Bloodborne Pathogens and Exposure Control Plan

 

Introduction 

Bloodborne Pathogens (BBP) are infectious microorganisms that can be present in human blood and cause disease in humans. In addition, human pathogens may be present in other body fluids, tissues, and human-derived cultures commonly referred to as Other Potentially Infectious Materials (OPIM). Workers in many different jobs may be at risk for occupational exposure to BBP and/or OPIM while performing their regular duties. To protect such workers, the Occupational Safety & Health Administration (OSHA) published the Bloodborne Pathogens Standard (29 CFR 1910.1030) in 1991. On this page, we will review the BBP standard and how its elements are implemented at UVM.

The Bloodborne Pathogens Standard (29 CFR 1910.1030)

Bloodborne Pathogens and Other Potentially Infectious Materials

Universal Precautions

UVM's Exposure Control Plan for Bloodborne Pathogens

Contact Us

 

The Bloodborne Pathogens Standard (29 CFR 1910.1030)

The Bloodborne Pathogens Standard was developed by OSHA to reduce or eliminate the occupational exposure to Bloodborne Pathogens or Other Potentially Infectious Materials in workers that may come in contact with blood or OPIM during the course of their regular job duties. In order to protect "at risk" employees, OSHA requires employers to take the following measures:

  1. Establish an Exposure Control Plan (ECP) and update it annually
  2. Implement the use of Universal Precautions
  3. Implement the use of Engineering Controls, Work Practice Controls, and Personal Protective Equipment (PPE)
  4. Provide the Hepatitis B vaccination at no cost to the employee
  5. Provide post-exposure evaluation and follow-up in case of exposure
  6. Use labels and signs to communicate hazards
  7. Provide proper containment and disposal of Regulated Medical Waste (RMW)
  8. Provide training to employees
  9. Maintain employee medical and training records

The above mentioned measures are an integral part of the Exposure Control Plan. In the following sections, we will review UVM's ECP and other important information.

 

Bloodborne Pathogens and Other Potentially Infectious Materials

Human blood may carry infectious microorganisms, or bloodborne pathogens, that can be transmitted to other humans causing disease. Some of these pathogens are:

- Hepatitis B Virus or HBV
- Hepatitis C Virus or HCV
- Human Immunodeficiency Virus or HIV
- Human T-lymphotropic Virus or HTLV
- Epstein-Barr Virus or EBV
- Human Papillomavirus or HPV
- Cytomegalovirus or CMV

Besides blood, there are Other Potentially Infectious Materials (OPIM) that can transmit diseases, including:

  1. Certain body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body flid that is visibly contaminated with blood, and all body fluids in situations in which 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. Primary cell cultures; 
  4. Established cell cultures that have not been tested for BBP or are of unknown origin;
  5. HIV-, HBV-, or HCV-containing cell or tissue cultures, organ cultures, culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV, HBV or HCV.

 

Universal Precautions 

The term Universal Precautions is described in the OSHA Bloodborne Pathogens Standard as an approach to infection control. Universal Precautions is the practice of treating human blood and OPIM as if they were infectious for BBPs, by using the appropriate engineering and work practice controls, as well as the required personal protective equipment, to reduce or eliminate occupational exposure to them.

 

UVM's Exposure Control Plan for Bloodborne Pathogens

Table of Contents

1. Policy

2. Program Administration and Responsibilities

3. Determination of Occupational Exposure Risk in UVM Personnel

4. Methods of Implementation and Control

A. The Exposure Control Plan
B. Universal Precautions
C. Engineering Controls
D. Administrative Controls
E. Personal Protective Equipment
F. Handwashing Facilities
G. Emergency Showers, Eyewashes, and Drench Hoses
H. Work Area Restrictions
I. Specimen Handling and Transport
J. Regulated Medical Waste Disposal
K. Needles and Other Sharps
L. Contaminated Equipment
M. Housekeeping
N. Laundering of PPE
O. Communication of Hazards (Labels & Signs) 

5. Training

6. Hepatitis B Vaccination

7. Emergency Response to an Exposure

8. Recordkeeping

A. Safety Training Records
B. Records Maintained for At-Risk Personnel
C. Sharps Injury Log

APPENDICES:

A. ECP Definitions

B. Hepatitis B Virus CDC Fact Sheet

C. Hepatitis C Virus CDC Fact Sheet

D. Human Immunodeficiency Virus CDC Basic Information

E. Hepatitis B Virus Pathogen Safety Data Sheet

F. Hepatitis C Virus Pathogen Safety Data Sheet

G. Human Immunodeficiency Virus Pathogen Safety Data Sheet

H. Risk Designation Form

I. Hepatitis B Vaccine Information Statement

J. Hepatitis B Vaccine Consent / Refusal Form

K. Injury & Incident Reporting

L. Evaluation of Sharps Container Performance Form

M. Safety Feature Evaluation Form for Safety Syringes

 

1. Policy

The University of Vermont has established a policy to protect employees, students, and affiliates from exposure to bloodborne pathogens and other potentially infectious materials during the course of their work and/or research training. UVM's Bloodborne Pathogens Policy mandates that all supervisors of "at risk" personnel and "at risk" personnel follow the Bloodborne Pathogens Exposure Control Plan. Questions about the ECP should be addressed to the supervisor or the Department of Risk Management & Safety (RM&S).

 

2. Program Administration and Responsibilities

A. Departments or Supervisors are responsible for:

1. Determining, in conjunction with RM&S, whether their personnel are "at risk" for exposure to BBP
2. Making the ECP available to "at risk" personnel
3. Implementing the ECP and ensuring compliance with it
4. Ensuring "at risk" employees complete UVM's BBP training annually
5. Providing "at risk" employees with training on the specific hazards encountered in the work/research place, and the controls used to minimize/eliminate the risk of exposure, that are required by the BBP Standard

6. Offering "at risk" personnel the Hepatitis B vaccination and documenting whether they receive it or decline it 
7. Maintaining all documentation required by OSHA for "at risk" personnel
8. Providing and maintaining all necessary safety controls (engineering controls, administrative controls, and personal protective equipment) to minimize/eliminate the risk of exposure

9. Filling and filing the Employer’s First Report of Injury (FROI) with assistance from exposed employees, or assisting students/affiliates fill and file the Incident Report Form no later than 72 hours post exposure
10. Ensuring that all required medical actions, including post-exposure evaluation and follow-up, take place 
in a timely manner

B. The Department of Risk Management and Safety (RM&S) is responsible for:

1. Determining, in conjunction with Departments or Supervisors, whether UVM personnel are "at risk" for exposure to BBP
2. Reviewing the ECP and Sharps Injury Log at least annually, or as needed, to reflect changes in procedures
3. Following up periodically with departments regarding suggestions for safer sharps
4. Providing, in conjunction with supervisors, annual BBP training, as well as:
    4a. Updating the BBP online training periodically
    4b. Providing customized classroom trainings, upon request, for issues pertaining to specific work   environments that are not covered by the general BBP online training

C. "At Risk" personnel are responsible for:

1. Reviewing and understanding the ECP
2. Completing the BBP training annually and all required trainings specific to their work environment and duties
3. Complying with the Methods of Implementation and Control

4. Accepting or declining the Hepatitis B vaccination

5. Reporting all exposure incidents to their supervisor and RM&S personnel, and seeking medical assistance, if necessary, as soon as possible

D. The Occupational Health Provider is responsible for:

1. Providing information about the Hepatitis B vaccine and administering the vaccination series and titer to UVM personnel who present a signed Risk Designation Form
2. Providing post-exposure evaluation and follow-up to exposed UVM personnel

 

3. Determination of Occupational Exposure Risk in UVM Personnel 

Any person who works, studies, or volunteers at UVM, and who may come in contact with blood or other potentially infectious materials during the course of their regular duties at UVM – regardless of the use of personal protective equipment – may be at risk for occupational exposure to BBP.
 
The "at risk" determination should be made by the responsible department or supervisor together with RM&S staff based on the expected level of risk inherent to the assigned work or research duties. "At risk" personnel shall comply with the BBP Standard and follow the procedures specified in this ECP.
 
 

4. Methods of Implementation and Control

A. The Exposure Control Plan

The Exposure Control Plan (ECP) is explained to "at risk" personnel during their initial and yearly BBP training. The ECP is reviewed annually by RM&S.
 

B. Universal Precautions

Universal Precautions must be used to prevent exposure to bloodborne pathogens and other infectious materials in the workplace. This is accomplished by :
 

- Treating blood and OPIM as if they were infectious
- Avoiding direct contact with blood and OPIM
- Utilizing the proper engineering and administrative controls, as well as the necessary PPE, to prevent exposure. 

C. Engineering Controls

Engineering controls constitute the first line of defense against exposure to infectious agents by removing the hazard or placing a barrier between the worker and the hazard. For more information, please visit our webpage on how to Identify and Control Hazards

D. Administrative Controls

Administrative controls are measures that reduce the risk of exposure to infectious agents by altering the manner in which a task or procedure is performed. For more information, please visit our webpage on how to Identify and Control Hazards

E. Personal Protective Equipment

Personal Protective Equipment (PPE) constitutes the last line of defense against exposure to infectious agents. PPE should be worn when the implementation of engineering and work practice controls is not sufficient to eliminate the risk of exposure. For more information regarding PPE, please visit our PPE webpage

F. Handwashing Facilities

Handwashing facilities should be available to personnel who are at risk for exposure to infectious materials. If there isn't any handwashing facility near the location where exposure may occur, supervisors must provide other alternatives such as antiseptic towelettes or an antiseptic cleanser and paper towels (or clean cloth/towel). In that case, the hands should be washed with soap and water as soon as possible. Supervisors should list the location of alternative cleansing stations and ensure that they are accessible and well maintained at all times.
 
G. Emergency Showers, Eyewashes, and Drench Hoses
 
Safety showers and eyewashes/drench hoses - or in their defect, a safety station with eyewash solution - should be available in buildings where infectious materials are being handled, such as research and teaching laboratories. Safety showers and eyewashes/drench hoses should be flushed, at a minimum, once a month to ensure proper functioning and prevent the growth of microorganisms. If water appears muddy, discolored or with debris, the equipment should be flushed more frequently. Flushings should be recorded in a flush log posted in a visible location near the flushed equipment. 
 
Eyewash stations consisting of an eyewash solution should be properly maintained, ensuring that the solution is not expired or contaminated.
 

H. Work Area Restrictions

In work areas where there is risk of exposure to infectious materials, personnel are not allowed to eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses. Food and beverages should not be stored in refrigerators, freezers, shelves, cabinets, countertops or bench tops, on in the same area where infectious materials are stored or are being handled.
 
All procedures and tasks should be conducted in a manner that minimizes splashing, spraying, splattering and generation of droplets of infectious materials. Mouth pipetting and handling of infectious materials with bare hands are strictly forbidden.
 

I. Specimen Handling and Transport

Blood and OPIM specimens will be placed in a secondary container before transporting them to labs on the same floor. When transporting the samples to a different floor or building, a tertiary container must also be used. The use of secondary and tertiary containment practices helps prevent leakages during the collection, handling, processing, storage, and transport of biological samples. The containers used for this purpose should be labeled with a biohazard label.
 

J. Regulated Medical Waste Disposal

Regulated Medical Waste (RMW) - also known as infectious or biohazardous waste - generated at UVM must be disposed of safely following the regulations of the Vermont Department of Environmental Conservation (DEC). Infectious waste must be identified as such, segregated from the normal solid waste stream, and treated accordingly. For procedures regarding the collection and disposal of biohazardous waste at UVM, please visit our Biowaste Management webpage
 
K. Needles and Other Sharps
 
Sharps are devices that can penetrate the skin including, but not limited to, needles, capillary tubes, scissors, scalpels, Pasteur and serological pipettes, pipette tips, pointed or edged plastic or glass, instruments, and broken glass.
Contaminated sharps and needles must not be recapped, removed, bent, sheared or broken. For additional information on how to collect and dispose of sharps at UVM, please visit our Biowaste Management webpage 
 
L. Contaminated Equipment, Instruments, Devices and Other Items
 
Equipment, instruments, devices and other items that become contaminated with infectious materials must be decontaminated as soon as possible. In addition, contaminated equipment must be decontaminated prior to servicing, shipping, or final disposal, unless it is not possible. Unless otherwise specified, decontamination should be performed using 10% bleach, allowing a minimum contact time of 30 minutes. Equipment that cannot be decontaminated, or that is regularly used in laboratories with infectious materials (for work, storage, or disposal), should be labeled with a biohazard sign.
 

M. Housekeeping

Good housekeeping is crucial for the prevention of exposure to infectious materials. Areas that become contaminated with infectious materials should be decontaminated as soon as possible. All infectious materials and contaminated sharps should be disposed of properly in biowaste boxes and sharps containers, respectively. Infectious materials should be properly labeled and stored in secondary containers. 
 

N. Laundering of PPE

Supervisors must arrange for laundering of reusable PPE worn by UVM personnel during the performance of their duties. PPE must be laundered either by vendors approved by RM&S or in departmental washers specifically used for that purpose. Please contact Safety@uvm.edu if you have questions about approved vendors. Washing of PPE at home is strictly forbidden.      

In order to prevent the spread of infectious agents while handling contaminated laundry, the following procedures should be used:

- Wear gloves, and additional clothing coverings as necessary, when handling and/or sorting contaminated laundry 
- Handle contaminated laundry as little as possible, with minimal agitation
- Place contaminated laundry in leak-proof containers lined with a red biohazard bag before transport.

O. Communication of Hazards (Labels & Signs)

Infectious materials must be labeled with an appropriately sized red or orange biohazard label that may be accompanied by the word "biohazard". All infectious materials that leave the workplace must be appropriately labeled. Laboratories in which blood or OPIM are used must have BSL-2 door signs posted on all entrances.
 
Only approved red biohazard bags will be used for the collection of biowaste in solid closable waste containers. Also, only approved sharps containers displaying the biohazard sign will be used for the collection of contaminated sharps. Supervisors will ensure that all measures regarding communication of hazards are followed by their personnel.
 
 

5. Training 

UVM personnel that may be at risk for occupational exposure to bloodborne pathogens or OPIM must receive initial and annual refresher BBP training. "BBP: Safety Around Bloodborne Pathogens" can be completed at: http://www.uvm.edu/safety/lab/safetytraining. In addition, supervisors must provide specific training regarding procedures and tasks that carry a risk for exposure to infectious agents particular to their work environment.
 
The following topics are covered in the Safety Around Bloodborne Pathogens training:
 

- The OSHA BBP Standard and how to obtain a copy
- The UVM ECP and how to obtain a copy
- The Hepatitis B vaccine, including its efficacy, safety, method of administration, benefits and contraindications, and that it will be provided free of charge
- The appropriate actions to take, and persons to contact, in an emergency involving blood or OPIM
- The procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that is available
- The post-exposure evaluation and follow-up that UVM is required to provide following an exposure incident
- The signs, labels, and color coding required by the OSHA BBP Standard and used at UVM
- The methods to recognize tasks and other activities that may involve exposure to blood and OPIM
- What constitutes an exposure incident

In addition to this training, supervisors must provide specific work related details including:
 

- An explanation of the use and limitations of engineering controls and administrative controls
- An explanation of the types, uses, location, handling, removal, decontamination and disposal of PPE. 

 

6. Hepatitis B Vaccination and Titer

Supervisors or RM&S will provide training to "at risk" personnel on the Hepatitis B vaccine as explained on section 5. The Hepatitis B vaccination series should be administered, as soon as possible, to personnel designated "at risk" who request the vaccine. Post-vaccination testing for antibodies to Hepatitis B surface antigen (anti-HBs) shows whether the vaccine elicited a sufficient immune response against HBV and is recommended by the CDC. The OSHA BBP standard requires that the CDC guidelines be followed. For these reasons, all UVM personnel receiving the HBV vaccine series to comply with the BBP standard should have a post-vaccination titer done within two months of the last Hepatitis B vaccine dose. Vaccination is highly recommended unless:
 
  1. The person has previously received the series and has a high antibody titer
  2. Antibody testing reveals that the person has developed immunity against the Hepatitis B virus
  3. A medical evaluation shows that vaccination is contraindicated.
 
"At risk" personnel must read the Hepatitis B Vaccine Information Statement and sign the Consent / Refusal Form, which will be kept on file in the workplace by the supervisor. Persons who decline vaccination may request and obtain the vaccine at a later date.
 
 

7. Emergency Response to an Exposure

In case of exposure to blood or other potentially infectious materials, you must act fast to prevent possible serious health problems. Follow these key steps after the exposure:

A. Seek First Aid and/or Medical Attention Immediately
  • Remove contaminated clothing.
  • Wash any area exposed to blood or OPIM with tepid water and soap for 15 minutes.
  • In case the exposed area has been injured, encourage bleeding if the wound is small, apply an antiseptic, and cover with sterile dressing.
  • Seek medical attention immediately; depending on the severity of exposure/injury, go to your occupational health provider or call UVM police (dial 911 or 6-3473) for assistance in proceeding to the emergency room. NEVER walk yourself to the ER if you are severely injured or sick.
 
B. Report the Exposure
  • Notify your supervisor of the exposure. He/she must complete, with your assistance, a First Report of Injury (if you are an employee) or an Incident Report Form (for non-employees) within 72 hours of the incident. For more details on incident reporting and to download the forms, please visit our Incident Reporting webpage.
  • Send the filled form to RM&S and keep a copy for your records.
 
C. Seek Post-Exposure Evaluation and Medical Follow-Up
  • Contact your occupational health provider within 24 hours of the exposure - the sooner, the better - to make an appointment for a post-exposure follow-up:
                  *  If you are a UVM employee, contact Concentra Health Care at: 802-658-5756
                  *  If you are a student, contact the Student Health Center at: 802-656-3350
  • Your occupational health provider will need to know the details of the exposure and your immunization status, including:
                  *  The source and route of exposure: e.g., contaminated needlestick.
                  *  Information about the potentially infectious material: e.g., department and name of patient it came from.
                  *  Your immunization status.
                  *  The nature of medical attention given in the first place.
  • A healthcare professional will:
                  *  Evaluate the exposure.
                  *  Determine if post-exposure prophylaxis should be administered.
                  *  Decide if any other tests or medication are necessary.
                  *  Send you a copy of your medical evaluation.
 
You may consult with your private physician instead of your occupational health provider. In that case, you should forward any medical information to RM&S to help resolve any Worker’s Compensation claim. 
 
In addition, RM&S will review the circumstances in which the exposure happened including:        
                  *  The location, date, and time of the exposure
                  *  The task that was being performed when the exposure occurred
                  *  The type of device or instrument used for the task
                  *  The PPE and/or engineering and work practice controls used
                  *  The safety training records of the exposed person

 

8. Recordkeeping

A. Safety Training Records

Safety training records are documented and managed by both RM&S in an online database and by the individual supervisors. In laboratories, the safety training records are kept in the Laboratory Safety Notebook. Training records include: 

  • The name, description, and date of the training sessions
  • The names of persons conducting the trainings
  • The names and job titles of all persons attending the training sessions.

 

B. Records Maintained for At-Risk Personnel

The following records should be kept on file for at-risk personnel: 

  • The Risk Designation Form
  • The Hepatitis B Vaccination Consent/Dissent Form
  • Medical records documenting receipt of all three shots for those persons who were vaccinated, if available
  • Medical records documenting that the vaccinated person has had an antibody titer performed after the vaccination series, if they were vaccinated in or after 1999, if available
  • Medical records for persons exposed to blood or OPIM during the performance of their duties at UVM, in accordance with 29 CFR 1910.1020
  • Documentation of training provided by the supervisor and of safety training provided by RM&S

     

    C. Sharps Injury Log

    In addition to the 29 CFR 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps should also be recorded in a Sharps Injury Log that is maintained by RM&S and reviewed at least annually.

    The details of all exposure incidents must be recorded, including:

    • The date of the incident
    • The type and brand of the device involved, if available
    • The department or work area where the incident occurred
    • An explanation of how the incident occurred
    • Follow-up measures to help prevent reoccurrence

     

    Contact Us

    If you have any questions or concerns, please do not hesitate to contact Environmental Health & Safety at 656-5400 or: Safety@uvm.edu

    Last updated: October 2013