Bloodborne Pathogens and Exposure Control Plan
Bloodborne Pathogens Program Summary
This program provides safety policies for the protection of Virginia Tech employees who have a potential for occupational exposure to human blood or other unfixed fluids or tissue that may contain bloodborne pathogens (BBP), such as Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV), and Hepatitis C Virus (HCV), among others. For more information, refer to the OSHA BBP Standard.
The Virginia Tech Environmental Health & Safety Bloodborne Pathogens Program (BPP) applies to employees with occupational exposure to other peoples' body fluids. These at-risk job duties include:
- Emergency response;
- First aid;
- Housekeeping;
- Plumbing;
- Regulated medical waste operations;
- Lab work with human body fluids;
- Phlebotomy;
- Medical/clinical work; and
- Research with human cell lines, or unfixed tissues and fluids.
If you can reasonably anticipate contact or being at risk of contact with human blood or other potentially infectious materials (including human cell lines/cultures) as a result of performing your research laboratory duties, the Bloodborne Pathogens Standard applies to you, and requires you to take bloodborne pathogens training through Virginia Tech Environmental Health & Safety.
Click here to learn about OSHA standards.
Each department that has employees who are at risk for occupational exposure to bloodborne pathogens must comply with the requirements of this program. Departments must develop work practices and procedures as outlined in this program, assure 'at risk' employees are provided access to training and vaccinations prior to hazard exposure, provide necessary personal protective equipment, and provide ongoing oversight to assure compliance is being maintained.
- OSHA Bloodborne Pathogens Standard 29 CFR 1919.1030 is a federal law prescribing certain prevention and response measures that employers must provide to protect at-risk workers from potential exposures to bloodborne pathogens.
- The standard is designed primarily for the health care industry, but also must be applied to other occupations in which workers are at risk of exposure to human blood and other potentially infectious materials.
- A key prevention measure required by OSHA is bloodborne pathogens training for at-risk workers.
Bloodborne Pathogens Exposure Control Plan Online Program
Purpose
- To provide safety policies for the protection of Virginia Tech employees who have a potential for occupational exposure to bloodborne pathogens, such as Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV), and Hepatitis C Virus (HCV), among others.
- To comply with the Occupational Safety and Health Administration regulation: 29 CFR 1910.1030, "Blood Borne Pathogens."
- To establish a program that provides Virginia Tech employees with the following services:
- Pertinent information;
- Training on safe work practices, engineering controls, and university policies related to occupational exposure;
- An offer of free Hepatitis B vaccination; and
- Infection prevention services following an exposure incident.
Scope
The Bloodborne Pathogens Program is designed to provide service to employees with occupational exposure to other peoples' body fluids. These at-risk job duties include:
- Emergency response;
- First aid;
- Housekeeping;
- Plumbing;
- Regulated medical waste operations;
- Lab work with human body fluids;
- Phlebotomy;
- Medical/clinical work; and/or
- Research with human bloodborne microorganisms.
Application
The Exposure Control Plan (ECP), developed by Virginia Tech Environmental, Health & Safety, is intended for distribution university-wide. Each department having employees at risk shall contribute specific policies and procedures to this plan. Departmental-specific materials shall be inserted in the document where required. This plan describes engineering controls, work practices, and personal protective equipment that, when used correctly, reduces on-the-job exposure to human blood and other infectious body fluids. Also described are the university's training, vaccination, and incident reporting programs.
Departments
Each department that has employees at risk of occupational exposure to bloodborne pathogens has the following compliance responsibilities and functions.
- Assigning accountability to implementation coordinators and/or supervisory personnel. Supervisors of employees with occupational exposure to blood and body fluids should have this responsibility listed in their P-112s, the personnel performance plan, and evaluation forms.
- Circulating exposure control plans after receiving from Environmental Health & Safety.
- Funding and providing personal protective equipment, as needed.
- Notifying Environmental Health & Safety before establishing research endeavors involving human pathogenic agents.
- Notifying Environmental Health & Safety of employee turnover.
- Contacting Environmental Health & Safety to enroll new hires in the program, within 2 days of the date of hire.
- Ensuring that new hires do not engage in activities with potential exposure until they have had the introductory training.
- Encouraging full participation of all at-risk employees, to include:
- Allowing attendance at training sessions, during normal work hours;
- Requiring 'at risk' employees to review the exposure control plan; and/or
- Requiring employees to follow safe work practices.
- The following departments have been identified by Environmental Health & Safety as having at-risk employees:
- Animal Resources and Care Division;
- Athletics;
- Biochemistry;
- CEC housekeeping;
- Chemistry (Peters Center);
- Division of Campus Planning, Infrastructure, and Facilities housekeeping and building services teams;
- Virginia-Maryland College of Veterinary Medicine;
- Electrical and Computer Science Engineering;
- Environmental, Health & Safety
- Family & Child Development;
- Human Nutrition, Foods, and Exercise;
- Mechanical Engineering;
- Police;
- Rescue Squad;
- Residential Programs housekeeping; and
- Student Health Services
Note, however, that the above list is not exhaustive. If at-risk employees are identified in your department that is not already enrolled in the Bloodborne Pathogens Program, please contact Environmental Health & Safety immediately at 540-231-4034 or sowen@vt.edu.
Implementation coordinators
Each department with at-risk employees should appoint an implementation coordinator. This individual will be responsible for ensuring that the Exposure Control Plan is complete and accessible. Completion of the plan involves inserting department-specific policies and procedures where indicated. Accessibility means that all at-risk employees shall be informed of the location of the departmental Exposure Control Plan and shall be encouraged to read its contents.
In the absence of an appointed implementation coordinator, these duties will fall to supervisors of at-risk employees.
Summary of responsibilities:
- Receiving the university Exposure Control Plan;
- Completing department-specific sections of the Exposure Control Plan;
- Storing the Exposure Control Plan in an accessible location;
- Communicating the Exposure Control Plan location to all at-risk employees;
- Reviewing and updating department-specific sections annually, or earlier if work processes change; and
- Conducting annual review sessions with employees.
Supervisors
Virginia Tech employees who supervise at-risk employees have certain responsibilities under this plan. They are to act as implementation coordinators in departments where no one has been assigned to that role. Also, they need to ensure that newly hired employees receive the introductory training and must allow employees to receive the vaccinations during normal work hours. Supervisors also need to secure personal protective equipment, such as gloves, for employees. Also, supervisors need to be familiar with reporting requirements in the event of an exposure incident.
In summary, supervisors:
- Call Environmental Health & Safety when new employees are hired (within 2 days);
- Allow employees to receive vaccinations during normal work hours;
- Provide gloves and other protective equipment to employees; and
- Report exposure incidents to Environmental Health & Safety and assist with report paperwork.
At-risk employees
Every employee that can reasonably anticipate exposure to blood or other potentially infectious materials during their normal job duties has certain compliance responsibilities.
Responsibilities under this plan:
- Attending training sessions;
- Complying with procedures outlined in this plan;
- Adhering to universal precautions; and
- Reporting exposure incidents to supervisors and Environmental Health & Safety.
Environmental Health & Safety
Environmental Health & Safety is responsible for coordinating the following program elements.
- Identification of at-risk employees;
- Conducting introductory training classes;
- Conducting annual refresher classes for supervisors;
- Maintaining records of training and vaccination for all program participants;
- Funding the Hepatitis B vaccinations for at-risk employees;
- Providing post-exposure follow-up, to include recordkeeping and infection prophylactic services;
- Creating, distributing, and revising (as regulations/recommendations change) the university-wide Exposure Control Plan;
- Operating a Regulated Medical Waste Disposal Program, in compliance with state Department of Environmental Quality regulations; and
- Oversight of departmental compliance.
Contractors
Contractors must follow procedures outlined in Virginia Tech's Contractor Safety Program.
Certain procedures must be followed and tools must be used to keep employees safe from exposure to infectious diseases found in blood, such as Hepatitis B Virus, Human Immunodeficiency Virus, and Hepatitis C Virus. These are explained in detail in the following sections. Here is a list of the general topic headings:
Universal precautions is a term that means a certain mindset or attitude toward other peoples' blood or body fluids. If all at-risk employees adopt this way of thinking, chances are good that they will consistently act in a safe manner when working with human body fluids.
This new attitude can be summarized as follows:
- Assume that ALL blood is positive for HIV, HBV, and HCV;
- Assume that ALL other human fluids/tissues are also positive;
- When it's difficult to differentiate, treat ALL fluids as potentially infectious;
- Assume that ALL individuals are carrying these disease organisms;
- Avoid skin contact with blood and other potentially infectious materials;
- Avoid eye, nose, and mouth contact with blood and other potentially infectious materials; and
- Avoid punctures/sticks with contaminated sharp objects.
Engineering controls are devices and tools that prevent exposure to health hazards. These sorts of safety controls shall be used, in conjunction with work practice controls, to eliminate or minimize employee exposure. These controls are extremely important, as they are the best methods of preventing exposure.
These devices/equipment must be inspected and maintained on a regular basis by the implementation coordinator or designee. Worn parts and equipment must be replaced as soon as indicated through the inspection process.
Here are some common engineering controls used to protect employees from bloodborne pathogens:
Handwashing facilities
Each department shall provide readily accessible handwashing facilities. This means that there must be a facility to supply adequate running water, soap, and single-use towels or hot-air drying machines.
Alternate handwashing devices
When running water handwashing facilities is not feasible, the department shall provide either an appropriate antiseptic hand cleanser with clean cloth/paper towels OR antiseptic towelettes.
Needle safety devices
Departments using medical sharps must make all reasonable attempts to implement the use of these safety devices, instead of traditional sharps. There are many new products on the market that are designed to prevent needle-stick injuries.
Here are some examples:
- Needle-less connectors for IV delivery systems (e.g., a blunt cannula for use with pre-pierced ports and valved connectors that accept tapered or luer ends of IV tubing);
- Protected needle IV connectors (e.g., the IV connector needle is permanently recessed in a rigid plastic housing that fits over IV ports);
- Needles that retract into a syringe or vacuum tube holder;
- Hinged or sliding shields attached to phlebotomy needles, winged-steel needles, and blood gas needles;
- Protective encasements to receive an IV stylet as it is withdrawn from the catheter;
- Sliding needle shields attached to disposable syringes and vacuum tube holders;
- Self-blunting phlebotomy and winged-steel needles (a blunt cannula seated inside the phlebotomy needle is advanced beyond the needle tip before the needle is withdrawn from the vein); and/or
- Retractable finger/heel-stick lancets.
Desirable features in needle safety devices:
- The device is needleless;
- The safety feature is an integral part of the device;
- The device preferably works passively (requires no activation by user);
- The user can easily tell whether the safety feature is activated;
- The safety feature cannot be deactivated and remains protective through disposal; and
- The device is easy to use and practical.
Sharps containers
Proper containers for the storage of contaminated sharps must be provided by the departments. These containers must meet the following description:
- Puncture resistant;
- Closeable;
- Leakproof; and
- Labeled (Biohazard) or color-coded (orange/red).
Splash guards
Laboratory equipment that can potentially vaporize or splash blood should be equipped with a splash guard or similar protective device.
Resuscitation masks
Resuscitation masks must be made available to all first responders. These devices prevent fluid exchange during the administration of CPR.
Biosafety cabinets
Biosafety cabinets are used in biological laboratories across campus whenever the possibility of exposure to airborne pathogens is present.
Download the Department-Specific Information Sheet for Engineering Controls (doc | PDF).
Work practice controls are procedures that employees need to follow in order to keep themselves safe. These required procedures are to be followed by all at-risk employees and must be enforced by all departments.
Hand/skin washing
It is extremely important that all at-risk employees follow strict hand/skin washing procedures at the following times:
- After removing gloves or other personal protective equipment and
- Following contact with blood or other potentially infectious fluid.
Hands and other skin areas must be washed with soap and water OR antiseptic cleanser (in the absence of water). Mucous membranes must be flushed with copious amounts of water (at least 15 minutes of flushing).
When an antiseptic cleanser or towelette is used, washing with water and soap should follow as soon as possible.
Sharps handling
Whenever a needle or other sharp device is exposed, injuries can occur. Data shows that approximately 38 percent of percutaneous injuries occur during use and 42 percent occur after use and before disposal.
In addition to risks related to device characteristics, needlestick injuries have been related to certain work practices such as:
- Recapping;
- Transferring a body fluid between containers; and
- Failing to properly dispose of used needles in puncture-resistant sharps containers.
If recapping cannot be avoided, it must be accomplished through the use of a mechanical device, such as forceps. Also, the one-hand scoop method is allowed, if done safely.
Minimizing splashing
All procedures involving blood or other potentially infectious materials must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets.
Avoiding ingestion
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are strictly prohibited in work areas where there is a reasonable likelihood of occupational exposure. This, however, does not apply to hand cream.
- Food and drink shall not be kept where blood or other potentially infectious materials are present.
- Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
Dealing with contaminated equipment
The following procedures must be followed when having potentially contaminated equipment serviced:
- Look for evidence of contamination.
- Decontaminate if necessary and feasible.
- If NOT feasible, label equipment with BIOHAZARD label.
- Include on the label which parts are contaminated.
- Convey information to affected employees and servicing representatives prior to shipping, so that precautions can be taken.
Download the Department-Specific Information Sheet for Engineering Controls (doc | PDF).
General
Where occupational exposure remains after the implementation of engineering and work practice controls, personal protective equipment (PPE) must also be used.
Departments shall provide, at no cost to the employee, appropriate PPE including, but not limited to:
- Gloves;
- Gowns;
- Lab coats;
- Face shields;
- Masks;
- Eye protection;
- Mouthpieces;
- Resuscitation bags;
- Pocket masks; and/or
- Mechanical respiratory devices.
PPE is considered appropriate if it is needed for, and is capable of, preventing blood or other fluids from passing through to the employee's clothing, skin or mucous membranes. Departments must complete a formal PPE hazard assessment to determine and document what PPE must be provided and used for hazard exposures.
Departments must ensure proper use, accessibility, cleaning, disposal, repair and replacement of PPE.
Employees must remove PPE before leaving the work area or whenever the PPE has become saturated with blood or other potentially infectious materials. Used PPE must be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
Gloves
Gloves must be worn when it can be reasonably anticipated that the employee may have hand contact with:
- Blood;
- Other potentially infectious materials;
- Mucous membranes; and
- Non-intact skin.
Or when:
- Performing vascular access procedures and
- and when handling contaminated surfaces.
Guidelines for glove use
| GLOVE TYPE: | WASHABLE? | DECONTAMINATE? | WHEN TO DISCARD: |
| Disposable | NO | NO | Torn, punctured, contaminated |
| Utility | YES | YES | cracked, peeling, torn, punctured, deteriorating |
Face and eye protection
Masks, goggles, glasses, and face shields are to be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
Body protection
Gowns, aprons, lab coats, clinic jackets, and other protective body clothing are to be worn in occupational exposure situations when appropriate. The type and characteristics of the PPE will depend upon the task and degree of exposure anticipated.
All worksites are to be maintained in clean and sanitary conditions at all times. To meet the OSHA regulatory requirements, each work area covered by this program must establish a written cleaning schedule. All such schedules should be included in this manual, following this section.
How?
Following is a table of Cleaning/Reprocessing methods recommended by the Centers for Disease Control (CDC). Decontamination methods can be selected according to that information.
When?
Decontamination/cleaning of surfaces and equipment must be performed at the following times:
- At the frequency determined in the written schedule;
- Following a contamination incident;
- Following routine procedures that may cause contamination; and
- At the end of work shifts, if contamination may have occurred since the last cleaning.
What?
The following are surfaces that are likely to need decontamination:
- Lab equipment;
- Bench/countertops;
- Receptacles intended for reuse, that may store bloody material; and
- Environmental surfaces: Large areas, such as ambulance interiors, entire lab rooms, etc.
Other notes on housekeeping
- Protective coverings must be removed and replaced as soon as feasible when they become obviously contaminated or at the end of the work shift if they may have become contaminated during that shift. Coverings include:
- Plastic wrap;
- Aluminum foil; and
- Imperviously-backed absorbent paper.
- Broken glass must not be picked up directly with the hands. It shall be cleaned up mechanically. Use a brush and dustpan, tongs, or forceps.
- Employees must never reach their hands into containers of contaminated sharps.
Cleaning/decontamination methods
| Sterilization | Destroys: | All forms of microbial life, including high numbers of bacterial spores |
| Methods: | Steam under pressure (autoclave) Gas (ethylene oxide) Immersion in EPA-approved chemical for prolonged period (e.g.6-10 hours) or according to manufacturer instructions |
|
| Use: | Instruments used to penetrate skin or to contact sterile body parts | |
| High-level Disinfection | Destroys: | All forms of microbial life EXCEPT high numbers of bacterial spores |
| Methods: | Hot water pasteurization (80-100°C, 30 min) Exposure to EPA-approved chemical "sterilant" for 10-45 min or as direct. |
|
| Use: | Reusable instruments or devices that come in contact with mucous membranes | |
| Intermediate-Level Disinfection | Destroys: | Mycobacteruim tuberculosis Vegetative bacteria Most viruses Most fungi DOES NOT kill bacterial spores |
| Methods: | EPA-registered "hospital disinfectant" chemical germicides that label a claim for tuberculoid activity Commercially available chemicals that contain at least 500ppm free available chlorine (a 1:100 dilution of bleach) (1/4 cup bleach per gallon tap water) |
|
| Use: | Surfaces that contact skin AND have been contaminated with blood or fluids. (surfaces must be wiped off prior to using above germicides) |
|
| Low-level Disinfection | Destroys: | Most bacteria Some viruses Some fungi NOT Mycobacterium tuberculosis or spores |
| Methods: | EPA-registered "hospital disinfectant" without label claim of tuberculoid activity. |
|
| Use: | These agents are excellent cleaners and can be used for routine housekeeping in "at risk" work |
Handling
- Contaminated laundry must be handled as little as possible.
- Employees that have contact with contaminated laundry must wear protective gloves and other appropriate personal protective equipment.
- Employees are not to take contaminated clothing home for laundering. The department must arrange to have an approved Laundry Service collect and clean these items or provide access to laundering equipment in the work area.
- Please contact Environmental Health & Safety for assistance if needed at 540-231-4034 or sowen@vt.edu.
Storage
- Contaminated laundry must be bagged or contained at the location where it was used and must not be sorted or rinsed in the location of use.
- Proper containers are as follows:
- Labeled with the Biohazard symbol, or color-coded fluorescent orange or orange-red and
- Capable of preventing soak-through, if laundry is wet and presents a reasonable likelihood of leakage to the exterior of the container.
Transportation
- Contaminated laundry must be transported in proper containers, as described above.
- Laundry personnel must use Universal Precautions when handling ALL laundry.
Labels
What is a proper label?
A sticker or placard that contains:
- The word BIOHAZARD;
- The biohazard symbol;
- Anything color-coded:
- Fluorescent orange
- Orange-red
- Containers of regulated waste;
- Refrigerators/freezers containing blood or other potentially infectious materials;
- Containers used to store or transport the above-mentioned fluids; and
- Equipment that cannot be decontaminated (location of contamination must be written on label).
Signs
Departments must post signs at the entrance to HIV/HBV research laboratories. These signs must be color-coded and contain the following information:
- Name of infectious agent;
- Special requirements for entering the area; and
- Name, phone number of responsible person.
For a list of upcoming classes, click here.
Is training mandatory? If so, when?
Yes, Per 29 CFR 1910.1030, “Bloodborne Pathogens”, anyone with potential for occupational exposure to human blood, tissue, body fluids or other potentially infectious material (OPIM) of human origin must attend bloodborne pathogens training yearly. New employees should be enrolled in a bloodborne pathogens class within 10 days of their start date or they should not be exposed to any tasks or situations that would pose a risk for exposure to human blood, tissue, fluid, or OPIM of human origin until after they have attended bloodborne pathogens training.
What is the length of the class?
1 hour.
Is the training available online?
Only through BSRL for researchers, all other employees must register for classroom or Zoom sessions.
When is refresher training required?
Annually.
Please see the online class schedule for more information.
How do I sign an employee up for a class? How do I sign up for a class?
Visit the Environmental Health & Safety training website to learn about available classes and to register for the appropriate class.
How do I organize a large group training?
Refresher training for large workgroups can be arranged at the convenience of the group. Contact Sarah Owen at sowen@vt.edu to work out a day, time, and location for the training.
Environmental Health & Safety training responsibilities
Environmental Health & Safety administers the university-wide training and information program as described below. All trainers are familiar with the OSHA Standard and its application to the university work environment. The credentials of the trainers are on file in the Environmental Health & Safety office.
Environmental Health & Safety has the following training responsibilities:
- Development of written Exposure Control Plan for distribution to all affected university departments;
- Provide introductory training sessions that cover:
- The OSHA Standard;
- Pathogen Transmission and epidemiology;
- Exposure Control Plan requirements and policies; and
- The Hepatitis B Vaccination Program.
Department training responsibilities
Departments must appoint an implementation coordinator to ensure that department-specific training is performed annually or as needed, on the following subjects:
- New tasks that present occupational exposure;
- Department-specific sections of the Exposure Control Plan;
- Available engineering controls;
- Required work practice controls; and
- Location and use of personal protective equipment.
All training must be conducted during normal working hours, at times convenient to employees.
Purpose
- To provide an offer of Hepatitis B Vaccination to all Virginia Tech employees who have occupational exposure;
- To provide testing, evaluation, and counseling to employees who have exposure incidents; and
- To document employee vaccinations and declinations.
General
- All medical services will be provided at NO COST to the employee.
- The university will provide, through Environmental Health & Safety, all approved services.
- All medical services will be made available at a reasonable time and place.
How to receive the vaccination series
- Employees must attend an introductory training session prior to receiving the vaccinations.
- All vaccinations will be arranged through Environmental Health & Safety. Please call 540-231-4034 or email sowen@vt.edu to arrange needed vaccinations and training.
- The series involves three separate injections, spaced at one and six-month intervals.
- Employees may choose to decline the vaccinations and must sign a copy of the Declination Form. Declinations might be made for medical or personal reasons, or because the employee has already been vaccinated. If an employee declines the vaccination, but at a later date decides to accept, the university, through Environmental Health & Safety, shall make the series available at that time provided he or she is an at risk employee.
- At the time of preparation of this manual, the U.S. Public Health Service did not recommend a routine booster for Hepatitis B. If the recommendation status should change, then the university, through Environmental Health & Safety, shall provide that service to all employees.
- For more information on the vaccination, please visit http://www.cdc.gov/ncidod/diseases/hepatitis/b/factvax.html.
Following an exposure incident, Environmental Health & Safety will immediately arrange a confidential medical evaluation and follow-up. Environmental Health & Safety follows all Centers for Disease Control (CDC) recommendations for follow-up after occupational exposure to Hepatitis B, Hepatitis C, and HIV. Post-exposure services include:
- Documenting the route(s) of exposure, and the circumstances under which the exposure incident occurred;
- Identifying and documenting the source individual, unless it is infeasible or prohibited by law to do so;
- Testing the source individual's blood to determine HBV and HIV infectivity, if unknown. Consent of the source individual must be obtained prior to testing;
- Collecting and testing of the exposed employee's blood to determine serological status for HBV, HCV, and HIV. This collection should be accomplished as soon as possible after exposure;
- Administering of post-exposure prophylaxis, when medically indicated and as recommended by the U.S. Public Health Service;
- Counseling;
- Evaluating reported illnesses; and
- Conducting follow-up testing of exposed employee's blood.
Steps to take following an exposure incident
- Immediately inform your direct supervisor;
- Wash the injured area thoroughly;
- If you are an employee, complete the Employers Accident Report: Employers Accident Report;
- If you are an employee, Contact Juliet Dadras, Environmental Health & Safety Occupational Health nurse, at 540-230-3998 or mjdadras@vt.edu. After normal work hours, contact the Virginia Tech Police Department at 540-231-6411 and request they contact the on-call Environmental Health & Safety representative. Students who have a potential exposure should consult with their primary care physician immediately;
- Complete the Exposure Incident Report Form and return it to Environmental Health & Safety; and
- Employees will be provided instructions by Environmental Health & Safety regarding the Occupational Health physician's recommended testing and treatment.
Environmental Health & Safety division shall maintain records on each Virginia Tech employee with occupational exposure. Records will be maintained for the duration of the individual's employment at Virginia Tech, plus 30 years.
Employee written consent shall be necessary prior to the release of any information therein. However, records will be made available to representatives of OSHA, the U.S. Department of Labor and Industry upon inspection request.
Information maintained by Environmental Health & Safety includes:
- Name of the employee;
- Social security number of the employee;
- A copy of the employee's Hepatitis records, including:
- Vaccination Records
- Titer Results (if available)
- Declination forms
- Attachments to declination forms
- Exposure incident report and physician's written opinion forms, if applicable;
- Copies of evaluation and testing results associated with an exposure incident; and
- Training records.
AIDS: Acquired Immune Deficiency Syndrome. The disease results when the HIV virus attacks the human immune system.
Blood: Human blood, human blood components, and products made from human blood.
Bloodborne pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to:
- Hepatitis B Virus (HBV)
- Human Immunodeficiency Virus (HIV)
- Hepatitis C Virus (HCV)
- Human T-Lymphotrophic Virus Type 1
- malaria
- Syphilis
- Babesiosis
- Brucellosis
- Leptospirosis
- Arboviral Infections
- Relapsing Fever
- Creutzfeldz-Jakob Disease
- Viral Hemorrhagic Fever
Clinical laboratory: A workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.
Contaminated sharps: Any blood-contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, and exposed ends of dental wires.
Decontamination: See chart in Housekeeping section for detailed definitions.
Engineering controls: Equipment or devices that isolate or remove the bloodborne pathogens hazard from the workplace. Examples include sharps disposal containers, self-sheathing needles, equipment slash guards, biosafety cabinets, etc.
Exposure incident: A specific incident in which blood or other potentially infectious material contacts the employee in one of the following ways:
- Eye;
- Mouth;
- Other mucous membranes;
- Non-intact skin surface; and/or
- Puncture/stick/cut with a sharp contaminated object.
HBV: Hepatitis B Virus, a bloodborne pathogen that may cause inflammation of the liver.
HIV: Human Immunodeficiency Virus, a bloodborne pathogen that attacks the immune system and ultimately causes AIDS.
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):
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 fluid mixed with blood; and/or
- Any unknown body fluid.
The following human tissues:
- Any unfixed tissue;
- Any unfixed organ (other than intact skin).
The following research media:
- HIV-containing cell culture;
- HIV-containing tissue/organ culture;
- HIV- & HBV- containing culture media; and/or
- Infected research animal tissue.
Regulated medical waste: A waste stream that is regulated by the Department of Environmental Quality and must be disposed of through EHS, even if it has been autoclaved or treated with another form of decontamination. The particulars of the waste stream are:
- Cultures and stock of microorganisms and biologicals. Discarded cultures, stocks, specimens, vaccines, and associated items likely to contain organisms likely to be pathogenic to healthy humans.
- Blood and blood products. Wastes consist of human blood, human blood products, and items contaminated by human blood.
- Human tissues and other anatomical wastes. All human anatomical wastes and all wastes that are human tissues, organs, body parts, or body fluids.
- Sharps. It is university protocol to include all sharps in the regulated medical waste stream. That is ALL hollow-bore needles, pipettes, and glassware from biological labs or medical settings.
- Some animal carcasses, body parts, bedding, and related wastes. Animal carcasses, body parts, bedding, and related wastes if the animal has been intentionally infected with pathogenic organisms and is likely to be contaminated.
Regulated medical waste EXEMPTIONS: The following waste streams are not subject to the requirements of regulated medical waste regulations when dispersed among other solid wastes and not accumulated separately:
- Used products for personal hygiene, such as diapers, facial tissues, and sanitary napkins.
- Material, not including sharps, containing small amounts of blood or body fluids, but containing no free-flowing or unabsorbed liquid (Band-Aids).
Universal precautions: An approach to infection control, where ALL body fluids and individuals are treated as known positives for HIV and HBV.
Work practice controls: Procedures that reduce the likelihood of exposure through the manner in which tasks are performed.
- Emergency response: First responders, first aid providers;
- Health services personnel;
- Athletic trainers and sports support staff;
- Spill response/housekeeping/custodial personnel;
- Dining Services personnel;
- Facilities/utilities repair and maintenance personnel;
- Police and security officers;
- Waste management personnel and regulated medical waste operators;
- Lab workers who handle certain biohazardous materials, human body fluids, human bloodborne microorganisms; and/or
- Medical/clinical work.
- If your work situation could place you into contact, or potential contact with one or more of the biohazardous materials listed below, you are considered at risk for bloodborne pathogens exposure:
- Human blood/blood products blood components;
- Human or NHP tissue cell cultures (primary or established lines);
- Unfixed tissue or organs from humans, living or dead;
- Other potentially infectious materials of human origin: sexual fluids, cerebrospinal fluid, organ fluids, joint fluids, amniotic fluid, saliva (from dental procedures), or any body fluid containing visible blood;
- HIV or HBV-containing cell or tissue cultures, culture medium or other solutions; and/or
- Blood, organs, other tissues, or cell lines from experimental animals infected with HIV or HBV.
- Practices that increase your exposure risk include:
- Use of needles with no safety devices;
- Using needles preferentially over alternative, safer means;
- Careless handling and disposal of sharps (e.g., needles, broken glass, scalpels, blades, etc.);
- Failing to use splash guards, face shields, safety glasses, disposable gloves, or lab coats in situations that require them for protection;
- Failing to use containment equipment;
- Failing to wash hands;
- Failing to properly decontaminate surfaces and lab equipment;
- Failing to properly decontaminate and dispose of hazardous waste;
- Failing to follow universal precautions; and/or
- Creating aerosols while cleaning spills, cleaning bathrooms or unclogging drains.
- When contact occurs between blood, tissue, or other materials of human origin that are potentially infectious AND
- An injury site on your body (such as a needlestick);
- Your mucous membranes (eyes, nasal passages, mouth); or
- A non-intact skin surface (such as exposed skin that is chapped, abraded, etc.).
- Remove PPE and provide immediate care to the exposed site by washing wounds and skin with soap and water for 15 minutes, or flush eyes/mucous membranes with fresh water for 15 minutes.
- Call 911 if a serious injury has occurred; administer first aid as needed.
- Inform your direct supervisor about the incident immediately, even if it is only a potential exposure.
- Visit a medical provider or an emergency department for evaluation within 1-2 hours of the incident. Inform the medical provider about the specific material to which you have been (or may have been) exposed.
- Complete the Employers Accident Report.
- Contact Environmental Health & Safety at 540-231-3600 during regular business hours; call 911 after hours.
- Complete Exposure Incident Report and return to Environmental Health & Safety.
- Receive instructions regarding the Occupational Health physician's recommended testing and treatment.
Each department that has employees who are at risk for occupational exposure to bloodborne pathogens must comply with the requirements of this program. Departments must develop work practices and procedures as outlined in this program, assure at-risk employees are provided access to training and vaccinations prior to hazard exposure, provide necessary personal protective equipment, and provide ongoing oversight to assure compliance is being maintained.