Blood-borne Pathogen Exposure Plan

A: Introduction
B: Policy
C: Program Administration
D: Disciplinary Action
E: Definitions
F: Epidemiology
G: Route of Transmission
H: Employee Exposure Determination
I: Methods of Compliance
J: Personal Protective Equipment
K: Housekeeping
L: Laundry
M: Hepatitis B Vaccination
N: Post-exposure Evaluation
O: Healthcare Providers
P: Waste Removal/Disposal
Q: Training
R: Record Keeping
S: Appendices

A: Introduction

Acquired Immunodeficiency Syndrome (AIDS) and Hepatitis B warrant serious concerns for workers occupationally exposed to blood and other body fluids that contain bloodborne pathogens. In recognition of these potential hazards, the Occupational Safety and Health Administration (OSHA) implemented a  Bloodborne Pathogens regulation, [29 Code of Federal Regulations (CFR) 1910.1030] to help protect workers from these health hazards.

The major intent of this regulation is to prevent the transmission of bloodborne diseases within potentially exposed workplace occupations. The standard is designed to reduce and prevent employee exposure to the Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) and other bloodborne diseases. The standard recommends that employers follow universal precautions, which means that all blood or other potentially infectious material must be treated as being infectious. Employers must perform an employee exposure evaluation. If employee exposure is recognized as defined by the standard, then the standard mandates that an Exposure Control Plan (ECP) be developed to include; engineering controls, work practices, personal protective equipment, HBV vaccinations and training. The standard also mandates practices and procedures for housekeeping, medical evaluations, communication of hazards, and recordkeeping.

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B: Policy

The College of Saint Benedict and the Order of Saint Benedict (OSB) are committed to providing a safe and healthful learning and work environment for all employees, students, residents and visitors.  In pursuit, the following Exposure Control Plan (ECP) is prepared to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations 1910.1030.

The ECP is a key document to assist our campuses in the protection against infectious diseases. The implementation ensures compliance with the OSHA standard. All employees should therefore be familiar with the ECP and carefully follow the procedures and work practices as outlined.

The College of Saint Benedict and OSB recognize that some of the Class I or Class II employees sometimes work at off-site facilities that have the potential for exposure to bloodborne pathogen (BBP).  Employees who must work at an off-site facilities are required to comply with the procedures and work practices outlined in that facilities exposure control plan. Supervisor or project director who arranges with the outside facility must request, satisfy themselves with and document training of the employees in the exposure control plan of that facility before work begins. Employees should remain vigilant at all times and request sufficient protection.

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C: Program Administration

C.1 The Environmental Health Safety Office:

  • is responsible for coordinating the implementation of the ECP in accordance with the requirements of applicable federal, state and local bloodborne pathogen regulations.
  • will maintain and update the written ECP at least annually and whenever necessary to include new or modified tasks and procedures.
  • will oversee that all medical actions required are performed and that appropriate medical records are maintained.
  • will assist in coordination of training, documentation of training, and making the written ECP available to employees.
  • assist departments in identifying the appropriate personal protective equipment (PPE), engineering control supplies (i.e.. sharp containers, etc.), labels, and red bags as required by the standard.
  • Arrange and coordinate the disposal of potential infectious waste, with an off-site facility

C.2 The Human Resources Office:

  • In collaboration with the departments, is responsible for reflecting any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.
  • Inform the employee and the Environmental Health and safety officer of the need for training before the employee performs such tasks with occupational exposure
  • participate in the annual review of the ECP

C.4 Participating Department Chair, Director or Supervisor

  • provide department specific employee orientation and enforce procedures consistent with the college ECP.
  • have the responsibility for written safety (housekeeping) protocols and will ensure that effective disinfectants are purchased.
  • maintain and provide all necessary personal protective equipment (PPE), engineering controls (i.e.. sharp containers, etc.), labels, and red bags as required by the standard. Will ensure that adequate supplies of the aforementioned equipment are available.
  • submit information for review and request changes to the ECP as necessary for the effectiveness to the department.
  • provide time for employees to complete training and medical requirements. Schedule tasks consistent with employee training.
  • participate in the annual review of the ECP

C.5 First Aid Providers/CSB Security Officers (5000) or OSB Life safety (911 or 2144)

In addition to routine services, security or life safety officers will

  • if  needed, assist victim with transport arrangements to medical facility for the initial evaluation of the exposure incident
  • obtain and secure a preliminary exposure incident information.
  • inform the Environmental Health and Safety Officer of exposure incident as soon as feasible
  • assist in contacting custodial services for a clean up.
  • help with the transportation of potentially infectious waste to the central accumulation area.

C.6 Employees

Those employees who are reasonably anticipated to have contact with or exposure to blood or other potentially infectious materials (Class I and Class II) are required to comply with the procedures and work practices outlined in this ECP.

Other employees who are NOT reasonably anticipated to have contact with or exposure to blood or other potentially infected materials are expected to observe "universal precaution" as described in this ECP and use discreet judgment when offering voluntary assistance to a victim.

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D: Disciplinary Action

Our institutions are obligated to comply with the requirements of Federal Standard 29 CFR 1910.1030. Failure on employee’s part to comply with the requirements or the creation of unsafe/unsanitary conditions or unsafe acts will subject the employee to appropriate disciplinary course of action as provided in the employee’s relevant handbook.

E: Definitions

Following are some common words and phrases that specifically apply to this ECP. The definition of these words and phrases are also included in paragraph 1910.1030 (b) of 29 CFR, provided as Appendix A to this ECP.

Blood - human blood, human blood components, and products made from human blood.

Blood-borne Pathogens - pathogenic micro-organisms that are present in human blood and can infect and cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV), and Human Immunodeficiency Virus (HIV).

Contaminated - the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Exposure Incident - a specific eye, mouth, 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.

Occupational Exposure - reasonably 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.

Other Potentially Infectious Materials (OPIM)

1. The following human body fluids:

  • semen
  • vaginal secretions
  • cerebrospinal fluid
  • synovial fluid
  • pleural fluid
  • pericardial fluid
  • peritoneal fluid
  • amniotic fluid
  • saliva in dental procedures
  • any body fluid visibly contaminated with blood
  • 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)

3. HIV-containing cells or tissue cultures, organ cultures, and HIV or HBV-containing cultures medium or other solutions; and

4. Blood, organs, or other tissue from experimental animals infected with HIV or HBV.

Regulated Waste

  1. Liquid or semi-liquid blood or other potentially infectious materials;

  2. Contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed;

  3. tems that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling

  4. Contaminated sharps; and

  5. Pathological and microbiological wastes containing blood or other potentially infectious materials.

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F: Epidemiology

There are several diseases that are caused by bloodborne pathogens (BBP’s). Many bloodborne pathogens are fairly exotic and you may never encounter them. However, a few BBP’s are fairly common and present a risk to employee who come in direct contact with potentially infectious materials such as human blood and certain body fluids.

Among the more common bloodborne pathogens that employees could be exposed to on the job include but are not limited to, hepatitis B virus (HBV) Hepatitis C (HCV) and human immunodeficiency virus (HIV).

F.1 Hepatitis  virus

Hepatitis B virus (HBV) - is a virus that causes an infection of the liver potentially leading to liver disease, liver cancer and possibly death.

Hepatitis B:

Is an inflammation of the liver, caused by infectious and highly contagious HBV. It is characterized by jaundice and usually accompanied by fever and systemic manifestation.

effect - It is transmitted through blood, attacks the liver causing permanent damage, possible liver cancer or possible death.

symptoms - The symptoms vary for each person. Symptoms of HBV infection may range from no symptoms, to brief flu-like symptoms, to severe jaundice, abdominal pain, fatigue, nausea, fever and may result into serious illness. If symptoms do occur, they may not be evident until 2 to 6 months after the person is infected. However, studies have shown that an infected person can be infectious to others several weeks before the onset of symptoms.

medical control - currently there are pre-exposure vaccines that can effectively prevent infection against HBV. The vaccine is introduced into the body in a 3-shot series over a six month period. Licensed hepatitis B immune globulin are also available for use against HBV in a post-exposure incidence.

Class I or Class II employees reasonably anticipated to encounter blood and potentially infectious materials in the course of their jobs are entitled to the vaccination at no cost. If employee previously declined the vaccination but would like to receive it at this time, or if the employee would like to discuss the vaccination further, contact Environmental Health and Safety office at 5277(CSB) or 3267(OSB).

Hepatitis C Virus (HVC) -

F.2 Human Immunodeficiency Virus (HIV)

HIV is the virus that gradually weakens the immune system of the infected person, leaving that person unable to fight off other infections. This leads to acquired immunodeficiency syndrome (AIDS) and will ultimately cause death.

Acquired Immune Deficiency Syndrome (AIDS):

Is a major failure of the body’s ability to fight infection and suppress multiplication of abnormal cells such as cancer

effects - It involves the immune system including special blood cells (Lymphocytes) and cells of the organs (bone marrow, spleen, liver and lymph glands)

symptoms – infected person may have no symptoms or may experience multiple symptoms, including night sweats, fever, loss of weight, white fungus on tongues, throat swelling, dry cough, shortness in breath, diarrhea, swelling of lymph nodes, sensitivity to bruising and bleeding from skin lesions.

medical control - not yet accomplished. Medical advances have been made in recent years regarding HIV treatment. Several antiviral drugs, called protease inhibitors, have been found to slow the replication of the virus, but this is NOT a cure. Currently there is no vaccine, no cure and once HIV positive, one is a carrier and contagious.

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G: Route of Blood-borne Pathogen Transmission

The pathogens HIV and HBV which can cause these diseases may be found not only in human blood, but also in other potentially infectious materials (OPIM) including the following body fluids:

  • blood products (such as plasma or serum)
  • semen
  • vaginal secretions
  • cerebrospinal fluid
  • pleural fluid (or lung fluid)
  • synovial fluid (or fluid from your joints)
  • amniotic fluid (or uterine fluid)
  • peritoneal fluid (or fluid that fills your body cavity)
  • saliva in dental settings
  • any body fluid that is visibly contaminated with blood
  • any body fluid that you can’t tell what it is

It is a required practice to use Universal Precautions when handling these body fluids.

The following body fluids are not expected to be infectious sources of bloodborne pathogens (unless they are visibly contaminated with blood):

urine; feces; vomit; tears; sweat; sputum; nasal secretions

Although these body fluids are not currently classified as infectious sources of bloodborne pathogens, universal precautions, good personal hygiene practices must be followed when handling these materials.

Some items found in clinical or laboratory setting are also considered to be other potentially infectious materials (OPIM) and they include:

  • any unfixed tissue or organ, other than intact skin, from a living or dead person
  • cell or tissue cultures that may contain bloodborne pathogens
  • organ cultures and culture medium or other solutions that may contain HIV or HBV
  • blood from experimental animals infected with HIV, HBV or other BBPs.

Transmission of Bloodborne Pathogens.

Bloodborne pathogens can be transmitted when infectious blood or OPIM is introduced into the bloodstream of a person. The routes of infection with HBV and HIV are generally similar for people at risk of occupational exposure. The primary routes are:

Percutaneous (parenteral) Exposure

this is when the infected blood or OPIM is introduced directly into the body through a break in the skin. Examples include: a contaminated needle-stick or a cut with a piece of contaminated glass.

Permucosal (via mucous membrane)

this means that the infected blood or OPIM enters the body through contact with a mucous membrane found in the eye, nose and mouth when these areas are splashed, rubbed with contaminated hands or touched with implements.

The HBV virus is particularly dangerous since it can survive on dried surfaces at room temperature for at least one week. This means that a surface can be dangerously contaminated without any visible signs if the work areas are not thoroughly cleaned immediately after being contaminated with infectious material.

There are many more HBV-infected people than HIV-infected people in a community. Thus the chance of exposure to HBV is greater. Hepatitis B virus is much more infectious than HIV.

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H: Employee Exposure Determination

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e., employees are considered to be at risk of exposure even if they wear personal protective equipment).

This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency.

H.1 Classification I

A list of job classifications in which all of the employees have risk of occupational exposure.

At the College of St. Benedict, the following job classifications are in this category:

  • Health-Care personnel (student health center)
  • Athletic Trainer
  • Campus Security Officer
  • Custodians (Full Time Employees)
  • Lifeguard
  • Nursing Faculty

At the Order of St. Benedict, the following job classifications are in this category:

  • Healthcare Providers (Retirement Center)
  • Athletic Trainer/Athletic Equipment Manager
  • Security Officers/EMT/Lifeguard
  • Custodial
  • Laundry

In addition, OSHA requires a listing of job classifications in which some employees may have occupational exposure. Since not all the employees in these categories would be expected to incur exposure to blood or other potentially infectious materials, tasks or procedures that would cause these employees to have occupational exposure are also required to be listed in order to clearly understand which employees in these categories are considered to have occupational exposure. The job classifications and associated tasks for these categories are as follows:

H.2 Classification II

A list of job classifications in which some of the employees have risk of occupational exposure; and the list of specific tasks and procedures causing the occupational exposure.

The table below lists the job categories at the College of St. Benedict:

Job Class:

Tasks or Procedures
Athletic Head Coaches

 

 Tasks that involves Blood or OPIM while performing duties of Athletic Trainers in an off-site conditions
Transportation – Designated Bus Driver While performing custodial services that involves Blood and other OPIM
Nutrition Faculty While performing experimental procedures that involves Blood and other OPIM
Plumbing While working on sanitary fixtures that have the potential for exposure to Blood and other OPIM.
 
The table below lists the job categories at the Order of St. Benedict:
 

Job Class:

Tasks or Procedures
Athletic Head Coaches

 

Working with injuries, changing of dressing, and cleaning of blood spills.
Lab Assistants/Exposed Faculty

Handling blood products and other body fluids in classrooms during planned activities.
Waste Water Plant Operator/Plumbers Handling and working with waste products that may contain blood and other body fluids.

Note: All exposure determinations were made without regard to the use of Personal Protective Equipment (PPE).

H.3 Voluntary Assistance

Voluntary "Good Samaritan" acts which result in exposure to blood or other potentially infectious materials from assisting a fellow employee (i.e., assisting a co-worker with nose bleed, giving CPR or first aid) are not included in the Bloodborne Standard. However, at the College of St. Benedict and OSB, such incidences will be evaluated on case by case basis and the college may offer post-exposure evaluation and follow-up for victims.

In case of bleeding, assistance such as fetching first aid kit, handing supplies to the victim and maintaining dialogue with the victim until bleeding has stopped or until help arrives is most valuable and every employee is encouraged to just do that. Such assistance should be sufficient for most of the type of incidences we experience on our campus. If the bleeding is such that the victim cannot contain it single handed and you must help, then follow the fairly easy concepts explained here, but remember take the time to assess the conditions so that you will be better able to cope with the emergency.

Place a sterile dressing over the wound if you have one available. If you don't have sterile first aid supplies, use a clean cloth. Apply direct pressure over the wound to control bleeding.

NOTE: While the risk of disease transmission is slight when your skin is intact, placing a barrier between your skin and the victim's blood is a wise idea. Use disposable rubber gloves if possible. ANY barrier is better than none.

Do not remove dressing if it becomes blood soaked. Apply an additional dressing instead.

Don't release pressure until help arrives.

Wash your hands thoroughly when you are finished.

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I: Methods of Compliance

Employees covered by the Bloodborne Pathogens Standard will receive an explanation of the ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees will have an opportunity to review this Plan at any time during their work shifts by contacting their supervisor or by contacting EH&S officer, at 5277 or 3267.

I.1 Universal Precaution

All employees will utilize Universal Precautions. The term "universal precautions" refers to a system of infectious disease control which assumes that all blood or body fluids are infectious and requires every worker exposed to direct contact with blood or body fluids to be protected as though such body fluids were infected with Hepatitis B (HBV), Human Immunodeficiency Virus (HIV) or other infectious agents. Therefore, universal precautions are intended to prevent workers from parenteral, mucous membrane, and non-intact skin exposures to infectious agents.

I.2 Engineering Control and Work practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. Some of the specific engineering controls and work practice controls we will use are listed below:

Product Design Evaluation

New technology for needles and sharps will be evaluated and implemented whenever possible to further prevent accidental needle sticks and cuts. Our engineering controls (i.e., sharps containers, etc.) will be inspected by the supervisor or project director and maintained or request for maintenance/replacement as appropriate.

Examples of engineering controls include, but are not limited to:

  • self-sheathing needles
  • puncture-resistant disposal containers for contaminated sharps, or broken glass
  • leakproof bag and container for accumulation of biohazard waste
  • mechanical needle recapping devices
  • bio-safety cabinets
  • ventilated laboratory hoods

Note: Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. If the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is absolutely necessary for the procedure, the recapping or removal of the needle must be done by the use of a mechanical device or a one-handed technique. Procedures where recapping is necessary must be forwarded to EH&S office in order to be included in the ECP.

I.3 Handwashing

Handwashing is the single most important means of preventing the spread of infection. It is vitally important to clean hands thoroughly after contact with potentially infectious material. This helps to protect the employee from hand-to-mouth infection and also prevents the hand-to-hand spread of contamination to fellow employees.

Examples of Handwashing practice controls include, but are not limited to:

  • providing readily accessible hand washing facilities
  • washing hands immediately or as soon as feasible after removal of gloves.
  • At non-fixed sites (e.g., emergency scenes off sites or in transit) which lack hand washing facilities, interim hand washing measures, such as antiseptic towelettes and paper towels shall be provided. Employees can later wash their hands with soap and water as soon as feasible
  • washing body parts with soap or flush mucous membranes with water immediately or as soon as possible after skin contact with blood or other potentially infectious materials occurs

I.4 Work Practice Controls

  • eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses in work areas are prohibited where there is a likelihood of occupational exposure bloodborne pathogen.
  • food and drink are prohibited from being kept in refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where blood or other potentially infectious materials are present
  • all procedures or clean up involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, splattering, and generation of droplets of these substances
  • specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport or shipping
  • examine equipment which may become contaminated with blood or other potentially infectious materials prior to servicing or shipping and decontaminating such equipment as necessary. Items will be labeled per the standard if not completely decontaminated
  • Invasive procedures such as the use of co-workers or other people for withdrawing or introducing blood or fluids, for practice purposes, are not encouraged. Permission to conduct such practice must be granted by the chair person, in which case the chair must demonstrate that the procedure is safe and currently the most acceptable practice based on research by a professional organization such as Center for Disease Control (CDC) or by regulation.

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J: Personal Protective Equipment

Personal protective equipment (PPE) are barriers designed to prevent employees from having direct contact with blood or other potentially infectious materials.

Personal protective equipment (PPE) must also be used if occupational exposure remains after instituting engineering and work practice controls, or if controls are not feasible. Baseline information will be provided during the initial training, in the use of the appropriate personal protective equipment. PPE training for employees' specific job classifications or tasks and procedures will be provided by the supervisor or project director for work they will perform.

Additional training will be provided, whenever necessary, such as if an employee takes a new position or if new duties are added to their current position. Supervisors or project directors will provide the additional training as appropriate. Environmental Health and safety office will be available for assistance.

When there is a potential for occupational exposure, the supervisor shall provide and ensure that the employee uses appropriate personal protective equipment such as, but not limited to the following:

  • GLOVES
  • GOWNS
  • APRONS
  • LABORATORY COATS
  • HEAD COVERINGS
  • FOOT COVERINGS
  • UTILITY GLOVES
  • EYE PROTECTION
  • FACE SHIELDS OR MASKS WORN WITH EYE PROTECTION    
  • MOUTH PIECES, RESUSCITATION BAGS, POCKET MASKS, OR OTHER VENTILATION DEVICES

Supervisors shall provide, at no cost to the employee, appropriate personal protective equipment when there is anticipated occupational exposure. Personal protective equipment will be considered 'appropriate" only if it does not permit blood or other potentially infectious materials to pass through mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

The appropriate personal protective equipment in the appropriate sizes will be readily accessible at the worksite or is issued to employees by the project supervisor. Hypoallergenic gloves, glove liners, powder-less gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.

Employees with first aid responder responsibilities such as security officer must have quick access to kits having gloves, ventilation devices, pocket masks or mouthpieces, eye protection, aprons, and disinfectant towelettes for hand washing. In addition to their personal Kits, these PPE's can be found in the Bloodborne Pathogen kits located in most of the building on campus. The list of supplies contained in a standard kit is provided in Appendix H.

As a general rule, all employees using PPE must observe the following precautions:

  • Wash hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
  • Remove protective equipment before leaving the work area and after a garment becomes contaminated.
  • Place used protective equipment in appropriately designated areas or containers when being stored, washed, decontaminated, or discarded.
  • Wear appropriate gloves when it can be reasonably anticipated that you may have contact with blood or other potentially infectious materials 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.
  • Following any contact of body areas with blood or any other infectious materials, you must wash your hands and any other exposed skin with soap and water as soon as possible.
  • Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deterioration. Never wash or decontaminate disposable gloves for reuse or before disposal.
  • Wear appropriate face and eye protection such as a mask with glasses with solid side shields or a chin length face shield when splashes, sprays, spatters, or droplets of blood or other potentially infectious materials pose a hazard to the eye, nose, or mouth. If a garment is penetrated by blood and other potentially infectious materials, the garment(s) must be removed immediately or as soon as feasible.

Note to Supervisors: ANY PERSONAL PROTECTIVE EQUIPMENT CHOSEN SHALL FORM AN EFFECTIVE BARRIER.

THE TYPE AND CHARACTERISTICS WILL DEPEND UPON THE TASK AND DEGREE OF EXPOSURE ANTICIPATED.

GENERAL WORK CLOTHES (e.g. uniforms, pants, shirts or blouses) OR EYE GLASSES NOT INTENDED TO FUNCTION AS PROTECTION AGAINST A HAZARD ARE NOT CONSIDERED TO BE PERSONAL PROTECTIVE EQUIPMENT.

THE SUPERVISOR SHALL ENSURE THAT THE EMPLOYEE USES APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT.

THE SUPERVISOR SHALL ENSURE THAT APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT IN APPROPRIATE SIZES IS READILY ACCESSIBLE

Contact the Environmental Health and Safety Office at 5277 or 3267 for assistance in the selection and coordination of the purchase of PPE .

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K: Housekeeping

Housekeeping refers to maintaining the work site in a clean and sanitary condition, which helps to minimize occupational exposure to blood or other potentially infectious materials. Housekeeping procedures are specific for cleaning and decontaminating the environment, equipment, and work surfaces, and for handling contaminated laundry.

Note: EPA registered tuberculocidal disinfectants are appropriate for the cleaning of blood or OPIM. A list of EPA approved disinfectants is provided in Appendix F. A solution of 5.25 percent sodium hypochlorite, (household bleach), diluted between 1:10 and 1:100 with water, is also acceptable (OSHA) for cleaning contaminated surfaces.

Quaternary ammonium products are appropriate for use in general housekeeping procedures that do not involve the cleanup of contaminated items or surfaces.

The particular disinfectant used, as well as the frequency with which it is used, will depend upon the circumstances in which a given housekeeping task occurs (i.e., location within the facility, type of surface to be cleaned, type of soil present, and tasks and procedures being performed).

The following procedures are provided as a general practice for house keeping in a laboratory setting. To ensure a complete decontamination, it is recommended that employees plan procedures as specific as possible to the task.

  • Decontaminate work surfaces with an appropriate disinfectant after completion of procedures, immediately when overtly contaminated, after any spill of blood or other potentially infectious materials, and at the end of the work shift when surfaces have become contaminated since the last cleaning.
  • Remove and replace protective coverings such as plastic wrap and aluminum foil when contaminated.
  • Inspect and decontaminate, on a regular basis, reusable receptacles such as bins, pails, and cans that have a likelihood for becoming contaminated. When contamination is visible, clean and decontaminate receptacles immediately, or as soon as feasible.
  • Always use mechanical means such as tongs, forceps, or a brush and dust pan to pick up contaminated broken glassware; never pick up with hands even if gloves are worn.
  • Tore or process reusable sharps in a way that ensures safe handling.
  • Place regulated waste in closed and labeled or color coded containers. When storing, handling, transporting or shipping, place other regulated waste in containers that are constructed to prevent leakage.
  • When discarding contaminated sharps, place them in containers that are closed, puncture-resistant, appropriately labeled or color-coded, and leak proof on the sides and bottom.
  • Ensure that sharps containers are easily accessible to personnel and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. Sharps containers also must be kept upright throughout use, replaced routinely, closed when moved, and not allowed to overfill.
  • Do not manually open, empty, or clean reusable contaminated sharps disposal containers.

Discard all regulated waste according to federal, state, and local regulations, i.e., liquid or semi-liquid blood or other potentially infectious material; items contaminated with blood other potentially infectious materials that would release these substances in a liquid or semi-liquid state if compressed; items caked with dried blood or other potentially infectious materials and capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials, should be treated as regulated waste and discarded following appropriate procedure.

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L: Laundry

The following requirements must be met, with respect to laundry/linen contaminated with blood or OPIM:

  • Handle contaminated laundry as little as possible and with a minimum of agitation.
  • Use appropriate personal protective equipment when handling contaminated laundry.
  • Place wet contaminated laundry in leak proof, labeled or color-coded containers before transporting.
  • Bag contaminated laundry at its location of use.
  • Never sort or rinse contaminated laundry in areas of its use.
  • Use red laundry bags or those marked with the biohazard symbol unless universal precautions are in use at the facility and all employees recognize the bags as contaminated and have been trained in handling the bags.
  • All CSB/OSB custodial personnel who are involved in gathering laundry must have determined and be familiar with the receiving facility's control procedure. If universal precautions are not used, isolate laundry with visible blood or OPIM, then clearly mark with orange biohazard labels or use red labeled bags before sending it to a facility for cleaning. Leak proof bags must be used when necessary to prevent soak-through or leakage.
  • When handling and/or sorting contaminated laundry, utility gloves and other appropriate personal protective equipment (i.e., aprons, mask, eye protection) shall be worn.

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M: Hepatitis B Vaccination

The clinic chosen by the employee will provide information on Hepatitis B vaccinations, addressing its safety, benefits, efficacy, methods of administration and availability. The Hepatitis B vaccination series will be made available at no cost, within 10 days of initial assignment to employees who have occupational exposure to blood or other potentially infectious materials unless:

  • the employee has previously received the series
  • antibody testing reveals that the employee is immune
  • medical reasons prevent taking the vaccination; or
  • the employee chooses not to participate

If an employee chooses to decline HB vaccination, then the employee must sign a statement to this effect. (See Appendix C for Mandatory declination statement.)

Employees who decline may request and obtain the vaccination at a later date at no cost, by contacting the Environmental Health and Safety office 5277 or 3267. Documentation of refusal of the HB vaccination will be kept with the employee's other medical records.

To ensure employees are aware of the importance of the Hepatitis B vaccination, it is recommended that all involved in hiring to encourage employees to consider the efficacy, and benefits of the vaccination, the fact that it is given at no cost, and during work hours.

Highlights of Hepatitis B Vaccination (view summary chart)

  • Participation in pre-screening is not a prerequisite for receiving Hepatitis B vaccination
  • Hepatitis B vaccination provided even if employee declines but later accepts treatment
  • Employee must sign statement when declining HB vaccination
  • Vaccination administered in accordance with United States Public Health Service (USPHS) recommended protocol
  • HB vaccination booster doses must be available to employees if recommended by USPHS

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N: Post-Exposure Evaluation

Post Exposure Evaluation and Follow-up Procedures for Reporting, Documenting and Evaluating the Exposure

Should an exposure incident occur contact your supervisor, a first responder, CSB Security at 5000, or OSB Life Safety at 911 immediately. Each exposure must be documented, on a 'Exposure Report Form' (see Appendix D). Environmental Health and Safety will review and provide any additional information as needed. The incident report will:

  • Document the routes of exposure and how exposure occurred.
  • Identify and document the source individual, unless it can be established that identification is infeasible or prohibited by State or local law.

An immediately available confidential medical evaluation and follow up will be conducted by a licensed Healthcare Provider of choice. The following elements will be performed:

  • Obtain consent to test source individual's blood as soon as possible to determine HIV and HBV infectivity. Test and document the source's blood test results
  • If the source individual is known to be infected with either HIV or HBV, testing need not be requested to determine the known infectivity.
  • Provide the exposed employee with the source individual's test results and information about applicable disclosure laws and regulations concerning the source identity and infectious status.
  • After obtaining consent, collect exposed employee's blood as soon as feasible after the exposure incident and test blood for HBV and HIV serological status.
  • If the employee does not give consent for HIV-serological testing during the collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days. The employee must be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Services.
  • Given the employee appropriate counseling concerning precautions to take during the period after the exposure incident. The employee must also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.

Appendix D 'Exposure Report Form' will be given to the employee, in order to provide additional relevant medical information for the medical evaluation. Original records on this appendix will be maintained with employee's medical records.

The Environmental Health and Safety Officer will review the circumstances of the exposure incident to determine if procedures, protocols and/or training need to be revised.

If consent is not obtained, CSB/OSB must show that legally required consent could not be obtained. Where consent is not required by law, the source individual's blood, if available, should be tested and the results documented.

If, during this time the exposed employee elects to have the baseline sample tested, testing shall be done as soon as feasible.

Following an exposure incident, prompt medical evaluation and prophylaxi's is essential. Timeliness is, therefore, an important factor in effective medical treatment. Recent information from CDC indicates that evaluation within two hours is most helpful particularly with HIV incident. Effective medical treatment may still be conducted within 72 hours from the time of exposure to HBV.

Highlights of Post Exposure Evaluation and Follow-up Requirements

  • Documentation of exposure routes and how exposure incident occurred
  • Identification and documentation of source individual's infectivity, if possible
  • Collection and testing of employee's blood for HBV and HIV serological status (employee's consent required)
  • Post-exposure prophylaxis when medically indicated
  • Counseling
  • Evaluation of reported illnesses

Go to Blood-borne Pathogen Exposure Plan index.

O: Healthcare Provider

Environmental Health and Safety officer will ensure that health care professionals responsible for employee's HB vaccination and post-exposure evaluation and follow-up, have a copy of the OSHA Bloodborne Standard.

Environmental Health and Safety officer or the Human Resource office will ensure that the health care professional evaluating an employee after an exposure incident receives the following:

  • a description of the employee's job duties relevant to the exposure incident
  • routes of exposure
  • circumstances of exposure
  • relevant employee medical records, including vaccination status

Healthcare Professional's Written Opinion

The attending Healthcare Provider will provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days after completion of the evaluation.

For HB vaccinations, the healthcare professional's written opinion will be limited to whether the employee requires or has received the HB vaccination.

The written opinion for post-exposure evaluation and follow-up will be limited to whether or not the employee has been informed of the results of the medical evaluation and any medical conditions which may require further evaluation and treatment.

All other diagnoses must remain confidential and not be included in the written report.

Go to Blood-borne Pathogen Exposure Plan index.

P: Waste Removal/Disposal

P.1. Labeling

All employees involved in the biohazard waste removal will ensure that warning labels are affixed or red labeled bags are used as required. Employees are to notify, in the following order; the custodian for the area, CSB Security (5000), OSB Life Safety (911), or Environmental Health and Safety (5277 or 3267), if they discover unlabeled regulated waste containers. See Appendix B, for Minnesota State Labeling Requirements.)

P.2. Disposal

The Class I or Class II employee designated for the custodial services at the work site or the department from which a potentially infectious waste exists will have the overall responsibility for the waste. The accumulated infectious waste that has the potential to release blood or OPIM, will be placed in a container that is leakproof or puncture resistant or a combination of both depending on waste media, for safe transportation. The responsible person will inform CSB Security (5000) or OSB Life Safety (911) of the existence of such waste. In a timely manner, the security will transport the waste to a designated accumulation center.

Unless they are visibly contaminated with blood, clean up of the following body fluids: urine; feces; vomit; tears; sweat; sputum; nasal secretions which currently are not expected to be infectious sources of bloodborne pathogens shall be disposed of as a regular waste.

P.3. Waste Disposal Procedures in the Teaching Laboratory. (Review Infectious Waste Summary)

The responsibility for decontamination and proper disposal of biohazardous waste in teaching laboratories lies with the producing facility (e.g., laboratory and department). The safety officer for academic programs will assist in coordinating the waste activities and in the disposal of sharps and pathological waste including animal carcasses.

Departments or laboratories that have specific biosafety procedure shall use this ECP as a minimal standard. As a general practice the teaching laboratories will utilize Autoclave machine if available, to decontaminate potentially infectious waste before disposal into regular waste stream.

  • Contaminated solid waste including cloth, plastic and paper items that have been exposed to potentially infectious (unknown) or infectious agents shall be placed in biohazard bags and decontaminated by autoclaving. Double or triple bagging may be required to avoid rupture or puncture of the bags
  • All liquid waste from humans or animals such as blood, blood products and certain body fluids, known not to contain infectious agents, can be disposed of directly by flushing down a sanitary sewer. All other liquid biohazardous waste needs to be autoclaved or treated with a disinfectant prior to disposal.
  • All sharps must be placed in a rigid, puncture resistant, closable and leakproof container, which is labeled with the word "Sharps" and the biohazard symbol. Contaminated Pasteur pipettes are considered sharps and need to be disposed of in a sharps container.
  • Cultures and stocks of infectious agents shall be placed in biohazard bags and decontaminated by autoclaving. Double or triple bagging may be required to avoid rupture or puncture of the bags.
  • Waste that has been autoclaved or has under-gone approved disinfection procedure may now be placed in ordinary trash bag and disposed directly into a non-regulated mechanically emptied dumpster.

Go to Blood-borne Pathogen Exposure Plan index.

Q: Training

All employees who have or are reasonably anticipated to have occupational exposure to blood-borne pathogens, the Class I and Class II job lists, will receive the initial training before assigned to work and the mandatory annual refresher training thereafter.

Q.1 What training is required:

Department Chair or Manager must arrange or contact EH&S to arrange for the initial training for newly hired and for the annual refresher for participating employees in the department. Based on need, a general awareness training session can be scheduled in January/February for regular full time employees. Additional awareness training for student workers will be arranged on as need basis typically at the beginning and end of each academic year.  All training will provide appropriate information applicable to our work environment.

Employees who attend training as a requirement of their annual refresher (Class I & II) must do so in order to satisfy the requirements. If an employee misses a scheduled class, She or he may request for a session by contacting EH&S office. Individual training whether initial or a refresher, will most likely take a different format, including interactive computer based training (CBT), with instant access to a qualified trainer. On-going employees who have attended the training session at least once and are not classified as Class I or Class II in the College ECP are not required to attend annual training. However, such employee may come into any general session, supervisor permitting or refer to the ECP in order to stay current with the practice of "universal precaution".

Each training program will be appropriate in context, including the following elements:

  • An accessible copy of the regulatory text of this standard and an explanation of its contents.
  • An explanation of the epidemiology, transmission, and symptoms of bloodborne diseases.
  • An explanation of the College of St. Benedict's exposure control plan and the means by which the employee can obtain a written copy.
  • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  • An explanation of the use and limitations of methods that will prevent or reduce exposure including engineering controls, work practices, and personal protective equipment.
  • Information on the types, basis for selection, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
  • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that employees will be offered the vaccination series free of charge.
  • Information on the appropriate actions to take and persons to contact in an emergency.
  • 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.
  • An explanation of the signs and labels and/or color coding required.
  • Name of individual to contact for further information.
  • Questions and answer session

Q.2 When training is required:

Initial training must be completed before assignment to tasks where occupational exposure may take place, and a refresher session at least annually thereafter. Often there will be need to hire or re-assign employee to a Class I or Class II job category, in between training session. In order to satisfy the "training within ten working days" requirement, the hiring departments and the human resources must provide the Environmental Health & Safety office with such information at least one week before the scheduled start date. The Environmental Health & Safety will conduct or arrange for the required training for the employee. The supervisor or project director will conduct the site specific orientation.

Q.3 Recordkeeping requirements:

Training records must be maintained for three years from the date on which the training occurred. Training records must include the dates of the training sessions, the contents or a summary of the training session, the names and qualifications of persons conducting the training, and the names and job titles of all persons attending the training sessions.

Go to Blood-borne Pathogen Exposure Plan index.

R:Record Keeping

R.1 Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.20.

Human Resources Department is responsible for maintenance of the required medical records and they are kept at the Human Resources Office in the Main Building.

All employee medical records will be kept confidential and will not be disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by the standard or as may be required by law.

Employee medical records shall be maintained for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.20.

Employee medical records shall be provided upon request of the employee or to arrange having written consent of the employee within 15 working days.

R.2 Training Records

Bloodborne pathogen training records will be maintained at the Environmental Health and Safety Office.

The training record shall include:

  • the dates of the training sessions;
  • the contents or a summary of the training sessions;
  • the names and qualifications of persons conducting the training;
  • the names and job titles of all persons attending the training sessions.

Training records will be maintained for a minimum of three (3) years from the date on which the training occurred.

Go to Blood-borne Pathogen Exposure Plan index.

 

S: APPENDICES

APPENDIX A

Copy of OSHA standard 29 CFR 1910.1030

APPENDIX B

ITEM

NO LABEL REQUIRED

BIOHAZARD LABEL

RED COLOR-CODED CONTAINER
 

REGULATED WASTE CONTAINER

  

X

  
REUSABLE CONTAMINATED SHARPS  

X

OR X
REFRIGERATOR/FREEZER HOLDING BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS (OPIM)

 

X
CONTAINERS USED FOR STORAGE, TRANSPORT, OR

SHIPPING OR BLOOD OR OPIM

  

 

X

OR X
BLOOD/BLOOD PRODUCTS RELEASED FOR CLINICAL

USE

X

    
INDIVIDUAL SPECIMEN CONTAINER OF BLOOD OR OPIM REMAINING IN FACILITY

X2

OR X

OR X
SPECIMENS SHIPPED FROM THE PRIMARY FACILITY TO ANOTHER FACILITY  

X

OR X
INDIVIDUAL CONTAINERS OF BLOOD OR OPIM PLACED IN LABELED CONTAINER DURING STORAGE, TRANSPORT SHIPMENT, OR DISPOSAL

X

    
CONTAMINATED EQUIPMENT NEEDING SERVICING OR SHIPPING  

X3

  
CONTAMINATED LAUNDRY

X4

OR X

OR X
LAUNDRY SENT TO ANOTHER FACILITY THAT DOES NOT USE UNIVERSAL PRECAUTIONS  

X

OR X
  1. Although 1910.1030 allows either form of labeling for regulated waste containers, the Minnesota Infectious Waste Control Act (Minn. Stat. 116.76 to 116.83) requires Infectious (regulated) waste to be labeled with the biohazard symbol or with the words "Infectious waste" written in letters no less than one inch in height. (Minn. Stat. 116.78, Subd. 2) Employers who dispose of regulated/infectious waste at their facility (i.e., an on-site incinerator) may use either form of labeling. However, employers whose regulated/Infectious waste is collected or shipped off-site for disposal, must label the infectious in accordance with Minn. Stat. 116.78.
  2. Labels are not required if universal precautions are used in handling all specimens and containers are recognizable as containing specimens.
  3. Specifying, in addition, the location of the contamination.
  4. Alternative label or color code must be used when facility uses universal precautions in handling laundry and employees can recognize containers as requiring compliance with universal precautions.

APPENDIX C

OSHA Regulations (Standards - 29 CFR)

(Click for printable version)

Hepatitis B Vaccine Declination (Mandatory) - 1910.1030 Appendix A

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.

 

___________________________ _____________________ _________

Name of Employee (Print) / Signature / Date

[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992;
57 FR29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996]

APPENDIX D

EXPOSURE INCIDENT REPORT

(Click for printable version)

(ROUTES AND CIRCUMSTANCES OF EXPOSURE INCIDENT)

Please Print

DATE COMPLETED ___________________________________________________________

EMPLOYEE’S NAME____________________________________ SS# ___________________

HOME PHONE ___________________BUSINESS PHONE____________________________

DOB______________________ JOB TITLE ________________________________________________

EMPLOYEE VACCINATION STATUS _____________________________________________

DATE OF EXPOSURE _______________ TIME OF EXPOSURE_________________ AM PM

LOCATION OF INCIDENT (BUILDING, STREET, ETC. - BE SPECIFIC):___________________

NATURE OF INCIDENT (ACCIDENT WHILE CLEANING, SPORTS, TRAUMA, MEDICAL EMERGENCY) BE SPECIFIC:

______________________________________________________________________________________

______________________________________________________________________________________

DESCRIBE WHAT TASK (S) YOU WERE PERFORMING WHEN THE EXPOSURE OCCURRED (BE SPECIFIC:)

______________________________________________________________________________________

______________________________________________________________________________________

WHERE YOU WEARING PERSONAL PROTECTIVE EQUIPMENT (PPE)? YES_____ NO____

IF YES, LIST

__________________________________________________________________

_____________________________________________________________________________

DID THE PPE FAIL? YES_____ NO_______

IF YES, EXPLAIN HOW:

___________________________________________________________________________________

WHAT BODY FLUIDS WERE YOU EXPOSED TO (BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIAL)? (BE SPECIFIC):

______________________________________________________________________________________

______________________________________________________________________________________

WHAT PARTS OF YOUR BODY BECAME EXPOSED? BE SPECIFIC.

_____________________________________________________________________________

ESTIMATE THE SIZE OF THE AREA OF YOUR BODY THAT WAS EXPOSED. ____________

_____________________________________________________________________________________

FOR HOW LONG?______________________________________________________________

DID A FOREIGN BODY (NEEDLE, NAIL, OR OTHER SHARPS ETC.) PENETRATE YOUR BODY?

YES__________ NO__________

IF YES, WHAT WAS THE OBJECT?________________________________________________

WHERE DID IT PENETRATE YOUR BODY?_________________________________________

WAS ANY FLUID INJECTED INTO YOUR BODY? YES_________ _____NO__________

IF YES, WHAT FLUID?_____________________________ HOW MUCH?_________________

DID YOU RECEIVE MEDICAL ATTENTION? YES_____________ NO_______________

IF YES, WHERE?______________________________________________________________

WHEN_______________________________________________________________________

BY WHOM____________________________________________________________________

IDENTIFICATION OF SOURCE INDIVIDUAL(S)

NAME(S)_____________________________________________________________________

DID YOU TREAT THE PATIENT DIRECTLY? YES____ NO_______

IF YES, WHAT TREATMENT DID YOU PROVIDE, BE SPECIFIC:________________________

OTHER PERTINENT INFORMATION_______________________________________________

_________________________________________________________________________

 

________________________________________________ ___________________

Signature of Supervisor or person preparing this report / Date

 

__________________________________________________ ___________________

Signature of the Employee / Date

 

(Click for printable version)

APPENDIX E

List of Products registered with the EPA which are effective against Hepatitis B Virus (HBV) and Human Immunodificiency Virus (HIV).

Selected EPA - Registered Disinfectants .

This information is provided as a service of the National Antimicrobial Information Network and is based on the most recent information available from the US Environmental Protection Agency. This list is updated periodically as new information is obtained, accounting for label changes, cancellations, transferals of registrations, and label edits.

NOTE: If you have questions regarding a particular products registration status, you can compare its EPA registration number with the EPA Reg #: number on this list. The EPA Reg#: number may consist of two or three sets of digits separated by hyphens "-". The first number refers to the Registrants Identification number. The second number represents the Product identification number. The third number represents the Distributor/Relabeler Identification number. This lists contains the primary registrants products. Other companies may repackage and rename products but do not change the formulation. These renamed products do not appear on this list. Some products may have more than one trade name for a registration number.