Exposure Incidents | Bloodborne Pathogens

An exposure incident is 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. Examples of exposure incidents include:

• A puncture from a contaminated sharp;

• An emergency responder getting blood or OPIM in a cut or in the mouth while administering first aid or CPR to an injured employee; or

• Maintenance or janitorial personnel getting blood or OPIM in a cut or open sore while cleaning up following an incident.

Employees should immediately report exposure incidents. This allows for timely medical evaluation and follow-up by a health care professional as well as for timely testing of the source individual’s blood for HIV and HBV. Reports must be treated by employers in the strictest confidence.

Evaluating the incident

It is the employer’s responsibility to establish procedure for evaluating exposure incidents. When evaluating an exposure incident, thorough assessment and confidentiality are critical issues. At the time of the exposure incident, the exposed employee must be directed to a health care professional. The employer must provide the health care professional with a copy of the bloodborne pathogens standard, a description of the employee’s job duties as they relate to the incident, a report of the specific exposure (accident report), including route of exposure, and relevant employee medical records, including hepatitis B vaccination status.

The medical evaluation and follow-up must at the very least:

• Document the routes of exposure and how exposure occurred.

• Identify and document the source individual if feasible and not prohibited by law.

• Obtain consent and test source individual’s blood as soon as possible to determine infectivity and document the source’s blood test results. Testing cannot be done in most states without written consent. If consent is not obtained, the employer must show that legally required consent could not be obtained. Where consent is not required by law, the source individuals’s blood, if available, should be tested and the results documented.

• If the source is known to be infectious for HBV or HIV, testing need not be repeated to determine the known infectivity.

• Provide the exposed employee with the test results and information about applicable disclosure laws and regulations concerning the source identity and infection status.

• Obtain consent, collect, and test exposed employee’s blood as soon as possible after the exposure incident.

• If the exposed employee consents to baseline blood collection but does not consent to HIV serologic testing, the employee’s blood samples must be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee agrees to have the baseline sample tested, such testing shall be conducted as soon as feasible.

Following the post-exposure evaluation, the health care professional will provide a written opinion to the employer. This opinion is limited to a statement that the employee has been informed of the results of the evaluation and told of the need, if any, for further evaluation or treatment. All other findings are confidential. The employer must provide a copy of the written opinion to the employee within 15 days of the evaluation.

Labeling | Bloodborne Pathogens

Containers of regulated waste, refrigerators and freezers containing blood and other potentially infectious materials, and other containers used to store, transport, or ship blood or other potentially infectious materials must be labeled with fluorescent orange or orange-red biohazard warning labels. The warning label must contain the biohazard symbol and must have the word BIOHAZARD on it and be attached to each object by string, wire, adhesive, or another method to prevent loss or unintentional removal of the label.

Biohazard Symbol

These labels are not required:

1. When red bags or red containers are used;

2. On individual containers of blood, blood components or blood products clearly marked as such and which have been released for transfusion or other clinical use; or

3. On individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal.

Housekeeping

The Centers for Disease Control state that HBV can survive for at least one week in dried blood on surfaces so it’s very important to clean and sanitize properly. Contaminated work surfaces must be decontaminated with a disinfectant following an emergency incident. Take into consideration the appropriate methods of decontamination based upon the location within the facility, type of surface, types of contamination, if any, and tasks or procedures being performed.

Decontamination procedures

Clean up and decontamination must be done with appropriate disinfectants which include diluted bleach solutions and EPA-registered tuberculocides (List B), sterilants (List A), or products registered against HIV/HBV(List D). The lists of these EPA registered products are available from the National Antimicrobial Information Network at (800) 447-6349 or its website at (http://ace.orst.edu/info/nain/lists.htm). OSHA allows the use of these products provided the surfaces have not become contaminated with agents, volumes, or concentrations for which higher level disinfection is recommended.

Follow the label instructions regarding the amount of disinfectant and the length of time it must remain wet on the surface. For employees who will be responsible to clean up following a bloodborne pathogens related incident, training must include the proper use of the disinfectant.

Fresh solutions of diluted household bleach are also considered appropriate for disinfection of environmental surfaces and for decontamination of sites following initial wiping up of blood or other potentially infectious materials. Contact time for bleach is generally considered to be the time it takes the product to air dry.

Solutions of bleach should not be stored in glass containers, but in material such as the plastic in which the bleach, the consumer product, is packaged in. Household bleach (5.25 sodium hypochlorite) diluted to the appropriate strength for the clean up job at hand is also an effective disinfectant. In addition, gross contamination must be cleaned up first with a soap and water solution, to ensure the disinfectant is completely effective.

Work surfaces and containers

All equipment and working surfaces that could have become contaminated must be cleaned and decontaminated as necessary. If thorough decontamination cannot be done immediately, a label must be attached to equipment stating which portions of the equipment remain contaminated to inform downstream servicing/repair employees of the hazard and precautions they need to take.

All coverings used for protecting working surfaces should be removed and replaced as soon as possible after they have been contaminated. All bins, pails, cans, and similar reusable receptacles must be decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as possible after visible contamination.

Sharp objects

Broken glassware, which may be contaminated, must be picked up only by using mechanical means such as tongs, brush and dust pan, or forceps—never with bare or gloved hands. Contaminated reusable items, such as sharps, may not be stored or processed in a way that requires employees to reach into containers where the contents cannot be seen or safely handled.

Contaminated laundry

Contaminated laundry that has been contaminated with blood or other potentially infectious materials should be handled as little as possible with a minimum of agitation. Protective gloves and other appropriate personal protective equipment should be used when handling these materials. Contaminated laundry must be placed and transported in bags or containers which prevent soak-through or leakage and properly labeled according to the BBP labeling requirements.

When a facility exercises universal precautions when handling soiled laundry, alternative labeling or colorcoding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions. Employees should not take contaminated clothing or protective equipment home to launder. It is the employer’s responsibility to provide, launder, repair, replace, and dispose of such materials.

Regulated waste

Regulated waste must be placed in closeable, leak-proof containers built to contain all contents during handling, storing, transporting, or shipping and labeled appropriately. Regulated waste is defined as:

• 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; and

• Pathological and microbiological wastes containing blood or other potentially infectious materials.

OSHA does not generally consider discarded feminine hygiene products to fall within the definition of regulated waste. These products should be discarded in waste containers which are lined in such a way as to prevent contact with the contents. OSHA notes, however, that it is the employer’s responsibility to determine which job classifications or specific tasks and procedures involve occupational exposure. For example, the employer must determine whether employees can come into contact with blood during the normal handling of such products from initial pick-up through disposal in the outgoing trash.

Personal Protective Equipment | Bloodborne Pathogens

In addition to instituting engineering and work practice controls, appropriate personal protective equipment (PPE) should be used to reduce the risk of exposure. Personal protective equipment is specialized clothing or equipment worn by employees for protection from contact with blood or other potentially infectious materials. Employers must make appropriate personal protective equipment readily available at no cost to at-risk employees. There must be a variety of sizes to provide a good fit.

What is "Appropriate"?

Personal protective equipment will be considered "appropriate" only if it does not permit blood or other potentially infectious substances and contaminated materials to pass through to, or reach, an employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes. This is considered under normal conditions of use and for the duration of time the protective equipment is in use. Hypoallergenic alternatives must be available to employees who have an allergic sensitivity to protective equipment, such as hypoallergenic or powderless gloves.

Types of PPE

Personal protective equipment consists of, but is not limited to, gloves, face shields, masks, and eye protection, gowns, aprons, and similar items. It is the employer's responsibility to ensure that:

• Appropriate personal protective equipment is used;

• The PPE is used correctly; and

• Protective equipment is properly cleaned, laundered, repaired, replaced, or disposed of as needed.

Disposable gloves should be a standard component of emergency response equipment and should be donned by all personnel prior to initiating any emergency patient care tasks involving occupational exposure. Extra pairs should always be available. There is no single type or thickness of glove appropriate for all situations. Selection criteria should include dexterity, durability, fit, and the tasks that will be undertaken while the gloves are worn.

PPE Declination

An employee may temporarily and briefly decline wearing personal protective equipment under rare and extraordinary circumstances, and when in the employee's professional judgment, it prevents the delivery of health care or public safety services or poses a greater hazard to workers. For example, in the case of emergency responders, this could occur when a firefighter rescues an individual who is not breathing from a burning building and discovers that the necessary resuscitation equipment is lost or damaged and the firefighter must administer cardiopulmonary resuscitation.

When the employee makes this judgment, the circumstances must be investigated and documented to determine whether changes can be instituted to prevent such occurrences in the future. In general, appropriate personal protective equipment is to be used whenever occupational exposure may occur.

The employer also must ensure that employees observe the following precautions for handling and using personal protective equipment:

• Remove garments penetrated by blood or other infectious materials immediately, or as soon as feasible.

• Before leaving the work area contaminated protective equipment must be placed in appropriately designated areas or containers for storing, washing, decontaminating, or discarding.

• Wear appropriate gloves when there is a potential for hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.

  An exception to this occurs when an employee in a volunteer blood donation center judges that routine gloving for phlebotomies is not necessary. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised.

• Disposable (single use) gloves, such as surgical or examination gloves, must be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. They cannot be washed or decontaminated for reuse.

• Utility gloves may be decontaminated for reuse if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration, or when their ability to function as a barrier is compromised.

• Wear appropriate face and eye protection such as goggles, glasses with solid side shields or chin-length face shields when splashes, sprays, spatters, or droplets of infectious materials pose a hazard to the eyes, nose, or mouth. These should be available on all emergency vehicles.

• Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. These should be used in accordance with the level of exposure encountered.

• An extra change of work clothing should be available.

Methods of Control | Bloodborne Pathogens

Engineering and work practice controls are the primary methods used to control the transmission of HBV and HIV. To the extent feasible, the employer must institute these controls to eliminate or minimize employee exposure to bloodborne diseases.

Engineering Controls

Engineering controls reduce employee exposure in the workplace by either removing the hazard or isolating the worker from exposure. Self-sheathing needles and special containers for contaminated sharp instruments are examples of engineering controls. Engineering controls must be examined and maintained or replaced on a scheduled basis.

For example, disposable airway equipment or resuscitation bags and mechanical respiratory assist devices, such as oxygen demand valve resuscitators, should be available on all emergency vehicles and to all emergency response personnel who respond to medical emergencies or victim rescues. Pocket mouth-to-mouth resuscitation devices designed to isolate emergency response personnel from direct contact with fluids should be provided.

Puncture-resistant sharps containers must be easily accessible and located in areas where needles, syringes, or other sharp instruments are commonly used.

Work Practice Controls

Work practice controls alter the manner in which a task is performed. Correct work procedures include proper handling and disposal of needles and sharps, used bandages and gauze, linens, and all other emergency items that come in contact with blood or other potentially infectious materials.

All procedures involving blood or other potentially infectious materials must be performed in such a manner as to minimize spattering, generating droplets, splashing, and spraying. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.

Needles and sharps

• Shearing or breaking of needles is prohibited. Needles must not be bent, removed, or recapped unless it can be demonstrated that no alternative is feasible or that such action is required by a specific medical procedure. Any recapping or removing of needles must be done through the use of a mechanical device or one-handed technique.

• Revised: 2002/10
  Blood tube holders with needles attached must be immediately discarded into a sharps container after the device’s safety feature is activated.

• Immediately, or as soon as possible after use, contaminated reusable sharps must be placed in puncture- resistant, leak-proof containers, labeled as a biohazard, or color-coded red until properly reprocessed. Specimens of blood or other potentially infectious materials must be placed in leak-proof containers.

Disposal receptacles

• Bags or receptacles containing articles or disposable items contaminated with body fluids must be labeled or color-coded according to the requirements of the BBP standard.

Restrictions

• In work areas where there is a reasonable likelihood of occupational exposure, safe work practices include restricting eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses, and preventing the storage of food and/or drink in refrigerators or other locations where blood or potentially infectious materials are kept.

Washing facilities

• Employers must provide readily accessible hand washing facilities and ensure that personnel wash hands and any other exposed skin area with soap and water, and flush mucous membranes with water immediately or as soon as feasible following contact with blood or other potentially infectious materials or after removing personal protective equipment.

• If hand washing facilities are not available, employees must be provided with antiseptic hand cleanser, clean cloth/paper towels, or antiseptic towelettes. In this instance, employees must be instructed to wash their hands with soap and running water as soon as possible.

Contaminated equipment

• Equipment, other than personal protective equipment, which during the course of operations could become contaminated with blood or other potentially infectious materials, must be checked routinely and, prior to servicing or shipping, must be decontaminated, unless the employer can demonstrate that decontamination of the equipment or portions of it is not feasible.

Law enforcement officers

• For law enforcement officers, there is a potential for exposure during searches and evidence handling. In these instances, employees should use caution in searching clothing and in searching purses or other similar items. Where the contents cannot be determined easily, contents should be emptied by turning the bag upside down over a flat surface. Also, to avoid tearing gloves, use evidence tape instead of staples to seal evidence.

Training At-Risk Employees | Bloodborne Pathogens

All employees with a potential for exposure must be provided with adequate training and information including:

1. General explanations of the modes of transmission, symptoms, epidemiology, warning signals relating to possible exposure, and procedures to follow if exposure occurs.

2. Appropriate methods for recognizing tasks that may involve exposure to blood or other potentially infectious materials and the use and limitations of practices that would reduce exposure. This includes engineering controls, work practices, and personal protective equipment.

3. Information on the use, location, and decontamination/disposal of personal protective equipment and clothing, and information on what to do in an emergency.

Each occupationally exposed employee must be given free BBP information and training at the time of initial assignment and at least once a year thereafter. The training must be provided during working hours. Additional training is needed when existing tasks are modified or new tasks are required which affect the employees' occupational exposure.

A variety of written material, oral presentations, films, videos, computer programs, or audiotapes can be used in the training program. The information that is presented must be appropriate to the employee's education, literacy level, and language.

OSHA requires that the trainer provide opportunities for interactive questions and answers with trainees. That means that training done solely with a video or film without a discussion period would be a violation of the BBP standard. However, direct access to a qualified trainer via a telephone hot line or an immediate e-mail answer is an acceptable alternative.

Training Program Elements

Training sessions must be comprehensive, including information on bloodborne pathogens as well as on OSHA regulations relating to this standard and the employer's exposure control plan.

At a minimum, the training program must include the following elements:

• An accessible copy and explanation of the standard;

• A general explanation of the epidemiology and symptoms of bloodborne diseases;

• An explanation of the modes of transmission of bloodborne pathogens;

• An explanation of the written exposure control plan and how to obtain a copy;

• An explanation of how to recognize events that may involve exposure to blood and other potentially infectious materials;

• An explanation of the basis for selecting personal protective equipment, including information on the types, selection, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment;

• An explanation of the use and limitations of safe work practices, engineering controls, and personal protective equipment;

• Information on hepatitis B vaccination, such as safety, benefits, effectiveness, and availability;

• An explanation of the procedures to follow if an exposure occurs, including methods of reporting and the medical follow-up that will be made available;

• Information on the post-exposure evaluation and follow-up required in the event of an exposure, and information on emergencies that relate to blood or other potentially infectious materials, follow-up procedures, and medical counseling;

• An explanation of information on warning signs, labels, and color-coding.

Trainer Qualifications

The person conducting the training must be knowledgeable in the subject matter, especially as it relates to the workplace that the training addresses. Trainer competency should be based on the completion of specialized courses, degree programs, or work experience.

Possible trainers include a variety of healthcare professionals such as infection control practitioners, nurse practitioners, registered nurses, occupational health professionals, physician's assistants, and emergency medical technicians.

Non-healthcare professionals, such as but not limited to, industrial hygienists, epidemiologists, or professional trainers, may conduct the training provided they are knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace.