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Bloodborne pathogens - exposure control plan

  1. PURPOSE

      This plan is designed to eliminate employee exposure to bloodborne pathogens. All human blood and other potentially infectious materials are considered to be infectious for Human Immunodeficiency Virus (HIV) and Hepatitis B virus (HBV) and will be treated as if infectious, i.e. with universal precautions. Since animal blood is not readily distinguished from human blood by appearance, this document's guidance for handling and disposal of human blood and sharps is recommended for all blood.


  2. SCOPE
    1. This exposure plan is mandatory for all University of Utah employees. The controls, decontamination and disposal sections are mandatory for students and visitors. The following jobs have some employees with the potential for contact with human body fluids during some activity in their job description and are covered by this plan.
    2. Grounds and Custodial staff transporting of waste containers. Discovery of improperly disposed of material. Blood on sidewalk, street, etc.
    3. This plan must be customized within departments/labs to be more specific and must be at least as stringent.
    4. Copies of the plan for a given area must be accessible to employees.
    5. The plan must be reviewed and updated annually.

  3. DEFINITIONS
    1. Blood - Human blood, including components and products
    2. Exposure Incident - means a specific eye, mouth, non-intact skin, inoculation, or injection contact with blood or other potentially infectious materials that results from the performance of job duties.
    3. Other Potentially Infectious Materials - semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, concentrated HIV and HBV viruses, and saliva in dental settings.
    4. Regulated Waste - means any liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.
    5. Universal Precautions - refers to a method of infection control in which all human blood and other potentially infectious materials are treated as if known to be infectious for HIV and HBV. It does not apply to feces, nasal secretions, sputum, sweat, tears, urine or vomitus unless they contain visible blood.

  4. RESPONSIBILITIES

    Supervisors will ensure:

      The procedures of this plan are followed. This includes a copy of this plan being available to workers, enforcing compliance with this plan, ensuring new employees are trained, performing follow-ups on incident exposures.

    Workers will:

      Perform duties as established in this plan and as trained.


  5. REQUIREMENTS
    1. General
        Grounds personnel may face the risk of exposure to human blood during performance of their duties. Blood or blood-contaminated needles, or containers may be encountered. Injuries on University property may result in blood on the streets or sidewalks.

        Although the only documented occupational risks of HIV and HBV infection are associated with injection, inoculation (including contamination of broken skin) or mucous membrane exposure to blood and other potentially infectious body fluids, as a precaution to University workers, when differentiation between fluid types is difficult, all body substances should be treated as if contaminated with human blood containing the HIV or HBV.

    2. Controls
      1. Wear protective gloves if exposure to blood contaminated body substances is remotely probable. Gloves will be worn for transporting biohazard containers.
      2. Anytime gloves are worn, remove the gloves prior to touching anything else and use an antiseptic cleaner until hands can be washed with soap and water.
      3. Use puncture-proof containers to store sharps and red biohazard labeled bags for other possibly contaminated items.
      4. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.

    3. Decontamination and Disposal
      1. Sharps - Do not use sharp objects if an alternative is available. Take precautions to prevent injuries from these objects. Never pick up broken glass without mechanical assistance (e.g. forceps). Keep puncture-resistant containers nearby.
      2. Disposal containers - Must be labeled and closed during transport. If there is a chance of leakage an additional labeled container should be used. The containers must be disposed of as infectious waste or decontaminated.
      3. Hand washing - Hands and other skin surfaces should be washed as soon as possible if contaminated. Always wash hands after removing gloves.
      4. Cleaning spills - Wearing gloves and other protective equipment as needed for splashing, promptly clean the spill. Absorb excess material with disposable towel then disinfect the area with a 1:100 house hold bleach to water solution. Red biohazard labeled bags should be available for removal of contaminated material from the site.
      5. Laundry - Any contaminated laundry will be sent to the University Hospital Laundry where Universal Precautions are observed or placed in a red biohazard labeled bag and sent to an off campus facility.

    4. Medical
      1. Costs will be borne by the supervising department and confidentiality will be ensured.
      2. After initial training, Hepatitis B vaccine will be made available to all personnel via an appointment with the Hospital Employee Health Nurse. The statement found at attachment 1 needs to be signed if the employee chooses to decline the vaccination at this time.

    5. Post-Exposure Evaluation
      1. Immediately following any exposure incident (specific eye, mouth, non-intact skin, or injection or inoculation with blood or other potentially infectious materials that results from the performance of job duties) a follow-up medical examination will be made available to the individual. This follow-up includes an offer to collect a blood sample from the exposed worker immediately following the incident and subsequent periodic samples later for HIV testing.
      2. The incident will be reported to the supervisor who will investigate. They will document the circumstances and measures to prevent recurrence.
      3. The source's blood will be tested if possible.

    6. Training
      1. Must be accomplished prior to beginning duties and repeated at least annually. It will consist of access to a copy of the OSHA Bloodborne Pathogen Standard and an explanation of its contents, a general explanation of epidemiology, symptoms and mode of transportation of bloodborne pathogens, an explanation of the Exposure Control Plan as well as an opportunity for interactive questions and answers with the person conducting the session.

    7. Recordkeeping
      1. Medical records will be maintained for the duration of employment plus 30 years.
      2. Training records will be maintained for at least 3 years.

  6. REFERENCES

      OSHA Bloodborne Pathogen Standard, 29 CFR 1910.1030. Attachment 4.

      University of Utah Biological Hazards Program, April 1991.

      Biosafety in Microbiological and Biomedical Laboratories. Barkley, E., and Richardson, J. (Eds.) (1988). Centers for Disease Control. Atlanta, GA, and National Institutes of Health, Bethesda, MD. HHSCDC 848395.

Attachment 1

HEPATITIS B VACCINE DECLINATION

Attachment 3

BLOODBORNE PATHOGEN EXPOSURE INCIDENT REPORT


11/7/97
3/13/02