REDWOODS COMMUNITY COLLEGE DISTRICT
Exposure Control Plan for
Blood-borne Pathogens
Table of Contents
BACKGROUND ..................................................................................................................... 1
INTRODUCTION ............................................................................................................................... 2
OVERVIEW OF BLOOD-BORNE PATHOGENS ....................................................................... 3
EMPLOYEES AND STUDENTS AT RISK ........................................................................5
METHODS OF COMPLIANCE AND SCHEDULE OF IMPLEMENTATION ........................ 6
PERSONAL PROTECTIVE EQUIPMENT .................................................................................... 8
CUSTODIAL ........................................................................................................................... 9
LAUNDRY ........................................................................................................................................ 10
HEPATITIS B IMMUNIZATION PLAN AND WAIVER PROCESS...................................... 11
POST-EXPOSURE EVALUATION AND FOLLOW-UP ...........................................................12
COMMUNICATION OF HAZARDS TO EMPLOYEES AND STUDENTS ..........................15
INFORMATION AND TRAINING ...............................................................................................16
RECORD-KEEPING .........................................................................................................................18
GLOSSARY ....................................................................................................................................... 19
INTERFACE WITH OTHER STANDARDS ............................................................................... 23
MANAGEMENT OF MEDICAL WASTE ................................................................................... 24
APPENDICES .................................................................................................................................. 25
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APPENDIX A, Sample Forms ........................................................................................... 26
APPENDIX B, Blood-borne Pathogens Standard, Title 8, California Code of Regulations
Section 5193 ........................................................................................................ 39
APPENDIX C, Most Frequently Asked Questions about the Blood-borne
Pathogen Standard ............................................................................................... 40
APPENDIX D, California Medical Waste Act ............................................................... 41
APPENDIX E, Resources for and Information on HIV IAIDS and Hepatitis B ............ 42
APPENDIX F, Exposure Determination Worksheets ..................................................... 43
APPENDIX G, Exposure Control Plan Checklist .......................................................... 45
APPENDIX H, Signs and Labels ....................................................................................... 46
APPENDIX I, Sharps Containers and Other Contaminated Material Containers ... 52
APPENDIX J, Preservation of Employee's Records ........................................................ 56
APPENDIX K, Labeling Requirements ............................................................................. 58
BACKGROUND
In September 1986, OSHA was petitioned by various unions representing healthcare employees
to develop an emergency temporary standard to protect employees from occupational exposure to
blood-borne diseases. The agency decided to pursue the development of 8CCR Section 5 1 9 3 .
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INTRODUCTION
The Redwoods Community College District (hereafter referred to as the District) is implementing
an Exposure Control Plan to ensure the well-being of and to protect the safety and health of our
employees and students. This plan has been developed to comply with state and federal
regulations pertaining to blood-borne pathogens and communicable diseases.
Employees and students are encouraged to read and are required to follow the guidelines and
procedures set forth in this plan. Questions regarding the contents of this plan should be brought
to your immediate supervisor or classroom instructor.
A copy of this plan can be found on the College’s web site.
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OVERVIEW OF BLOOD-BORNE PATHOGENS
HEPATITS
Hepatitis has been categorized into several distinct forms. Hepatitis A accounted f o r
approximately 28,500 cases in 1988. Hepatitis B was reported 23,200 times; and 2,620 cases of
non-A/non-B hepatitis were reported, as well as 2,470 cases of unspecified diagnoses. The United
States Public Health Services (USPHS) believes that the actual number of infections is many times
the reported n u m b e r .
Hepatitis A
Hepatitis A is a viral infection caused by a picornavirus, is commonly transmitted by the
fecal-oral route, and is generally controlled through good hand-washing techniques. NonA/Non-B Hepatitis (Hepatitis C/Hepatitis E)
Non-A/non-B hepatitis has been shown to be transmitted by the fecal-oral route and
parenterally. Parenterally transmitted, non-A/non-B hepatitis can make up as much as 40
percent of the acute viral hepatitis in the United States. Transfusion patients and parental
drug users are considered the groups most at risk. Healthcare staff who frequently works
with blood may be at risk. However, little is known about person-to-person transmission
of this disease.
Hepatitis B Virus (HBV)
The hepatitis B infection is caused by a specific virus known as a DNA virus. The
incubation period can be as long as 160 days, with an average of 120. The symptoms and
signs include anorexia, malaise, nausea, vomiting, abdominal pain, and jaundice. Chronic
carriers of the disease are common. The chronic stage of the disease is more common in
the younger individuals. The carrier is capable of passing the disease to others. The body
fluids containing the highest concentrations of the virus are the blood and blood fluids.
The potential risk for workers handling these fluids is obvious.
Although not transmitted through the fecal-oral route, HBV is commonly transmitted
through the use of contaminated needles or sexual contact. Transmission through blood
transfusion is rare only because of donor and blood supply screening. Transmission
through close personal contact can also occur.
Although about 300,000 people in the United States are infected with the virus annually,
as many as 1,000,000 may be carriers of the disease. Workers exposed to infected blood
are the most at risk. The USPHS lists those at highest risk as medical and dental
employees and staff in institutions and classrooms for the mentally retarded. Vaccines are
available for prevention and post-exposure situations.
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HIV/AIDS
HIV is transmitted through sexual contact and exposure to infected blood. Although the virus has
been isolated from many body fluids, it is known to be transmitted through contact with blood,
semen, and vaginal secretions. The reservoir of infection in the United States has surpassed
1,500,000 people and is increasing as more become infected annually. Therefore, the potential
risk for the healthcare worker is probably increasing.
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EMPLOYEES AND STUDENTS AT RISK
The District has determined that the following job classifications and responsibilities include
employees with potential occupational exposure:
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Physicians
Registered nurses
Nurse practitioners
Employees in clinical and diagnostic labs
Freestanding clinics (e.g. family planning clinics, urgent care clinics)
Dentists
Dental hygienists and assistants
Dental laboratory personnel
Custodians and other employees handling regulated waste
Medical or dental equipment service personnel (maintenance mechanics)
Emergency response personnel (e.g. EMT, paramedics)
Campus security personnel
Physical education instructors
Coaches
Trainers
Health occupations personnel
Early Childhood Education/Child Development Center personnel
Sewer plant operators and plumbers
Other Employee Situations Covered by this Plan
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Part-time, temporary, and student employees.
Employees trained in first aid who are expected or authorized to render first aid in an
emergency situation as part of their job duties.
Students Covered by this Plan
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Health Occupations majors
Students enrolled in life science lab courses
Early Childhood Education majors
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METHODS OF COMPLIANCE AND
SCHEDULE OF IMPLEMENTATION
Universal precautions will be observed to prevent contact with blood or other potentially infectious
materials (OPIM). Under circumstances in which differentiation between body fluid types is
difficult or impossible, all body fluids shall be considered potentially infectious materials.
Engineering and Workplace Controls
The following engineering and workplace controls shall be used to eliminate or minimize
employee exposure:
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ENGINEERING CONTROLS:
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HAND-WASHING FACILITIES: These shall be readily available. Hand-washing will be done
These shall be maintained on a regular schedule. A regular
system will include documentation of maintenance inspection, data, employee making
the inspection, findings, repair verification if needed, and signature of employee
conducting the inspection.
as soon after hand contamination as possible. If water is not available, an antiseptic hand
cleaner must be used with clean cloth, paper towels, or antiseptic towelettes.
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SHEARING AND BREAKING: Shearing and breaking of contaminated needles is
prohibited.
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BENDING, RECAPPING, OR REMOVAL:
Bending, recapping, or removal of contaminated
needles by hand is prohibited.
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REUSABLE
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The area where
employees eat and drink must be separated from contaminated work areas and clothing by
a partition.
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CONTAMINATED CLOTHING AND EQUIPMENT:
SHARPs: These pose the same exposure hazard as disposable sharps.
Therefore, their containers will meet the same requirements.
CONTAMINATED ENVIRONMENTAL SURFACES AND WORK AREAS:
Must be removed before entering a food
consumption area.
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Splattering or the
generation of droplets or aerosols of contaminated material must be avoided. Where such
a potential exists, face protection will be required.
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CONTAMINATED REUSABLE EQUIPMENT:
SPLATI'ERING OR THE GENERATION OF DROPLETS OR AEROSOLS:
Must be decontaminated to the extent possible
by employees with appropriate personal protective equipment.
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PERSONAL PROTECTIVE CLOTHING:
Must be worn to prevent body contamination
and shall be provided by the District.
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PERSONAL PROTECTIVE EQUIPMENT (SPLASH SHIELDS, CLOTHES, GWVES, ETC.):
not be taken home by the employee and should remain at work.
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SPLASHES ON PROTECTIVE CLOTHING:
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Should be inspected for soak-through.
Must
PERSONAL PROTECTIVE EQUIPMENT
1.
The District shall make personal protective gloves available to employees and students
in high-risk areas.
2.
Because not all gloves are completely impermeable, hand-washing after glove removal is
required.
3.
Gloves shall be inspected for wear and discarded should the integrity of the glove barrier
be compromised.
4.
Disposable gloves shall never be reused.
5.
The Human Resources Office and the Facilities Director, Maintenance & Operations will
analyze employee and student tasks and the type of exposure expected in order to
select personal protective clothing and equipment that will provide adequate protection.
These items may include gowns, aprons/laboratory coats, clinic jackets, surgical caps, and
shoe covers. This will be accomplished in view of the fact that there is no standardized
method of testing and classification of the resistance of clothing to biological hazards.
6.
Employees will be required to wear designated, required, protective equipment while on
duty.
7.
Students without designated, required, protective equipment will not be allowed to
participate in the class.
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CUSTODIAL
1.
The District will develop a Schedule of Disinfection for any work surface that may become
contaminated by the HIV or HBV virus. The type of sterilant utilized will be found on the
EPA list of Registered Sterilants and shall be approved for the highest antimicrobial
activity in order to kill HIV and the more resilient HBV virus.
2.
Protective covering will be replaced as soon as it is feasible.
3.
Broken glassware that may be contaminated will not be picked up with bare hands, nor
shall any employee reach into a container of broken glassware.
4.
Regulated waste includes the following categories:
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liquid blood or other potentially infected material (OPIM),
items contaminated with blood or OPIM which would release the blood if squeezed
or shaken,
items caked with dried blood or OPIM which could be released if handled,
contaminated sharps, and
pathological and microbiological wastes.
5.
Sharps containers will be designed according to regulations, will not be allowed to overfill,
and will be located so that employees will not have to walk long distances with used
syringes. Disposable sharps containers are recommended.
6.
Sharps containers will be inspected regularly according to the department administrator and
will be replaced as required.
7.
Other waste containers shall be of a capacity to hold the volume of waste generated
between scheduled pickups.
8.
All containers will be inspected for leakage potential. Secondary containers will be
available if leakage is possible.
9.
All containers holding contaminated material will comply with CCR, Title 8, Chapter 4.
(See Appendix H .)
10.
Removal of regulated waste will be performed in compliance with OSHA Instruction CPL
2-2.44B. Performance of removal activities shall be the responsibility of the Director,
Maintenance & Operations of Facilities and Grounds.
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LAUNDRY
1.
Contaminated laundry will not be sorted or rinsed at the location of use.
2.
Contaminated laundry will be bagged by employees utilizing proper personal protective
equipment and bagged with consideration for outside contamination and proper labeling.
3.
When contaminated laundry is shipped off site, it should be noted that the receiving facility
may not practice Universal Precautions. Proper labeling should reflect this according to
relevant regulations.
Title 8: CCR Section 5193(d)(4)(D)
a.
Contaminated laundry shall be handled as little as possible with a minimum of
agitation.
1)
Contaminated laundry shall be bagged or containerized at the location
where it was used and shall not be sorted or rinsed at the location of use.
2)
Contaminated laundry shall be placed and transported in bags or containers
labeled and color-coded in accordance with Subsection (g) (a) (A) of this
standard. When a facility utilizes Universal Precautions in the handling of
all soiled laundry, alternative labeling and color-coding is sufficient if it
permits all employees and students to recognized the containers as
requiring compliance with Universal Precautions.
3)
Whenever contaminated laundry is wet and presents a reasonable likelihood
of soak-through or of leakage from the bag or container, the laundry shall
be placed and transported in bags or containers that prevent soak-through
and/or leakage of fluids to the exterior.
b.
The employer shall ensure that employees and students who have contact with
contaminated laundry wear protective gloves and other appropriate personal
protective equipment.
c.
When a facility ships contaminated laundry off site to a second facility that does
not utilize Universal Precautions in the handling of all laundry, the facility
generating the contaminated laundry must place such laundry in bags or containers
that are labeled and color-coded in accordance with Subsection (g)(1)(A).
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HEPATITIS B IMMUNIZATION PLAN AND WAIVER PROCESS
1.
The Hepatitis B vaccination series shall be made available by the employer to all
employees and students with occupational exposure. In addition, a post-exposure
evaluation and follow-up will be made available to all employees who are exposed to the
HBV.
2.
The employee will contact the Human Resources Office and the Student Health Center for
any of these services.
3.
The District shall follow the regulations as stated in CCR, Title 8, Chapter 4, Section 5193
(f) concerning the management of the vaccination and follow-up programs.
4.
The basic requirements are that the vaccination and post-exposure evaluation and
follow- up, including prophylaxis, are as follows:
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available at no cost to the employee,
available at a reasonable time and place,
under the supervision of a licensed physician or other licensed healthcare worker,
provided according to the recommendations of the USPHS, and
all lab tests will be conducted by an accredited laboratory.
5.
Employees identified in the Exposure Control Plan shall be required to receive the
hepatitis B vaccine. The vaccine will be provided through the college health services at
no cost to the employee.
6.
Students identified in the Exposure Control Plan shall be required to obtain the hepatitis B
vaccine. The vaccine will be available through the college health services at a reduced
rate, payable by the student.
7.
Any at-risk employee or student refusing the vaccine must sign the approved waiver form.
(See Appendix A, Vaccination Declination Form.)
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POST-EXPOSURE E V A L U A T I O N AND FOLLOW-UP
The District realizes the importance of the follow-up and evaluation of HIV and HBV exposure
incidents. The District will, therefore, follow precisely the regulation as stated below:
1.
Following a report of an exposure incident, the employer shall make immediately available to
the exposed employee or student a confidential medical evaluation and follow-up, including
at least the following elements:
a)
Documentation of the route(s) of exposure and the circumstances under which the
exposure incident occurred.
b)
Identification and documentation of the source individual, unless the employer can
establish that identification is unfeasible or prohibited by state or local law.
c)
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The source individual's blood shall be tested as soon as feasible and after
consent is obtained in order to determine HBV and HIV infectivity. If
consent is not obtained, the employer shall establish that legally required
consent cannot be obtained. When the source individual's consent is not
required by law, the source individual's blood, if available, shall be tested
and the results documented.
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When the source individual is already known to be infected with HBV or
HIV, testing for the source individual's known HBV or HIV status need not
be repeated.
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Results of the source individual's testing shall be made available to the
exposed employee, and the employee shall be informed of applicable laws
and regulations concerning disclosure of the identity and infectious status
of the source individual.
Collection and testing of blood for HBV and HIV serological status.
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The exposed employee's or student's blood shall be collected as soon as
feasible and tested after consent is obtained.
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If the employee or student consents to baseline blood collection but does
not give consent at that time for HIV serologic testing, the sample shall be
preserved for at least 90 days. If, within 90 days of the exposure incident,
the employee or student elects to have the baseline sample tested, such
testing shall be performed as soon as feasible.
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2.
Additional collection and testing shall be made available as recommended
by the U.S. Public Health Service.
d)
Post-exposure prophylaxis, when medically indicated, as recommended by the U.S.
Public Health Service.
e)
Counseling
f)
Evaluation of reported illnesses.
INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL
a)
The employer shall ensure that the healthcare professional responsible for the
employee's or student's hepatitis B vaccination is provided a copy of the
regulation(s).
b)
The employer shall ensure that the healthcare professional evaluating an
employee or student after an exposure incident is provided the following
information:
c)
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A copy of this regulation
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A description of the exposed employee's duties as they relate to the
exposure incident, or description of the exposed student's duties related to
the exposure incident.
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Documentation of the route(s) of exposure and circumstances under which
exposure occurred, as required by Subsection (f)(3)(A)
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Results of the source individual's blood testing, if available
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All medical records relevant to the appropriate treatment of the employee
or student, including vaccination status, which are the employer's
responsibility to maintain as required by Subsection (h)(l)(B)2.
Healthcare Professional's Written Opinion
The employer shall obtain and provide the employee or student with a copy of the
evaluating healthcare professional's written opinion within 15 days of the
completion of the evaluation.
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The healthcare professional's written opinion for hepatitis B vaccination
shall be limited to whether hepatitis B vaccination is indicated for an
employee or student and if the employee or student has received such
vaccination.
The healthcare professional's written opinion for post-exposure evaluation and follow-up
shall be limited to the following information:
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The healthcare professional’s written opinion for hep B vaccination shall
be limited to whether hep B vaccination is indicated for an employee or
student has received such vaccination.
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The healthcare professional’s written opinion for post exposure evaluation
and follow-up shall be limited to the following information”
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The employee or student has been informed of the results of the
evaluation
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The employee or student has been informed of any medical conditions
resulting from exposure to blood or other potentially infectious materials
that require further evaluation or treatment.
All other findings or diagnoses shall remain confidential and shall not be included
in the written report.
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COMMUNICATION OF HAZARDS TO EMPLOYEES AND STUDENTS
LABELS AND SIGNS
1.
Warning labels will be placed on refrigerators and freezers containing blood or other
potentially infectious materials.
2.
Labels shall comply with Title 8, Section 6004, and Health and Safety Code Sections
25080-25082. (See Appendix H, Signs and Labels, and Appendix I, Sharps Containers
and O her Contaminated Material Containers.)
3.
Labels concerning biohazardous waste are covered in Health and Safety Code, Sections
25080-25082. Color coding is described in Title 8, Section 6003. (See Appendix H,
Signs and Labels.)
4.
The District shall post signs at the entrance to work areas as described in the regulation.
(See Appendix H, Signs and Labels.)
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INFORMATION AND TRAINING
1.
2.
The Human Resources Office and the Student Health Office will provide training to all
employees with occupational exposure as follows:
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Training will occur at the time a new employee comes on board and at least
annually.
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Retraining will occur as operations change affecting exposure.
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The programs will be provided at no cost and will be delivered during work hours.
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The content of the training will be appropriate for the educational level of the
employee.
The content of the training will include the following topics:
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An explanation of the Blood-borne Pathogens Standard;
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Blood-borne disease epidemiology and symptoms;
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Modes of transmission;
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Recognition of tasks and activities that expose employees to the viruses;
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The use and limitations of engineering controls, personal protective equipment, and
work practices;
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Types, use, location, removal, handling, and decontamination of personal
protective equipment;
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How to select personal protective equipment;
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Information on the hepatitis B vaccine;
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Handling emergencies involving blood or other potentially infectious materials;
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Exposure incident procedures and reporting;
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Information on post-exposure follow-up and evaluation;
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Signs, labels, and other warnings; and
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Questions and other interaction.
3.
The training for students in classes where exposure is possible shall be provided by the
instructor of record in the class in which the student is enrolled.
4.
The content of the training will include the following topics:
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An explanation of the Blood-borne Pathogens Standard;
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Blood-borne disease epidemiology and symptoms;
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Modes of transmission;
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Recognition of tasks and activities that expose students to the viruses;
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The use and limitations of engineering controls, personal protective equipment, and
work practices;
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Types, selection, and use of personnel protective equipment;
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Universal Precautions;
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Exposure incident procedures and reporting; and
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Questions and other interaction.
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RECORD-KEEPING
The Human Resources Office will maintain accurate records on occupational exposure of each
employee, and the Student Health Office will maintain accurate records on occupational exposure
of students pursuant to CCR 8 Section 3204 (d). (See Appendix J, Preservation of Records.)
These records will be confidential and will be released only by the employee's or student's
written permission or as required by law or regulation. The records will be maintained for thirty
years beyond the end of employment of the employee and thirty years beyond the end of
enrollment of the student.
CONTENT OF RECORDS
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Name and social security number of employees or students
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Copies of HBV vaccination status and other relevant records
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Copies of results of medical exams, testing, and follow-up
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Employer's copy of healthcare professional's written opinion as required in the regulation
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Copy of the information provided to the healthcare professional as required in the
regulation
TRAINING RECORDS
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Dates of training sessions
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Content summary of training
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Names and qualifications of trainers
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Names of job titles of all employees attending the training session
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Names and course title of students enrolled in life science lab and health occupations
courses
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GLOSSARY
BIOLOGICALCABINET
A device enclosed, except for necessary exhaust purposes, on three sides and top and bottom,
designed to draw air inward by means of mechanical ventilation, operated with insertion of only
the hands and arms of the user, and in which virulent pathogens are used. Biological cabinets are
classified as follows:
CLASS 1
A ventilated cabinet for personnel protection with an un-recirculated inward airflow away
from the operator and HEPA filtered exhaust air for environmental protection.
CLASS 2
A ventilated cabinet for personnel, product, and environmental protection having an open
front with inward airflow for personnel protection, HEPA filtered laminar airflow for
product protection, and HEPA filtered exhaust air for environmental protection.
CLASS 3
A totally enclosed, ventilated cabinet of gas-tight construction. Operations in the cabinet
are conducted through attached, protective gloves.
BLOO
Meaning human blood, human blood components, and products made from human blood.
BLOOD-BORNE
PATHOGENS
Pathogenic microorganisms that are present in human blood and that can cause disease in humans.
These pathogens include, but are not limited to, HBV and HIV.
CHIEF
The Chief of the Division of Occupational Safety and Health of the California Department of
Industrial Relations, or designated representative.
CLINICAL LABORATORY
A workplace where diagnostic or other screening procedures are performed on blood or other
potentially infectious materials.
CONTAMINATE
The presence, o r the reasonably anticipated presence, of blood or other potentially infectious
materials on a surface or in or on an item.
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CONTAMINATED
LAUNDRY
Soiled with blood or other potentially infectious materials, or may contain sharps.
CONTAMINATED
SHARPS
Any contaminated object that can penetrate the skin, including, but not limited to, needles,
scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
DECONTAMINATION
The use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens
on a surface or site 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. Decontamination
includes procedures regulated by Health and Safety Code Section 25090.
EMERGENCY RESPONSE
The response by employees, who are designated by their employer as emergency response
personnel, to fire, accident, earthquake, explosion, or other incidents.
ENGINEERING CONTROLS
Controls (e.g. sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.
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.
HAND-WASHING FACILITIES
A facility providing an adequate supply of running, potable water, soap, and single-use towels or
hot-air drying machines.
HBV
Hepatitis B virus.
HV
Human immunodeficiency virus.
LICENSED HEALTHCARE PROFESSIONAL
A person whose legally permitted scope of practice allows him or her to independently perform
the activities required by Subsection (t), hepatitis B vaccination, and post-exposure evaluation and
follow-up.
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NIOSH
The National Institute for Occupational Safety and Health, United States Department of
Health and Human Services.
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 any employee's duties.
ONE-HAND TECHNIQUE
Procedure wherein the needle of a reusable syringe is capped in a sterile manner during use. The
technique employed shall require the use of only the hand holding the syringe, so the free hand
is not exposed to the uncapped needle.
OTHER POTENTIALLY INFECTIOUS MATERIALS
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The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial
fluid, pleural fluid, pericardia! fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any other body fluid that is visibly contaminated with blood such as saliva or
vomitus, and all body fluids in situations such as emergency response, where it is difficult
or impossible to differentiate between body fluids.
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Any unfixed tissue or organ (other than intact skin) from a human (living or dead).
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HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing
culture medium or other solutions; and blood, organs, or other tissues from experimental
animals infected with HIV or HBV.
PARENTERAL
Piercing mucous membranes or the skin barrier through such events as needle-sticks, human bites,
cuts, and abrasions.
PERSONAL PROTECTIVE EQUIPMENT
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.
PRODUCTION FACILITY
A facility engaged in industrial-scale, large-volume, or high-concentration production of HIV or
HBV.
REGULATED WASTE
Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that
would release blood or semiliquid state if compressed; items that are caked with dried blood or
other potentially infectious materials and are capable of releasing these materials during handling;
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contaminated sharps; and pathological and microbiological wastes containing blood or other
potentially infectious materials. Regulated waste includes "medical waste" regulated by Health
and Safety Code, Chapter 6.1.
RESEARCH LABORATORY
A laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research
laboratories may produce high concentrations of HIV or HBV but not in the volume found in
production facilities.
SOURCE INDIVIDUAL
Any individual, living or dead, whose blood or other potentially infectious materials may be a
source of occupational exposure to the employee. Examples include, but are not limited to,
hospital and clinic patients, clients in institutions for the developmentally disabled, trauma victims,
clients of drug and alcohol treatment facilities, residents of hospices and nursing homes, human
remains, and individuals who donate or sell blood or blood components.
STERILIZE
The use of a physical or chemical procedure to destroy all microbial life, including highly resistant
bacterial endospores. Sterilization includes procedures regulated by Health and Safety Code
Section 25090.
UNIVERSAL PRECAUTIONS
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 blood-borne pathogens.
WORK PRACTICE CONTROLS
Controls that reduce the likelihood of exposure by altering the manner in which a task is
performed (e.g., prohibiting recapping of needles by two-handed techniques).
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INTERFACE WITH OTHER STANDARDS
The District recognizes that this plan must work with other regulations. The following statements
indicate how the District will comply with other similar requirements found in other regulations.
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The Hazard Communication Standard, Title 8 Section 5194, applies only to chemicals in
the workplace and does not apply to biological hazards such as blood-borne disease.
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Records concerning employee exposure to blood-borne pathogens and records about HIV
and HBV status are employee medical records according to 29 CPR 1910.20.
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The Respiratory Protection Standard, 29 CPR 1910.134, does not apply since no
respirators are approved for biohazards. Nevertheless, r e s p i r a t o r s may not be
placed where they can be contaminated by body fluids.
•
The federal hazardous waste operations and emergency response standard includes workers
expected to respond to emergencies caused by the uncontrolled release of a hazardous
substance. The definition of hazardous substance includes biological agent or infectious
materials. Consequently, workers responding to emergencies caused by a release of
infectious material will receive appropriate HAZWOPER Training.
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MANAGEMENT OF MEDICAL WASTE
As a result of federal legislation, the California Infectious Waste regulations have been revised.
The California Medical Wastes Management Act provides for many changes to the old regulation.
The following briefly describes the provisions which may impact the Infection Control Plan for
blood-borne pathogens.
According to the 1990 California Medical Wastes Management Act, medical wastes include
materials classified as biohazards or sharps waste. Medical wastes may be generated as a result
of medical treatment, diagnosis, or immunization.
Biohazardous waste included in the Blood-borne Pathogens Infection Control Plan is medical waste
and, therefore, will be regulated by the Waste Management Act.
Sharps waste also described in the Blood-borne Pathogens Infection Control Plan is regulated by
the Medical Waste Management Act. This includes items having rigid comers, edges, or
protuberances capable of cutting or piercing. Examples include knives, needles, syringes, and
broken glassware.
Large Quantity Generators (LQGs) of medical waste include those facilities generating more than
200 pounds per month. LQGs must prepare a Medical Waste Management Plan and develop
methods for storage, containment, and treatment. Record-keeping is also required.
Most school facilities would be classified as Small Quantity Generators (SQGs). SQGs must
register with the State Department of Health Services if they use any on-site treatment methods.
If the facility treats waste on site, they must develop a Medical Waste Management Plan and
include medical waste treatment and tracking records. Those SQGs not treating waste on site must
prepare information on the storage, treatment, and disposal of medical waste and prepare medical
waste transport records as described in the Health and Safety Code Sections 25046 through 25047.
Medical Waste must be transported by a licensed hazardous waste hauler unless the generator has
a limited quantity exemption.
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APPENDICES
Appendix A Sample Forms
Appendix B
Blood-borne Pathogens Standard, Title i, California Code of Regulations Section
5193
Appendix C
Most Frequently Asked Questions about the Blood-borne Pathogen Standard
Appendix D California Medical Waste Act
Appendix E
Resources for and Information on HIVIAIDS and Hepatitis B
Appendix F
Exposure Determination Worksheets
Appendix G Exposure Control Plan Checklist
Appendix H Signs and Labels
Appendix I
Sharps Containers and Other Contaminated Material Containers
Appendix J
Preservation of Employee's Records
Appendix K
Labeling Requirements
Reviewed: June 2015
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APPENDIX A
Sample forms included in Appendix A:
Employees Eligible for Hepatitis B Vaccination
Informed Consent Signature Form
Vaccination Declination Form
Hepatitis B Vaccination Status Form
Exposure Determination Work Sheet
Record of Blood-borne Pathogens Exposure and Treatment
Blood-borne Pathogens Training Documentation
Source Individual Consent Form
Authorization for Disclosure by Health Care Provider of the Results of the Source
Individual Blood Test
Authorization for Disclosure by School District of the Results of the Source Individual
Blood Test
Occupational Exposure Incident Report Form
Post-exposure Evaluation and Follow-up Procedures
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