Bloodborne Pathogen Exposure - The Compliance Program

Revised August 2001

In accordance with the Bloodborne Pathogens Standard (29 CFR 1910.1030) the following exposure control plan has been developed.

I. Exposure Determination

OSHA recognizes two categories of employees who are at risk of occupational exposure.

A. Job classifications in which all employees have occupational exposure. These job classifications at Seton Hall University include:

Health Service Physicians
Health Service Nurse Practitioners
Health Service Nursing Staff
Health Service Student Health Aids
Athletics - Trainers
Athletics - Lifeguards
Athletics - Student Athlete Trainers

B. Job classifications in which some employees have occupational exposure. The tasks and procedures in which the occupational exposure occurs must also be listed.

Contract housekeeping staff servicing the Health Service
Contract housekeeping staff serving on teams for potentially infectious body fluid spill cleanup
Athletics - Strength and Conditioning Staff
Athletics – Coaches
Athletics – Facilities Staff
Athletics – Recreational Services Staff (intramurals/memberships)

In addition, Seton Hall University recognizes a third category of employees.

C. Job classifications in which all employees will be trained in bloodborne pathogens exposure control and post-exposure procedures. These employees, because exposure is not anticipated during their normal job duties, will not be offered Hepatitis B vaccinations.

Contract security staff
Contract housekeeping staff not covered in Section I.B. (above)
Residence Life Staff (Residence Hall Directors, Residence Assistants)

II. Methods of Compliance

A. Universal precautions will be observed to prevent contact with all potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual. See Appendix A for a summary of universal precautions in the workplace.

Throughout this plan, the term "potentially infectious material" will be defined to include:

Blood
Body fluid which contains blood
Any body fluid which is difficult to differentiate between body fluids
Semen
Vaginal secretions
Cerebrospinal fluid
Synovial fluid
Pericardial fluid
Peritoneal fluid
Amniotic fluid
Unfixed tissues
The following fluids do not contain enough HIV/HBV to cause infection:
Normal saliva
Feces
Urine
Sputum
Vomitus
Tears
Sweat
Nasal secretions

Note: If these fluids contain any blood at all, they should be considered potentially infectious. Even if blood is not visible, employees must follow universal precautions when cleaning up these materials.

B. The following engineering controls and work practices will be utilized to eliminate or minimize occupational exposure. Any equipment or practices involved will be examined and maintained or replaced as needed.

Puncture resistant, leak proof containers will be used for all potentially infectious sharps. These containers will be red and will be clearly labeled "BIOHAZARD."
Handwashing facilities will be provided for all employees with potential exposure. When handwashing facilities are not readily available, such as with mobile first aid kits, antiseptic towelettes or other infection control cleansers will be provided. When antiseptic towelettes or other cleansers are used, hands will be washed with soap and running water as soon as feasible. Employees are also required to wash hands or any other skin with soap and water immediately or as soon as possible after removing gloves or other personal protective equipment or following contact with blood or other potentially infectious materials.
Contaminated sharps (needles, lancets, etc.) will not be bent, broken, sheared, or recapped.
Safety syringes and/or "needleless systems" will be used in the University Health Service.
In work areas such as Health Service examination rooms where there is reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke or handle contact lenses. Food and beverages are not to be stored in refrigerators, freezers, shelves, cabinets or on counter tops where blood or other potentially infectious materials are present.
Mouth pipetting of blood or other potentially infectious materials is prohibited.
All procedures will be conducted in a manner that minimizes splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials.
Specimens of blood or other potentially infectious materials will be placed in a leak proof container during the collection, handling, processing, storage, and transport of the specimens. The container used for this purpose will be labeled as described in Section IV. A. of this plan.
Any specimen that could puncture a primary container will be placed in a secondary container which is puncture resistant. If outside contamination of the primary container occurs, the primary container will be placed within a secondary container that prevents leakage during handling, processing, storage, or transport and complies with all labeling requirements.
Equipment that has become contaminated with blood or other potentially infectious materials will be decontaminated as necessary unless the decontamination is not feasible. If decontamination is not feasible, the equipment will be discarded in compliance with University biohazardous waste disposal procedures.

C. Personal protective equipment used at Seton Hall University will be provided without cost to the employee. The equipment will be chosen based on anticipated exposure to blood or other potentially infectious materials. The protective equipment is considered appropriate only if it does not permit blood or other potentially infectious materials to pass through to reach the employee’s skin, clothing, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the protective equipment will be used.

The personal protective equipment available for reasonably anticipated activities on campus are listed below:

1. First Aid: disposable gloves, protective eye wear, face masks

2. CPR: disposable gloves, CPR mouthpiece, protective eye wear, face masks

Health Service procedures: disposable gloves, protective eye wear, laboratory coats

4. Clean up of potentially infectious materials: heavy duty water resistant gloves (or double disposable gloves), protective eyewear, face masks, and protective coveralls as needed.

The following people are responsible for maintaining supplies of personal protective equipment for the employees within their organization who may reasonably require it:

Contract Security Manager
Contract Housekeeping Manager
Associate Director of Health Service
Athletics Department Director
Director of Residence life

The use of appropriate personal protective equipment is mandatory when there is a reasonably anticipated chance for exposure to blood or other potentially infectious materials. Supervisors will ensure the use of personal protective equipment unless it is shown that the employee temporarily and briefly declined to use the protective equipment when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of healthcare or posed an increased hazard to the safety of the worker or a co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

All personal protective equipment (PPE) will be cleaned, laundered, and/or disposed of by Seton Hall University with no cost to the employee. Any garments which are penetrated by blood or other potentially infectious materials will be removed immediately or as soon as feasible. All PPE will be removed prior to leaving the work area and will be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

Gloves will be worn when it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, or mucous membranes or when handling or touching contaminated items or surfaces. Disposable gloves will not be reused, and will be replaced as soon as feasible if they are contaminated or torn or when their ability to function as a barrier is compromised. Latex free gloves will be available to those individuals who are allergic to latex.

Eye and face protection will be used whenever there is a reasonable anticipation of splashes, sprays, or droplets of blood or other potentially infectious materials that could contaminate eye, nose, or mouth.

Housekeeping

The Health Service will be maintained in a clean and sanitary condition as indicated in that department’s Infection Control Manual. This will include cleaning of examination room surfaces at a minimum of once per week with a 10% bleach solution or other equally effective disinfecting agent. This weekly cleaning will be conducted by the contract housekeeping service staff.

All equipment, environmental surfaces, and working surfaces will be cleaned and decontaminated as soon as feasible after contact with blood or other potentially infectious materials. The Associate Director of Health Services will be responsible for cleaning and decontamination of surfaces other than the weekly cleaning provided by housekeeping staff.

All surfaces will be decontaminated with a 10% bleach solution or other equally effective disinfecting agent. The disinfecting agent will remain on the surface for at least 10 minutes. Decontamination will be conducted only by individuals fully covered by this plan who have completed bloodborne pathogens training and have been offered Hepatitis B vaccinations.

All equipment that can be autoclaved will be decontaminated by autoclaving.

All reusable equipment will be decontaminated using an effective disinfecting agent.

Any protective coverings used to protect surfaces from contamination must be removed and replaced as soon as feasible when they become overtly contaminated. Disposal of these materials will follow the procedures described in this plan.

All bins, pails, cans, and similar receptacles which can reasonably be anticipated to become contaminated with blood or other potentially infectious materials will be inspected and decontaminated on a weekly basis. If decontamination is necessary a 10 % bleach solution or other equally effective disinfecting agent that will remain on the surface for at least 10 minutes will be used.

Any broken glassware that could be contaminated will be picked up using a broom and dust pan or other mechanical device. No such broken glass will be picked up with the hands even if gloves are worn.

D. Regulated Waste

Contaminated sharps will be collected in leak proof, puncture resistant, closable containers and will be labeled in accordance with Section IV. A of this plan. During use, the containers will be easily accessible to personnel and as close as feasible to the immediate area where sharps are anticipated to be found. The Seton Hall University Health Service will provide sharps containers to insulin dependent students and will exchange the containers on a regular basis.

Sharps containers will not be allowed to overfill and will be maintained in an upright position during use. When moving containers of contaminated sharps from the area of use the containers shall be closed immediately prior to removal and placed in secondary containment if leakage is possible. The secondary containment must meet all requirements described in the paragraph above, including proper labeling.

The University Policy for the Disposal of Regulated Medical Waste (RMW) contains detailed information on classification, segregation, treatment, storage, packaging/labeling/marking, logging and tracking of waste. It also outlines specific procedures for disposal of RMW by Athletics, College of Nursing, Health Service, Neuroscience, Psychology, Chemistry, Biology and Laboratory Services.

III. Hepatitis B Vaccine and Post-Exposure Evaluation and Follow-Up

General

Seton Hall University will make available the Hepatitis B vaccine and vaccination series to all employees who have an occupational exposure, and post exposure follow up to any employees who have had an exposure incident.

It is the responsibility of the supervisors of the affected departments in conjunction with the Human Resources Department of Seton Hall University, to ensure that all medical evaluations and procedures including the Hepatitis B vaccination series and post-exposure evaluation and follow-up including prophylaxis, will be

Made available at no cost to the employee.
Made available to the employee at a reasonable time and place.
Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.
Provided according to recommendations of U.S. Public Health Service.

All laboratory tests will be conducted by an accredited laboratory at no cost to the employee.

Hepatitis B Vaccination

The hepatitis B vaccination will be made available to the employee following training as described in Section IV. B (Information and Training) of this plan, and within 10 working days of initial assignment to all employees who have occupational exposure (as listed in Section I.A and Section I.B.) unless the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. The employee will provide documentation of previous vaccination and/or immunity test results. The hepatitis B vaccination will be made available through Care Station, 456 Prospect Avenue, West Orange, NJ (973) 731-6767.

If the employee initially declines Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, it will then be made available.

All employees declining the Hepatitis B vaccination offered by the University must sign the OSHA required waiver indicating their refusal. A copy of this form can be found in Appendix B of this plan.

If, at a future date, a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service, such booster doses will be made available.

C. Post Exposure Evaluation and Follow-Up

Post Exposure Procedures

All exposure incidents shall be reported, investigated, and documented. When the employee incurs an exposure incident, it must be reported immediately (within minutes if possible) to the employee’s supervisor.

The exposed employee will immediately receive a confidential medical evaluation and follow-up, including at least the following elements:

Documentation of the route of exposure, and the circumstances under which the exposure incident occurred.
Identification and documentation of the source individual unless it can be established that identification is infeasible or prohibited by state or local law. Interpretation of state and/or local law can be obtained from agencies such as the Board of Medical Examiners and the Bureau of Labor and Industries, Civil Rights Division.
The source individual’s blood will 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 University will establish that legally required consent cannot be obtained.
When the source individual is already known to be infected with HBV or HIV, testing need not be repeated.
The results of the source individual’s testing will be made available to the exposed employee and the employee will be informed of applicable laws and regulations, as interpreted by such agencies as the Board of Medical Examiners and the Bureau of Labor and Industries, Civil Rights Division, concerning disclosure of the identity and infectious status of the source individual.
Collection and testing of blood for HBV and HIV serological status will comply with the following:
1. The exposed employee’s blood will be collected as soon as feasible and tested after consent is obtained.
2. If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. All post exposure follow-up will be performed by Care Station, 456 Prospect Avenue, West Orange, NJ (973) 731-6767 during normal business hours. For exposures occurring outside of normal business hours, post exposure follow-up will be performed at Hospital Center at Orange, 188 S. Essex St., Orange, NJ (973) 266-2000.

Exposed employees should seek medical attention as soon as possible (within minutes if possible) following an exposure incident.

An SHU Incident Report is to be completed following any exposure incident.

Information provided to the Healthcare Professional
The employee’s supervisor and the Human Resources Director will ensure that the healthcare professional responsible for the employee’s post-exposure care is provided with the following as soon as feasible following the event:
1. A copy of 29 CFR 1910.1030.
2. A written description of the exposed employee’s duties as they relate to the exposure incident.
3. Written documentation of the route of exposure and circumstances under which exposure occurred.
4. Results of the source individual’s blood testing, if available
5. All medical records relevant to the appropriate treatment of the employee including vaccination status.
Healthcare Professional’s Written Opinion

The Human Resources Office will obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.

The healthcare professional’s written opinion for HBV vaccination will be limited to whether HBV vaccination is indicated for the employee and if the employee has received such vaccination.

The healthcare professional’s written opinion for post exposure follow-up will be limited to the following information:

A statement that the employee has been informed of the results of the evaluation
A statement that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation of treatment.

NOTE. All other findings or diagnosis shall remain confidential and shall not be included in the written report.

IV. Labeling, Training, Record Keeping

Labels and Signs
The supervisor of each work area as described in Section II. C of this plan will ensure that bio-hazard labels will be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport or ship blood or other potentially infectious materials.

The universal bio-hazard symbol will be used as shown below. It will be fluorescent orange or orange-red. Red bags or containers may be substituted for labels. However, regulated wastes must be handled in accordance with federal, state, and local laws.
Information and Training

The Director of each work area covered by this plan will ensure that training is provided to all employees with potential occupational exposure at the time of initial assignment to tasks where occupational exposure may occur. The training will be repeated within twelve months of the previous training. Training will be tailored to the education and language level of the employee. The training will be interactive and will cover the following:

A copy of the standard and an explanation of its contents.
A discussion of the epidemiology and symptoms of bloodborne diseases.
An explanation of the modes of transmission of bloodborne pathogens.
An explanation of the Seton Hall University Bloodborne Pathogen Exposure Control Plan (this program). A copy of this plan will also be provided.
The recognition of tasks that may involve exposure.
An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices, and personal protective equipment (PPE).
Information on the types, use, location, removal, handling, decontamination, and disposal of PPE.
An explanation of the basis of selection of PPE.
Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge.
Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up.
Information on the evaluation and follow-up required after an employee exposure incident.
An explanation of the signs, labels, and color coding systems.

Additional training will be provided to employees when there are any changes of tasks or procedures affecting the employee’s occupational exposure.

Record Keeping
1. Medical Records

The Human Resources Department is responsible for maintaining medical records for any employee with occupational exposure. These records will be kept confidential and must be maintained for at least the duration of employment plus 30 years.

The records will include the following:

The name and social security number of the employee.
A copy of the employee’s HBV vaccination status, including the dates of vaccination.
A copy of all results of examinations, medical testing, and follow-up procedures as required by Section III of this plan.
A copy of the information provided to the healthcare professional, including a description of the employee’s duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure.

Training Records

The University Compliance Officer is responsible for maintaining training records. They will be maintained for three years from the date of training and will include the following information:
These training records will be made available to the employee upon request. These records will also be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.
Transfer of Records

If, for any reason, this institution is closed and there is no successor employer to receive and retain the records for the prescribed period, the Director of the NIOSH will be contacted for final disposition.

Appendix A

SUMMARY OF UNIVERSAL PRECAUTIONS IN THE WORKPLACE

Hands should be washed before and after patient contact. Hands should be washed immediately following contamination with blood or other body fluids. Hands should be washed after gloving.
Gloves should be worn for procedures where there is blood or body fluids containing blood. Gloves should be worn by healthcare workers who have cuts, abraded skin, chapped hands or the like. Gloves should be worn during an instrumental exam of the otopharnyx, GI or GU tract, when performing an invasive procedure, when performing phlebotomy, and when cleaning blood or body fluid spills and during decontamination procedures.
Gloves should be made of appropriate material and should be of appropriate size for each healthcare worker. Gloves should not be used if peeling, cracked, discolored, or have other evidence of deterioration. Latex-free gloves are to be available.
Gloves should not be washed or disinfected for reuse.
Gowns should be worn when performing tasks that may cause blood or other body fluid splashes to skin or clothing. Gowns should be made of or lined with impervious material and should protect all areas of exposed skin.
Masks and protective eye wear should be worn when performing tasks that may cause blood or other body fluid splashes to mucosal membranes
Resuscitation equipment that minimizes the need for emergency mouth-to-mouth resuscitation should be strategically located throughout the facility.
Protective attire should be available for use when performing invasive procedures, in laboratories for processing body fluid specimens, and when performing or assisting with post mortem procedures.
There should be a definition of housekeeping operations to minimize risks of direct exposure to blood and body fluids including provision of protective attire for cleaning blood and body fluid spills and use of an approved environmental disinfectant.
Sharps/needles should not be recapped or purposely bent or broken by hand. Sharps/needles should not be removed from disposable syringes, or otherwise manipulated by hand. Sharps/needles receptacles should not leak, should be maintained in a sanitary condition, and equipped with a tight fitting cover if necessary to maintain a sanitary condition. Safety syringes and/or needleless systems will be used in University Health Service.
Sharps/needles should be placed in puncture resistant containers after use. Such containers should be easily accessible to all personnel, and shall not spill their contents if knocked over.
Lab specimens should be transported in a manner to prevent leaking.
The use of tags (BIOHAZARD) should be used for preventing accidental injury or illness to employees exposed to hazardous conditions, equipment, or operations. Such tags/signal words should be readable at a distance of five feet or more. Tag messages should be written or presented in pictographs, and should be understandable by all employees who may be exposed to the hazard. Tags should be affixed as close as possible to their respective hazards in a manner so as to prevent loss or unintentional removal. Tagged material should be double bagged where puncture or outside contamination is likely.
Employees at substantial risk of contacting blood or body fluids should be offered hepatitis B vaccinations.
Soiled linen should be bagged at point of origin and should not be sorted or rinsed in patient care areas.
Reusable patient equipment should be disinfected or sterilized before reuse.
There should be a procedure in place to follow-up employee exposures to possible HIV/HBV.
There should be an employee training program to provide all personnel with an understanding of Universal Precautions as it applies to their work practices.

References:

Centers for Disease Control. Recommendations for prevention of HIV transmission in health care settings.

MMWR 36S; 2s:1S-19S, 1987.

OSHA Instruction CPL2-2.44A. Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus.

Appendix B

Seton Hall University

Please sign one of the following statements:

Employee Statement Declining the HBV Vaccination

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 (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline 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 hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Name: #9; Date: #9;

Witness: #9; Date: #9;

Employee Statement of Receipt of HBV Vaccinations

I have received hepatitis B vaccinations. The date of my initial vaccination was ______________ The date of my final vaccination was _______________. I received a total of _______ vaccinations in all.

Name: Date: #9;