Appendix C

Bloodborne Pathogens Exposure Control Plan

One of the major goals of OSHA is to regulate facilities where employees could be exposed to bloodborne pathogens. Another is to promote safe practices to minimize the incidence of disease caused by these pathogens. Relative to this goal, OSHA enacted the Bloodborne Pathogen Standard, 29CFR1910.1030.

The purpose of the standard is to reduce occupational exposure to Hepatitis B virus(HBV), Human Immunodeficiency Virus(HIV), and other bloodborne pathogens that employees may come in contact with in the workplace.

North Carolina State University believes that there are a number of excellent principles to follow when working with infectious material or responding to medical emergencies.

  1. Minimize all exposure to all pathogenic organisms
  2. Do not underestimate the risk of exposure to pathogenic agents.
  3. Use as many engineering and work practices as possible to minimize exposure


Objectives

  1. To provide training, guidelines and procedures designed to prevent or minimize occupational exposure to blood borne pathogens and other poten- tially infectious agents
  2. To ensure compliance with applicable provisions in the Bloodborne Pathogen Standard


Authority

  1. OSHA Bloodborne Pathogen Standard 1910.1030
  2. Guidelines issued by the Centers for Disease Control


General Plan Management

There are four major groups that are responsible for the effective implementation of the Exposure control Plan. These are:

  1. Deans, Directors, Department Heads and Principal Investigators
  2. Supervisors of the clinical and research laboratory areas
  3. Employees
  4. Environmental Health and Safety

The following sections define the roles played by each of these groups in carrying out the plan. If there are changes in the assignment of these responsibilities, the plan will be updated to reflect the change(s).

  1. The Deans, Directors, Department Heads and Principal Investigators will be responsible for the overall management and support of the compliance portion of this plan. Responsibilities include:
    1. Overall responsibility for implementing the Exposure Control Plan for their organization
    2. Working with supervisors and employees to develop and administer any additional policies and procedures needed to support the effective implementation of this plan
    3. Revision and updating procedures for all areas of responsibility
    4. Scheduling periodic training seminars for employees
    5. Maintaining appropriate training records
  2. Supervisors are responsible for exposure control in their respective areas. They work directly with their employees to promote and ensure they follow proper exposure control procedures. In addition, supervisors will investigate exposure incident and the necessary action to prevent similar incidents.
  3. The employees have the most important role in the compliance program. The ultimate execution of the Plan rests in their hands. In this role they must do the following:
    1. Know what tasks they perform that have occupational exposure
    2. Attend the bloodborne pathogen training sessions
    3. Plan and conduct all operations in accordance with work practice controls
    4. Develop and practice good personal hygiene habits
  4. Environmental Health and Safety will do the following:
    1. Revise and update the Exposure Control Plan
    2. Conduct periodic audits to ensure that engineering controls are operational and that safety procedures are followed

    A copy of the Bloodborne Pathogen Exposure Control Plan is accessible and readily available to each employee during the normal work shift. A copy is kept in the employees respective department and in EH&S.



Definition of Occupational Exposure

As provided in 29CFR 1910.1030 occupation exposure means:

  1. "Occupational exposure means reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duty."
  2. Other potentially infectious materials means:
    1. Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleu- ral fluid, pericardial fluid, amniotic 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/HBV-containing cell or tissue cultures, organ cultures and HIV or HBV-containing medium or other solution: and blood, organs or other tissues from experimental animal infected with HIV or HBV.
    4. Other pathogens that are transmitted by ingestion or inhalation.


Exposure determination

Deans, Directors, Department Heads and Principal Investigators will determine and maintain a list of those employees who are exposed to potentially infectious materials.



Methods of Compliance

There are a number of areas that must be addressed in order to effectively eliminate or minimize exposure to bloodborne pathogens. The principal investigators and supervisors are responsible for ensuring compliance with NC State's Exposure Control Plan. The first five areas dealt with in the plan are:

  1. The use of Universal Precautions
  2. Establishing appropriate engineering controls
  3. Implementing appropriate work practice controls
  4. Using necessary personal protective equipment
  5. Housekeeping

Each of these areas is reviewed with employees during their bloodborne pathogens related training. By rigously following the requirements of OSHA's Bloodborne Pathogens Standard in these five areas, the employees' occupational exposure to bloodborne pathogens will be eliminated or substantially minimized.

  1. Universal Precautions

    2. At NC State, we observe the practice of "Universal Precautions to prevent contact with blood and other potentially infectious materials. All human blood and body fluids are treated as if they are known to be infectious for bloodborne or other pathogens. In addition, animal blood, fluids, and material and other human materials (i.e. feces, urine, etc. ) are handled as infectious materials.

    In circumstances where it is difficult or impossible to differentiate between body fluid types, we assume all body fluids to be potentially infectious. Principal Investigators and supervisors are responsible for overseeing the Universal Precaution Program in their departments.

  2. Engineering Controls

    3. Engineering Controls are used to eliminate or minimize employee exposure to bloodborne and other pathogens. Equipment such as sharps disposal containers, handwashing sinks, biological safety cabinets and special ventilated laboratory facilities are used as appropriate.

    EH&S periodically works with departments to review tasks and procedures performed where engineering controls can be implemented or updated. As part of this effort, EH&S will conduct audits of areas to identify three things:

    1. Areas where engineering controls are currently employed
    2. Areas where engineering controls can be updated
    3. Areas currently not employing engineering controls, but where engineering controls could be beneficial

    The following engineering controls are to be used throughout the University:

    1. Handwashing facilities (or antiseptic hand cleansers and towel or antiseptic towelettes), which are readily accessible to all employees who have the potential for exposure.
    2. Containers for contaminated sharps having the following characteristics:
      1. Puncture-resistant
      2. Color-coded or labeled with a biohazard warning label
      3. Leak-proof on the sides and bottom
      4. Closable
    3. Specimen containers which are:
      1. Leak-proof
      2. Color-coded or labeled with a biohazard warning label
      3. Puncture-resistant, when necessary
      4. Closeable
    4. Secondary containers which are:
      1. Leak-proof
      2. Color-coded or labeled with a biohazard warning label
      3. Puncture-resistant, if necessary

  3. Work Practice Controls

    4. There are a number of work practice controls to help eliminate or minimize employee exposure to bloodborne pathogens.

    Overseeing the implementation of work practice controls is the responsibility of the supervisors. They work in conjunction with deans, directors, department heads and principal investigators to effect this implementation.

    The following Work Practice Controls are part of the Bloodborne and Other Pathogens Compliance Program:

    1. Employees wash their hands immediately, or as soon as possible, after removal of gloves or other personal protective equipment.
    2. Following any contact of body areas with blood or any other infectious materials, employees wash their hands and any other exposed mucous membranes with water
    3. Contaminated needles and other contaminated sharps are not bent, recapped or removed unless:
      1. It can be demonstrated that there is no feasible alternative
      2. The action is required by specific medical procedure
      3. In the two situations above the recapping or needle removal is accomplished through the use of a mechanical device or a one- handed technique
    4. Contaminated reusable sharps are placed in appropriate containers immediately, or as soon as possible, after use
    5. Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in work areas where there is potential for exposure to bloodborne pathogens
    6. Food and drink is not kept in refrigerators, freezers, on countertops or in other storage areas where blood or other potentially infectious materials are present
    7. Mouth pipetting/suctioning of blood or other infectious materials is prohibited.
    8. All procedures involving blood or other infectious materials should be conducted to minimized splashing, spraying or other actions generating droplets of these materials
    9. Specimens of blood or other materials are placed in designated leak-proof containers, appropriately labeled for handling and storage
    10. .If outside contamination of a primary specimen container occurs, that container is placed within a second leak-proof container, appropriately labeled, for handling and storage.
    11. Equipment that becomes contaminated is examined prior to servicing or shipping, and decontaminated as necessary
    12. An appropriate biohazard warning label is attached to any contaminated equipment, identifying the contaminated portions. Information regarding the remaining contamination is conveyed to all affected employees, the equipment manufacturer and the equipment service representative prior to handling, servicing or shipping.

    Conduct an exposure determination when there is a new employee or an employee changes jobs.

  4. Personal Protective Equipment

    5. Personal protective equipment (PPE) is the employees' main line of defense against bloodborne pathogens. PPE is provided at no cost to protect employees against such exposure. This equipment includes, and is not limited to:

    1. gloves
    2. gowns
    3. laboratory coats
    4. face shields/masks
    5. safety glasses
    6. mouthpieces
    7. resusciation bags
    8. pocket masks
    9. hoods
    10. shoe covers

    The Department Head or Supervisor is responsible for ensuring that all work areas have appropriate PPE available to employees.

    Employees will have training in the use of the appropriate PPE for their job classification and tasks/procedures they perform. Employees will receive additional training if an employee takes a new position or new job functions are added to their current position.

    Compare the employees' previous job classification and tasks to those for any new job or function that they undertake to determine the need for additional training . Any needed training is provided by their department head or supervisor.

    Use the following practices to ensure that PPE is not contaminated and is in the appropriate condition to protect employees from potential exposure,

    1. Inspect all PPE periodically and repair or replace as needed to maintain its effectiveness
    2. Clean reusable PPE, launder and decontaminate as needed

    Employees shall adhere to the following practices when using their PPE:

    1. Remove immediately any garments penetrated by blood or other infectious materials
    2. Remove all PPE prior to leaving the work area
    3. Wear gloves in the following circumstances:
      1. Whenever employees anticipate hand contact with potentially infectious materials
      2. When performing vascular access procedures
      3. When handling or touching contaminated items or surfaces.
    4. Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured or otherwise lose their ability to function as an "exposure barrier."
    5. Utility gloves are decontaminated for reuse unless they are cracked, peeling, torn, or exhibit other signs of deterioration, at which time they are disposed.
    6. Masks and eye protection are used whenever splashes or sprays may generate droplets of infectious materials
    7. Protective clothing is worn whenever potential exposure to the body is anticipated
    8. Surgical caps/hoods or shoe covers/boots are used in many instance where "gross contamination " anticipated.

  5. Housekeeping

    6. Departments with the assistance of Custodial Services or other assigned employees shall support the following practices:

    Clean and decontaminate all equipment and surfaces contaminated with blood or other potentially infectious materials:

    1. Immediately when surfaces are contaminated
      1. After any spill of blood or infectious materials
      2. At the end of the work shift if the surface may have been contami- nated during that shift
    2. Protective coverings are removed and replaced:
      1. as soon as feasible when overtly contaminated
      2. at the end of the work shift if they may have been contaminated during the shift
    3. All pails, bins, cans , and other receptacles intended for use routinely are inspected, cleaned, and decontaminated as soon as possible if visibly con- taminated.
    4. Potentially contaminated broken glassware is picked up with mechanical means (dustpan and brush)
    5. Contaminated reusable sharps are stored in containers that do not require "hand processing."

    The following procedures are used with all types of infectious wastes:

    1. They are discarded or "bagged" in containers that are:
      1. closable
      2. puncture-resistant
      3. leak-proof if the potential for fluid spill or leakage exists.
      4. red or labeled with the biohazard warning label
    2. Containers for regulated waste are located throughout within easy access to employees and as close as possible to source of waste.
    3. Waste containers are maintained upright, routinely replaced and not allowed to overfill
    4. Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used.
    5. Whenever employees move containers of regulated waste from one area to another, the containers are immediately closed and placed inside an appropriate secondary container if leakage is possible from the fire container.


HIV and HBV Research Laboratories and Production Facilities

There are special policies and procedures for HIV and HBV in research laboratories. There are no production facilities at the University.


Hepatitis B Vaccination, Incident Reporting, Post-Exposure Evaluation and Follow-Up

  1. Vaccination Program

    2. The University has a vaccination program for Hepatitis B Virus. This program is offered at no cost, to all employees who my have an occupational exposure to bloodborne pathogens. If the employee declines the vaccine then the Declination Form (Appendix) must be completed and kept in the employees file.

    The vaccination program consists of a series of three inoculations over a six month period. As part of the bloodborne pathogen training, employees have received information regarding Hepatitis vaccination, including its safety and effectiveness.

    Each department is responsible for setting up the vaccination program.

  2. Incident Reporting, Post Exposure Evaluation and Follow-Up

    3. If an employee is involved in an incident where exposure to bloodborne or other highly infectious pathogens may have occurred, efforts should be focuses on getting medical consultation and treatment expeditiously. The following procedure should be followed:

    1. Report the incident to supervisor
    2. Supervisor with employee complete "Accident/Illness Form"
    3. Supervisor refers employee copy of Accident/Illness form to Environmental Health and Safety

    A confidential medical evaluation and follow-up will be conducted by a qualified healthcare professional at no charge to the employee. Follow-up may include vaccination, blood testing, and counseling.

    The employee's supervisor will investigate the circumstances surrounding the incident to determine what action (training, change in work practice, engineering controls) can be taken to prevent similar incidents in the future.

  3. Medical Recordkeeping

    4. To make sure that medical information is available

    All medical information is confidential. Information is not disclosed without the employee's written consent.

    Labels and Signs

    The most obvious warning of possible exposure to bloodborne and other pathogens are biohazard labels. The department is responsible for setting up and maintaining labeling and red "color-coded" container program.

    Labels or color-coding is required for:

    1. containers of regulated waste
    2. refrigerators/freezers containing blood or other potentially infectious materials
    3. sharps disposal containers
    4. other containers used to store, transport, or ship blood and other infectious materials
    5. laundry bags and containers
    6. contaminated equipment
    7. biohazard signs must be posted at entrances to HIV and HBV research laboratory facilities.

    Having well informed and educated employees is extremely important when attempting to eliminate or minimize exposure to bloodborne and other pathogens. Because of this, all employees who have the potential for exposure to bloodborne or other pathogens are put through a comprehensive training program and furnished with appropriate information.

    Employees will receive initial training and having training at least annually to keep their knowledge current. All new employees, as well as employees changing jobs or job functions, will be given any additional training their new position requires prior to beginning their new job assignments.

    Each department is responsible for maintaining documentation that all employees who have potential exposure to bloodborne or other pathogens receive training.

  4. Training Topics

    5. The topics covered in the training program include, but are not limited to the following:

    1. The Bloodborne Pathogen Standard
    2. The epidemiology and symptoms of bloodborne and other disease
    3. The modes of transmission of bloodborne and other pathogens
    4. The department's Exposure Control Plan
    5. Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials
    6. A review of the use and limitations of methods that will prevent or reduce exposure, including:
      1. Engineering controls
      2. Work practice controls
      3. Personnel protective equipment
    7. Selection and use of personal protective equipment including:
      1. types available
      2. proper use
      3. location
      4. removal
      5. handling
      6. decontamination
      7. disposal
    8. Visual warning of biohazards including labels, signs, and "color-coded" containers
    9. Information on the Hepatitis B Vaccine, including its:
      1. efficacy
      2. safety
      3. method of administration
      4. benefits of vaccination
      5. the vaccination program
    10. Actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
    11. The procedures to follow if an exposure incident occurs, including incident reporting
    12. Information on post-exposure evaluation and follow-up including medical con- sultation

  5. Recordkeeping

    6. Maintain employee training records in the employees' department. The training record will contain the following information:

    1. Dates of all training sessions
    2. Contents/summary of the training sessions
    3. Names and qualifications of the instructors
    4. Names and job titles of employees attending the training sessions

    If you have questions regarding the Bloodborne Pathogen Exposure Control Plan or other safety and health concerns, contact Environmental Health and Safety at 515-6858

EXPOSURE DETERMINATION

Included in the exposure determination.are all occupations that involve a potential for spill or splashes of blood or other potentially infectious material.

Examples of job classifications where employees may have occupational exposure to human blood or body fluids are:



Hepatitis B Vaccine Declination

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge. 




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