed with EHS at 970-420-8172. If yu want yur medical charges t be cnsidered fr Wrker s Cmpensatin, then yu will need t file a reprt f injury, which must be filled ut within 4 days at: https://wsnet.clstate.edu/cwis86/wwrkcmp/cmpdata/add/addclaimtest.aspx. Medical Evaluatin and Fllw up The immediately available cnfidential medical evaluatin and fllw-up will be cnducted by the treating physician and will include: Dcumentatin f the rutes f expsure, when, and hw the expsure ccurred. Obtaining cnsent and making arrangements t have the surce individual tested as sn as pssible t determine HIV, HCV and HBV infectivity, if pssible; dcumenting that the surce individual s test results were cnveyed t the emplyee s health care prvider. Nte: If the surce individual is already knwn t be HIV, HCV and/r HBV psitive, new testing need nt be perfrmed. Assuring that the expsed emplyee is prvided with the surce individual s test results and prviding infrmatin abut applicable disclsure laws and regulatins cncerning the identity and infectius state f the surce individual (e.g. laws prtecting cnfidentiality). After btaining cnsent, cllecting expsed emplyee s bld as sn as feasible after an expsure incident, and testing bld fr baseline HBV, HCV and HIV serlgical status. Nte: If the emplyee des nt give cnsent fr HIV,HBV, r HCV serlgical testing during cllectin f bld fr baseline testing, the baseline bld sample will be preserved fr at least 90 days; if the expsed emplyee elects t have the baseline sample tested during this waiting perid, testing will be perfrmed as sn as feasible. EHS ensures that the health care prfessinal evaluating an emplyee after an expsure incident receives the fllwing: A descriptin f the emplyee s jb duties relevant t the expsure incident. Circumstances f expsure. Rute(s) f expsure. Upn emplyee cnsent, relevant emplyee recrds, including vaccinatin status. Prcedures fr Evaluating the Circumstances Surrunding an Expsure Incident EHS will review the circumstances f all expsure incidents t determine: Engineering cntrls in use at the time PAGE 13
Wrk practices fllwed A descriptin f the device being used (including type and brand), if applicable Prtective equipment r clthing that was used at the time f expsure incident Lcatin f incident Prcedure being perfrmed when the incident ccurred Emplyee training All percutaneus injuries frm cntaminated sharps will be recrded in an incident lg by the BSO. If revisins t this ECP are necessary, EHS will ensure that apprpriate changes are made. (Changes may include an evaluatin f safer devices, adding emplyees t the expsure determinatin list, etc.) Initial Training and Annual Retraining EMPLOYEE TRAINING All emplyees required t participate in the ECP must have initial training and annual retraining. Initial training must be cmpleted befre perfrming duties by which ccupatinal expsure culd ccur. Several training techniques may be used, as apprved by EHS, including: Instructr led (by EHS r ECTs designated by EHS) Videtape prgrams Cmputer aided interactive training Training manuals/emplyee handuts Emplyee review sessins Training must cver, at a minimum, the fllwing elements: A cpy and explanatin f the OSHA bldbrne pathgen standard An explanatin f the CSU ECP and hw t btain a cpy Epidemilgy, symptms, and transmissin f bldbrne pathgen diseases An explanatin f methds t recgnize tasks and ther activities that may invlve expsure t bld and OPIM, including what cnstitutes an expsure incident An explanatin f the use and limitatins f engineering cntrls, wrk practices and PPE An explanatin f the types, uses, lcatin, remval, handling, decntaminatin, and dispsal f PPE An explanatin f the basis fr PPE selectin Infrmatin n the hepatitis B vaccine, including infrmatin n its efficacy, safety, methd f administratin, the benefits f being vaccinated, and that the vaccine is free f charge Infrmatin n the apprpriate actins t take, and persns t cntact, in an emergency invlving bld r OPIM Spill cleanup prcedures An explanatin f the prcedure t fllw if an expsure incident ccurs, including the methd f reprting the incident and the medical fllw-up available Infrmatin n the pst expsure evaluatin and fllw-up that the emplyer is required t prvide fr the emplyee fllwing an expsure incident An explanatin f the signs and label and/r clr cding required by the standard and uses at the University An pprtunity fr interactive questins and answers with the persn cnducting the training sessin PAGE 14
Training materials fr the University are available at Envirnmental Health Services, 141 General Services Building. Each participant must als be trained fr spill clean-up, and site-specific training with their supervisr r a designated trainer fr their area prir t assignment t tasks where ccupatinal expsure may ccur. Appendix I presents suggested cntent and template. Supervisrs are respnsible fr retentin f site-specific training recrds. It is strngly recmmended that cpies f these recrds be submitted t EHS. Additinally, Principal Investigatrs r supervisrs must prvide lab specific training fr researchers handling any cultures r ther materials ptentially cntaining human bld/bldbrne pathgens, OPIM r Human Derived Tissue Cultures. Training must include safety training specific fr the duties, equipment, and prtcls relative t each emplyee. Training must ensure that emplyees have sufficient prficiency in wrking with human pathgens r tissue cultures prir t being allwed t wrk with any materials ptentially cntaining human bldbrne pathgens. The emplyee must nt participate in wrk invlving infectius agents until prficiency is demnstrated. SUMMARY: REQUIREMENTS PRIOR TO ASSIGNMENT TO DUTIES WITH OCCUPATIONAL EXPOSURE It is the supervisr s respnsibility t ensure that: Prir t assignment t duties with ccupatinal expsure: Initial training is cmpleted, t include spill clean-up Site-specific training is cmpleted The Declaratin f Vaccinatin Preference is filed with EHS Vaccinatin, if requested, has been initiated Emplyees are re-trained annually Site-specific training is dcumented and maintained with the emplyee files. Cpies shuld be submitted t EHS RECORDKEEPING Training Recrds Recrds f training cnducted by EHS are maintained by EHS fr at least 3 years. Supervisrs are respnsible fr maintaining recrds f training dne n-site fr at least 3 years. The training recrds include: The dates f the training sessins The cntents r a summary f the training sessins The names and qualificatins f the persns cnducting the training The names and jb duties f all persns attending the training sessins Emplyee training recrds will be prvided upn request t the emplyee r the emplyee s authrized representative within 15 wrking days. Such requests shuld be addressed t the emplyee s supervisr. PAGE 15
Medical Recrds Medical recrds are maintained fr each emplyee with ccupatinal expsure in accrdance with 29 CFR 1910.1020, Access t Emplyee Expsure and Medical Recrds. All infrmatin is cnfidential. Infrmatin will nt be disclsed withut the emplyee s written cnsent, except as required r permitted by law. Emplyee medical recrds are prvided upn request f the emplyee r t anyne having written cnsent f the emplyee within 15 wrking days. Such requests shuld be sent directly t the medical prvider. Sharps Injury Lg All percutaneus injuries frm cntaminated sharps are als recrded in an Incident Reprt Lg. All Incidents must include at least: Date f the injury Type and brand f the device invlved (syringe, suture needle) Department r wrk area where the incident ccurred Explanatin f hw the incident ccurred This lg is reviewed as part f the annual prgram evaluatin and maintained fr at least 5 years fllwing the end f the calendar year cvered. If a cpy is requested by anyne, it must have any persnal identifiers remved frm the reprt. PAGE 16
APPENDIX I - BLOODBORNE PATHOGENS SITE-SPECIFIC TRAINING CHECKLIST In rder t cmplete the training requirements please review the site-specific training items listed belw with the emplyee. Check each item as it is reviewed r write N/A if it is nt applicable t yur wrk area. Administrative-These Items MUST be cmpleted Ensure that nline cmpnents have been cmpleted (Risk Assessment, Initial BBP training and quiz) Declaratin f Vaccinatin Preference must be signed and submitted Spill Kits and Persnal Prtective Equipment (PPE) (glves, eye prtectin, ventilatin devices, etc.) Lcatin and availability f spill kits and review f kit cntents Lcatin f PPE, and maintenance f reusable PPE, if applicable (cleaning, strage and inspectin) Engineering Cntrls Lcatin, peratin, and use f eyewash facilities Explanatin f engineering cntrls that are specific t the wrk envirnment (examples: eyewash statins, sharps cntainers bilgical safety cabinets, mechanical pipettrs, safer sharps devices, etc.). Bihazardus Waste Handling Discussin and clarificatin f which wastes generated in the wrk area are cnsidered bihazardus and hw thse items are t be segregated, stred, transprted, treated and dispsed f Review f hazardus waste pick-up prcedures if applicable t the wrk area Disinfectin & Spill Respnse/Expsure Incident Respnse/Expsure Cntrl Plan Review f the CSU prcedure fr handling spills f ptentially infectius materials Reminder that nn-dispsable items that were tuched with dirty glves must be decntaminated befre being put back int the spill cleanup kit Wh t cntact fr spill cleanup supplies, and fr reprting Other Site Specific Check Pints (List as needed) Additinal Requirements fr HIV, HBV, and HCV Research Labratries: BSL1/BSL2 nline training: https://wsnet.clstate.edu/cwis86/wtrainreg/onlineclass/bslunit1-2/train.aspx Read the CSU Bisafety Manual: http://www.ehs.clstate.edu/wbisafety/hme.aspx Infrmed f the jb assciated risks, and given an pprtunity t ask questins Review departmental security access prcedures Lab specific prcedures assciated with BBP and OPIM Department: Date f Training: Trainer (Printed Name): Trainer Signature: LIST TASKS OR PROCEDURES THAT MAY POSE RISK OF EXPOSURE TO HUMAN BLOODBORNE PATHOGENS: Emplyee Printed Name Emplyee CSU ID Number Emplyee Signature Cntinue n back if needed Please sign and date the cmpleted checklist. PAGE 17
Retain a cpy fr the emplyee file, and submit a cpy t CSU Occupatinal Health: jni.triantis@clstate.edu. Cntinued frm ther side Emplyee Printed Name Emplyee CSU ID Number Emplyee Signature PAGE 18