U M D N J
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R O B E R T
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J O H N S O N
M E D I C A L
S C H O O L
P O C T
P R O G R A M
Chapter
11
BLOODBORNE PATHOGENS
EXPOSURE CONTROL PLAN
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Procedure: UNIVERSAL PRECAUTIONS IN THE HANDLING OF BLOODBORNE
PATHOGENS
PURPOSE: To establish a policy for the handling of bloodborne pathogens and other potentially
infectious body substances.
PRINCIPLE:
Universal precautions are an approach to infection control designed to protect healthcare workers and
patients from exposure to bloodborne pathogens and other potentially infectious body substances.
Bloodborne pathogens refers to pathogenic microorganisms that are present in human blood, human
blood components, and products made from human blood that can cause disease in humans. These
pathogens include, but are not limited to hepatitis B virus (HBV), hepatitis C virus (HCV) and human
immunodeficiency virus (HIV).
1.1
Potentially infectious material includes:

all human blood

the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, and any body substance
that is visibly contaminated or possibly contaminated with blood, and all body fluids in
situations where it is difficult or impossible to differentiate between body fluids.

HIV containing cell or tissue cultures, organ cultures, and HIV or HBV containing culture
medium or other solutions
CLINICAL SIGNIFICANCE:
Healthcare workers incur risk of infection and subsequent illness from bloodborne pathogens with each
occupational exposure. By following universal precautions, that risk of occupational exposure and
subsequent illness will be minimized.
2.2
Unprotected (unvaccinated) healthcare workers have up to a 12 times greater risk of becoming
infected with the Hepatitis B Virus (HBV) than members of the population at large, 2% of which
are asymptomatic carriers of that virus. It is estimated that 1 in every 250 Americans is infected
with Human Immunodeficiency Virus (HIV) and as many as 88% of these individuals are unaware
of their infection and infectious status. These statistics underscore the necessity for adherence to
the principles of “Universal Precautions” in which all human blood, blood products and other
potentially infectious materials are treated as if they were KNOWN to be infectious.
PROGRAM ADMINISTRATION AND RESPONSIBILITIES
·
__________________ is responsible for overseeing the implementation of this Exposure Control
Plan (ECP). _____________________ will maintain and update the written ECP at least annually and
whenever necessary to:
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1) include new or modified tasks, services, and procedures; 2) reflect changes in technology that
eliminate or reduce exposure to bloodborne pathogens, and; 3) include written documentation regarding
the annual review and implementation of appropriate commercially available and effective safer medical
devices.
At this facility:
_________________________ is responsible for ensuring that effective disinfectants
are available and used.
________________________ is responsible for ensuring that new hires receive
required medical actions such as hepatitis B titers and/or vaccines within 10-days of
starting work unless:
·
The employee has previously received the series and has documentation,
·
Antibody testing reveals that the employee is immune or,
·
Medical reasons prevent the employee from taking the vaccination.
_________________________ is responsible
evaluation and follow up is conducted.
for
ensuring
that
post-exposure
_________________________ is responsible for ensuring that each worker covered by this Plan is
scheduled to attend training upon hire, as required, ensuring that training is appropriately documented,
and making the written ECP available to employees and PEOSH representatives.
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________________________ will ensure that all necessary personal protective
equipment (PPE), engineering controls (i.e., sharp containers, safer medical
devices, etc.), labels, and red bags as required by the standard, are available.
This person will also ensure that adequate supplies (and sizes, where applicable)
of this equipment and supplies are available.
_______________________ will be responsible for providing hepatitis B
vaccines for all personnel who have or are reasonably anticipated to have
occupational exposure to bloodborne pathogens.
In the event of an exposure incident, _______________________ will provide
post-exposure prophylaxis and counseling.
_______________________
will maintain confidential medical records
exposure incident reports for each employee for a minimum of 30-years.
_______________________ will be responsible for conducting both initial and
annual bloodborne pathogens training for all employees who have or are
reasonably anticipated to have occupational exposure to bloodborne pathogens.
Training records for a minimum of three years.
EMPLOYEE EXPOSURE DETERMINATION
The following is a list of job classifications/titles in which all employees have occupational exposure to
bloodborne pathogens or other potentially infectious material: (Additional pages may be attached, if
necessary.)
In certain job titles, some employees may perform activities in which there is
the potential for exposure to blood or body fluids. Below please list nontypical job titles and their respective tasks in which employees may have
the potential for exposure to blood or body fluids. For example, a
receptionist who may transport lab specimens. Note: there may be some
clinical jobs as well as non-clinical jobs in which not all employees have
exposure
Job Title
Task
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______________________________________
____________________________ ________________________________
____________________________ ________________________________
ENGINEERING AND WORK PRACTICE CONTROLS
Engineering Controls
Engineering controls will be used to prevent or minimize exposure to bloodborne pathogens. The
term engineering controls includes all control measures that isolate or remove a hazard,
encompassing not only sharps with engineered sharps injury protections and needleless systems
but also other devices designed to reduce the risk of percutaneous exposure to bloodborne
pathogens (e.g., sharps disposal containers). Where there are commercially available safe
medical devices that can be effectively used to eliminate or minimize the risk of exposure
to blood and other body fluids, they must be used.
At this facility, the following safety device(s) is made available and used by workers:

3.1
Safety lancets (Insert name of manufacturer and brand to used)
Personal Hygiene
No food or drink shall be kept in refrigerators, freezers, on shelves or on countertop or
benchtops, where blood or other potentially infectious materials are present.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses
are not permitted where there is a reasonable likelihood of exposure to blood and other
body substances.
Mouth pipetting/suctioning of any material (body fluid, reagent, distilled water, etc.) is
prohibited.
All procedures are to be performed in such a way that splashing, spattering, or droplet
formation is minimized.
Personnel will wash their hands and any other skin with soap and water immediately
following contact with blood or other potentially infectious materials.
Personnel will flush mucous membranes with water immediately following contact with
blood or other potentially infectious materials.
Personnel will wash their hands with soap and water immediately, or as soon as feasible,
after removal of gloves or other personal protective equipment (PPE).
3.2
Specimen Handling
When not being tested, tubes of blood should be kept closed in a vertical stopper-up
position.
3.3
Testing Equipment Handling
Any testing equipment in the lab may accidentally become contaminated with blood or
other potentially infectious materials. Follow each individual manufacturers instructions
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on how to decontaminate. If decontamination of the equipment or portions of it is not
feasible, clearly label the portion of the equipment that remains contaminated and call the
manufacturer’s hotline for further instructions or to place a service call.
3.1
Cleaning and Disinfecting
Contamination is described as the presence or the reasonably anticipated presence of
blood or other potentially infectious materials on an item or surface. All work areas will be
wiped clean with a 1:10 dilution of bleach at the beginning and end of each shift. Any
accidental spill of blood or other potentially infectious materials will be disinfected
immediately by applying a 1:10 dilution of bleach for 10 minutes to the area and then
wiping up. The benchtop must be wiped clean with 10% bleach and then 70% ethanol to
remove any bleach residue.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
4.1
Examples of PPE
Examples of personal protective equipment include gloves, gowns, laboratory coats, face
shields or masks, eye protection, and splash shield. All personal protective equipment
must be removed prior to leaving the laboratory area.
4.2
Gloves
Gloves are worn whenever it can reasonably be anticipated that there will be contact with
blood or other potentially infectious materials or when handling or touching contaminated
surfaces. This includes, but is not limited to: performing a fingerstick or venipuncture,
opening a tube for any reason, pipetting a sample, or in any way introducing a specimen
into an instrument or test system.
Disposable gloves are replaced as soon as practically possible when they become
contaminated or as soon as feasible if they are torn, punctured, or when their ability to
function as a barrier is compromised. Gloves should not be washed or decontaminated
for re-use. Gloves should be discarded into a red biohazard waste bag.
4.3
Protective Clothing
Clothing such as lab coats or jackets, aprons, or gowns are worn in occupational
exposure situations. The type and characteristics of such protective clothing must be
appropriate to the task and degree of exposure anticipated.
Lab coats or jackets are worn whenever it can reasonably be anticipated that there will be
contact with blood or other potentially infectious materials or when handling or touching
contaminated surfaces. This includes, but is not limited to: performing a fingerstick or
venipuncture, opening a tube for any reason, pipetting samples, or introducing a
specimen into an instrument or test system.
Lab coats or jackets, aprons, or gowns are replaced as soon as practically possible when
they become contaminated or as soon as feasible if they are torn, punctured, or when
their ability to function as a barrier is compromised. Disposables should be discarded
into a red biohazard waste bag. If street clothes are contaminated, they should be
removed and bagged. It is essential that contaminated clothing NOT be taken home for
cleaning purposes. Contaminated clothes will be discarded in a red biohazard waste bag
at the discretion of the laboratory director
4.4
Eye Protection and Shields
Face shields or goggles, and masks are worn whenever it can reasonably be anticipated
that there will be contact with blood or other potentially infectious materials or when
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handling or touching contaminated surfaces. This includes performing a fingerstick,
opening a tube for any reason, pipetting samples, or introducing a specimen into an
instrument.
A splashguard (stationary or adjustable) may be used in lieu of face shields and masks, if
used properly. The splashguard must be situated in between the facial area of testing
personnel and the point of handling potentially infectious materials.
Face shields, masks, goggles and splash guards are decontaminated as soon as
practically possible when they become contaminated or as soon as feasible if they are
damaged, or when their ability to function as a barrier is compromised. Disposables
should be discarded into a red biohazard waste bag.
Training
All workers who have or are reasonably anticipated to have occupational exposure to bloodborne
pathogens will receive training arranged by (list who arranges it). The training program will cover,
at a minimum, the following elements:
a.
An explanation of the contents of the PEOSH/OSHA Bloodborne Pathogens
Standard (see Appendix A) and information on how they can get a copy of the
standard;
b. A general explanation of the epidemiology and symptoms of bloodborne diseases;
c.
An explanation of the modes of disease transmission;
d. A review of the Exposure Control Plan and the steps that the employee can take to
obtain a copy of it;
e. An explanation of the appropriate methods that can be used to recognize and
evaluate tasks and activities with potential exposure;
f.
An explanation of the use and limitations of the different methods of control
including, but not limited to, engineering controls, work practices and personal
protective equipment;
g. Health care workers shall receive training in the use of safety devices utilized during
the course of their duties. Training shall be provided to the extent necessary to
ensure their proper and appropriate use. The employer shall monitor the
effectiveness of this training by conducting regular inspections (Appendix K, Form
D).
h. Information on how they can report complaints, dissatisfaction or “near miss” injuries
with safety devices utilized during the course of their duties.
i.
Information on the types, proper use, location, removal, handling and disposal of
personal protective equipment and the basis for selection of the different types of equipment;
j.
Information on the appropriate actions and procedures to follow if an exposure
occurs;
k. Information on the Hepatitis B vaccine including safety, benefits, efficacy, methods
of administration and that the vaccine will be free of charge;
l.
An explanation of the signs and labels required by the standard;
m.
An opportunity for interactive questions and answers; and
n.
Additional training for employees in HIV and HBV research laboratories which is
specific to the practices and operations of the laboratory.
Hepatitis B Vaccine
At this facility, The hepatitis B vaccination series will be made available at no cost within 10 days
of initial assignment to employees who have occupational exposure to blood or other potentially
infectious materials unless:
the employee has previously received the series;
antibody testing reveals that the employee is immune; or
there are medical reasons which prevent taking the vaccination.
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Post-Exposure Prophylaxis
At this facility, the following procedure will be followed for reporting, documenting and
evaluating exposure incidents for workers :
HOUSEKEEPING
Work Area
Work Areas are maintained in a clean and sanitary condition. Phones and computer
keyboards are not to be touched while the individual is wearing gloves. All equipment,
environmental and working surfaces are cleaned and decontaminated after contact with
blood or other potentially infectious material.
Broken glassware, which may be contaminated IS NOT to be picked-up by hand. Clean
up by mechanical means only.
REGULATED WASTE
6.1
Definition
Regulated waste is:
6.2

liquid or semi-liquid blood or other potentially infectious materials

contaminated items that would release blood or other potentially infectious materials
in a liquid or semi-liquid state if compressed

items that are caked with dried blood or other potentially infectious materials and are
capable of releasing these materials during handling

contaminated sharps

pathological and microbiological wastes containing blood or other potentially
infectious materials.
Other Regulated Waste Containment
Regulated waste is placed in containers that are constructed to prevent leakage,
appropriately labeled as a biohazard, and can be closed prior to removal. These
containers must be lined with a red biohazard bag.
If outside contamination of a regulated waste container occurs, place it in a second
container that will prevent leakage, is labeled biohazard, and is closed.
Disposal of regulated waste is the responsibility of the facility in accordance with all
federal, state and local standards.
BIOHAZARD WARNING LABELING
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Labels for biohazard warnings contain the word “BIOHAZARD” and the following symbol:
They are fluorescent orange or orange-red with symbols with lettering in a contrasting
color, either as an integral part of the container or affixed to it in such a fashion as to
prevent its loss or unintentional removal.
Biohazard warnings are affixed to:

Containers of regulated waste, refrigerators and freezers containing blood or
potentially infectious material.

All containers used to store, transport or ship blood or other potentially infectious
materials, except individual containers of blood or other potentially infectious
materials are placed in a labeled container during storage, transport, shipment or
disposal.
GENERAL GUIDELINES
Universal precautions should be used with regard to all blood and body fluids.
All specimens of blood and body fluids should be placed in a secure, closed, leakproof
container. Care should be taken to avoid contamination of the outside of the container or
its label.
ALL personnel processing specimens of blood or other body fluid should wear gloves.
Protective eyewear or splash guards should be used if mucous membrane contact may
be anticipated. Gloves should be changed and hands washed with soap and water after
completion of processing.
A biological safety cabinet (biological hood, dead air box in PCR, etc.) should be used for
procedures (blending, mixing, etc.) which have a potential for generating droplets.
Mouth pipetting is forbidden.
Working surfaces should be disinfected using an appropriate disinfectant following work
completion.
Contaminated materials and equipment should be appropriately decontaminated or
labeled, and appropriately disposed of.
Remove protective wear and wash hands upon completion of laboratory duties.
LIMITATIONS OF THE PROCEDURE
An employee may temporarily and briefly decline the use of personal protective
equipment only under rare and extraordinary circumstances when, in the employees
professional judgement, its use will prevent the delivery of healthcare or public safety
services, or will pose an increased hazard to themselves or a co-worker.
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When an employee makes such a judgement, the circumstances should be investigated
and documented in order to determine whether changes can be instituted to prevent such
occurrences in the future.
Following these guidelines will reduce the risk of exposure to infectious agents, but
cannot entirely eliminate that risk. All employees must recognize the risks to themselves
and must be careful at all times to act so as to minimize the spread of infections.
REFERENCES
(1)
NCCLS, Clinical Laboratory Technical Procedure Manual-Third Edition; Approved
Guideline. NCCLS document GP2-A3 (ISBN 1-56238). NCCLS Wayne, PA. 1996.
(2)
Berman, Lee, ed., Infection Control in Health Care, Current Concept Seminars, Inc.,
Hollywood, FL 33021
(4)
Fischbach, Frances ed., A Manual of Laboratory & Diagnostic Tests, 5th Edition,
Lippencott, Philadelphia, PA. 1987.
(5)
Jacobs,D.S., Kasten,Jr., B.L., Demott, W.R., Wolfson, W.L., ed., Laboratory Test
Handbook, 2nd Edition, Lexi-Comp Inc., Stow, OH 44224
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