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Purpose: The University has developed these guidelines to limit the occupational exposure to human blood or other potentially infectious materials since any exposure could result in the transmission of Bloodborne pathogens, which could lead to disease or death.
Authority: Bloodborne Pathogens Final Standard: CFR 29 1910.1030
Scope: These mandatory guidelines cover all University employees (faculty, staff, OPS staff, OPS student, and volunteers) who, as a condition of their employment, can be expected to come in contact with blood or other infectious materials. Examples of these employees within the University may include laboratory workers handling human blood or blood products, employees with CPR/First Aid duties as a condition of their employment, and individuals who handle bio-hazardous or medical wastes.
General Implementation: Each department with employees covered by these guidelines shall develop a written "Exposure Control Plan" detailing infection control methods, personal protective equipment, specialized equipment and materials needed.
The Exposure Control Plan shall cover the specific needs of each type of exposure potential, as outlined in this document. Forward a copy of the plan and any subsequent revisions to Environmental Health and Safety for review, and approval.
Determination and Documentation of Exposure: Maintain an updated list of each employee, job classification, and procedures/tasks where exposure may occur, regardless of frequency.
Bloodborne Pathogens are 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), hepatitis C virus, and human immunodeficiency virus (HIV).
Decontamination is the use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.
Engineering Controls are those controls (e.g. sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.
An Exposure Incident is 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 means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.
Other Potentially Infectious Materials (OPIM) are materials other than human blood are potentially infectious for bloodborne pathogens. These include 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 that is visibly contaminated with blood, and 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 or HBV-containing cell or tissue cultures, organ cultures, culture medium or other solutions; and 4) blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, or abrasions.
Personal Protective Equipment is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g. uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.
Sharps with Engineered Sharps Injury Protections:A non-needle sharp or needle device used for withdrawing body fluids, accessing a vein or artery, or administrating medications or other fluids, with a built-in safety or mechanism that effectively reduces the risk of an exposure incident.
Universal Precautions are an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Work Practice Controls are those practices that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles).
Methods of Compliance:
All workers shall follow Universal Precautions (treat all body fluids/materials as if known to be infectious), follow Good Standard Laboratory Practices, such as hand washing, and use available engineering controls (sharps disposal, biosafety cabinets and special waste containment). A Biosafety Checklist, such as Attachment C, may be used to assist in compliance efforts.
Personal Protective Equipment:
Each department shall provide the personal protective equipment (PPE) necessary for safe handling of biohazards, and provide employees training in the use and care of the equipment. Departments shall provide PPE without cost to employees. PPE may include, but is not limited to, impervious gloves, safety glasses, lab coats, disposable plastic aprons, antibacterial hand soap, disinfectant solutions, mouthpieces, and resuscitation bags.
Hepatitis B Vaccinations: Employees in positions with the potential for contact with human blood or other infectious materials shall receive Hepatitis B Vaccination (and boosters, if required or recommended by the physician) made available at no cost, within ten working days of assignment, via a University contracted licensed physician/health care professional. If an employee wishes to decline the vaccine, they must sign a “Mandatory Waiver for Declination of Hepatitis B Vaccination” found in Attachment B; however, the employee may request the vaccine at any time during the term of his assignment.
Post Exposure Evaluation and Follow-up: Any employee that incurs an exposure incident should report it to their immediate supervisor and obtain immediate medical attention.
The appropriate physician/health care professional will offer employees that have had an exposure a confidential post-exposure evaluation and follow-up. This evaluation will include documentation of the route of exposure, and the circumstances under which the exposure incurred; identification and documentation of the source individual, if applicable, unless the identification is unfeasible or prohibited by state or local law. Testing and follow-up consultation will be conducted as recommended by the physician. Employees must report the exposure incident to the Department of Human Resources within 24 hours, and complete an “Exposure Incident Investigation Form” found in Attachment D.
Medical Records: The University shall maintain copies of any medical records generated by this plan, as specified in the Standard, for the term of employment plus 30 years. Medical records shall be confidential and made available to the following people: the employee, anyone with consent of the employee, and upon request of OSHA, NIOSH, or State Department of Labor and Employment Security, Division of Safety.
Hazard Communication: Warning labels, including the orange or orange-red biohazard symbol will be apparent on all containers of regulated waste, refrigerators, freezers, and other containers used to store or transport blood or potentially infectious materials. Warning signs should be posted on doors to areas containing such materials.
Training: All University personnel involved in work which may expose them to biohazardous materials will be trained in handling those materials and methods for protecting themselves, other workers, and their environment from potentially infectious diseases as a result of their employment. All personnel involved and trained must sign the “Exposure Control Plan In-service Training Acknowledgement” found in Attachment A.
Departments are responsible for initial and annual training and documentation must remain on file for up to three (3) years. The training must be conducted in a formal manner, and must be presented in a manner understandable to the employee, cover mandatory topics and topics specific to the individual's duty, and be documented. The training must provide the following minimum information:
Laboratory workers shall receive additional training as it relates to their specific duties.
Training Records: Training records are maintained for each employee by their supervisor. Training records shall be maintained for three years from the date on which the training occurred.
CPR / First Aid: Employees who are anticipated to provide infrequent CPR/First Aid duties as a secondary condition of their employment will not be offered the Hepatitis Vaccine. However, if they perform a CPR/First Aid duty and are exposed, they will be offered the vaccine within 24 hours of the exposure. Any employees who are expected to perform First Aid in the normal course of their duties (e.g. first responders, law enforcement, and athletic trainers) will be offered the vaccine.
Records of Employees Working with Biohazards: All records required to be maintained by this procedure shall be confidential and made available to the following people: the employee, anyone with consent of the employee, and upon request of designated representatives of the Florida State Department of Labor and Employment Security, Division of Safety; the Assistant Secretary of Labor for Occupational Safety and Health, or the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services.
Accessibility: One copy of this plan will be maintained in a departmental file of the applicable areas and one copy in the EH&S Office.
Review: This Exposure Control Plan will be reviewed annually, and updated as necessary to remain current with legislative changes.
Biosafety in Microbiological and Biomedical Laboratories Centers for Disease Control