Bloodborne Pathogens Exposure Control Plan

Table of Contents

1. Statement
2. 2.0 Purpose/Scope
3. Definitions
4. References
5. Responsibilities
6. Exposure Determination
7. Universal Precautions
8. Engineering & Work Practice Controls
9. Personal Protective Equipment (PPE)
10. HIV, HBV, HCV Research
11. Hepatitis B Vaccination
12. BBP Post-Exposure Evaluation and Follow-up
13. Communication of Hazards to Employees
14. Recordkeeping
15. Links to Forms

1.0 Statement

It is the intent of California State University Channel Islands to provide employees and visitors with a safe and healthful environment. To this end, the University has established a Bloodborne Pathogens program which includes protections and safeguards for University employees exposed to blood and other potentially infectious materials during their normal job duties.

2.0 Purpose/Scope

2.1 Purpose

To establish a program that reduces the risk of occupational exposure to blood and other potentially infectious materials which also complies with the requirements specified in California Code of Regulations Title 8 §5193 "Bloodborne Pathogens".

2.2 Scope

The Bloodborne Pathogens Program applies to all University employees who have potential for occupational exposure to blood or other potentially infectious materials during their normal job duties.

3.0 Definitions

Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. Pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

Contaminated: The presence or the reasonably anticipated presence of blood or other potentially infectious materials on a surface, or in or on an item.

Engineering Controls: Controls (e.g. sharps disposal containers, needleless systems and sharps with engineered sharps injury protection) that isolate or remove the bloodborne pathogen(s) hazard from the workplace.

Engineered Sharps Injury Protection:

1. A physical attribute built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, which effectively reduces the risk of an exposure incident by a mechanism such as barrier creation, blunting, encapsulation, withdrawal or other effective mechanisms; or
2. A physical attribute built into any other type of needle device, or into a non-needle sharp, which effectively reduces the risk of an exposure incident.

Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee's duties

Other Potentially Infectious Materials (OPIM):

1. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and other body fluid that is visibly contaminated with blood such as saliva or vomitus, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids such as in emergency response;
2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead);
3. Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV:
• Cell, tissue, or organ cultures from humans or experimental animals;
• Blood, organs, or other tissues from experimental animals; or
• Culture medium or other solutions.

Personal Protective Equipment: Specialized clothing or equipment worn or used by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Sharp: Any object used or encountered that can be reasonably anticipated to penetrate the skin or any other part of the body, and to result in an exposure incident, including, but not limited to, needle devices, scalpels, lancets, broken glass and broken capillary tubes.

Universal Precautions: An approach to infection control; according to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and HCV, and other blood borne pathogens.

4.0 References

California Code of Regulations Title 8, Section 5193

5.0 Responsibilities

5.1 Environment, Safety, Risk Management

1. Establish and update the written "Exposure Control Plan".
2. Provide employee training as necessary.
3. Maintain copies of any "Exposure Incident Report".
4. Provide consultation to departments that have employees who may be exposed to bloodborne pathogens.

5.2 Deans, Directors, and other heads of administrative units

1. Provide the resources necessary to ensure that Personal Protective Equipment (PPE) is available for affected employees.
2. Ensure that all employees whose exposure determination is identified as Category I (Section 6.0) are offered Hepatitis B vaccinations in accordance with Section 11.0.
3. Ensure that all exposure incidents are documented on the Exposure Incident Report Form (Section 15.0) and reported to the Environment, Safety, and Risk Management Office.
4. Following an incident, ensure that the "Post Exposure Evaluations and Follow-up" provisions are completed and documented (Section 12.0).

5.3 Employees covered by the Exposure Control Plan

1. Understand the applicable components of the Exposure Control Plan.
2. Adhere to the practices and procedures of Universal Precautions.
3. Report any exposure, accident, injury or illness to their supervisor or Environment/Safety/Risk office.

6.0 Exposure Determination

Exposure determinations are based on an employee's reasonable potential for occupational exposure to blood or OPIM. The following exposure determination and task assessments shall be made without regard to the use of personal protective equipment.

Category I: Tasks that involve direct contact with blood, body fluids, or tissues. All procedures, or other job-related tasks that involve an inherent potential for percutaneous, mucous membrane, or skin contact with blood or OPIM, are Category I tasks. The use of appropriate protective measures will be required for every employee engaged in Category I tasks.

Category II: Tasks that involve no exposure to blood or OPIM, but may require performing unplanned Category I tasks. The normal work routine involves no contact with blood or OPIM, but contact may be required as a condition of employment. Appropriate protective measures shall be readily available for every employee engaged in Category II tasks.

Category III: University employees not classified in Category I or II of this section. These employees do not perform tasks that involve contact with blood or OPIM, and Category I tasks are not a job requirement. The normal work routine does not involve contact with blood or OPIM. Persons who perform these duties are not called upon as part of their job responsibilities to perform any category I tasks or assist in emergency medical care or first aid.

7.0 Universal Precautions

The University adheres to the practice of "Universal Precautions" to prevent contact with blood and other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials, regardless of the perceived status of the source individual.

8.0 Engineering & Work Practice Controls

Whenever practical and feasible, engineering controls shall be used as a first line of defense against occupational exposure to bloodborne pathogens. Work practice controls designed to either remove or isolate the employee from exposure will be used if engineered controls are not possible. Personal protective equipment will be the last option for employee protection.

8.1 Prohibited practices

1. Shearing or breaking of contaminated needles and other contaminated sharps.
2. Contaminated sharps shall not be bent, recapped, or removed from the devices.
3. Sharps that are contaminated with blood or OPIM shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
4. Disposable sharps shall not be reused.
5. Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps.
6. The contents of sharps containers shall not be accessed unless properly reprocessed or decontaminated.
7. Sharps containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of sharps injury.
8. Mouth pipetting/suctioning of blood or OPIM is prohibited.
9. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
10. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or OPIM are present.

8.2 Handling Contaminated Sharps

1. Contaminated sharps shall be discarded immediately or as soon as possible after use.
2. All sharps containers for contaminated sharps shall be easily accessible to personnel and located close to the immediate area where sharps are used.

8.3 Sharps Containers

1. All sharps containers for contaminated sharps shall be rigid, puncture resistant, leak proof on the sides and bottom, and must be properly labeled.
2. All sharps containers shall be maintained upright throughout use, and replaced when necessary.
3. Sharps containers shall not be filled beyond the line indicated on the container itself, or no more than ¾ full.
4. Sharps containers shall not be reused.
5. When moving containers of contaminated sharps from the area of use, the containers shall be closed prior to removal or replacement to prevent spillage or protrusion of contents.
6. If leakage of the primary container is possible, a secondary container must be used to prevent leakage during transport and handling. The secondary container must be properly labeled to identify the contents.

8.4 Regulated Waste

Contaminated wastes may be regulated. Please contact the Environment, Safety, Risk Management Office for proper disposal.

8.5 Handling Specimens of OPIM

Specimens of potentially infectious materials shall be placed in a container which prevents leakage during the collection, handling, processing, storage, transport, or shipping.

If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage.

8.6 Cleaning and Decontamination of Worksite

1. Disinfectants and/or germicides shall be applied to working area surfaces to ensure the area is maintained in a clean and sanitary condition.
2. Each Program is responsible for maintaining an appropriate cleaning and decontamination schedule.
3. Working surfaces and equipment shall be cleaned after completion of working procedures, when these items are overtly contaminated, immediately after a spill of blood or OPIM, routinely after the end of the work shift, or prior to maintenance or servicing.
4. Protective clothing shall be worn during clean-up procedures (i.e. gloves, goggles).
5. Reusable items that may be potentially infectious will be decontaminated before washing or reprocessing.
6. All containers, bins, pails, cans or similar receptacles intended for use in the disposal of infectious waste shall have a lid or top on the container. These containers should be collected on a daily basis or when the container becomes full.

8.7 Hygiene

1. Employees shall wash their hands immediately, or as soon as possible, after the removal of gloves or other personal protective equipment.
2. Following any contact of skin with blood or any other infectious materials, employees shall wash the affected area with soap and water as soon as possible. Mucous membranes must be flushed with water if exposed.

8.8 Laundry

1. Contaminated laundry shall be handled as little as possible.
2. Universal Precautions shall be utilized in the handling of all potentially contaminated laundry.

9.0 Personal Protective Equipment (PPE)

1. Wearing personal protective equipment can greatly reduce potential exposure to all bloodborne pathogens.
2. All personal protective equipment required for use must be readily accessible to employees and is chosen based on the anticipated exposure to blood or other potentially infectious materials.
3. Protective equipment is considered appropriate only if it does not permit blood or OPIM to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of use.
4. Personal protective clothing and equipment must be removed before leaving the work area or when the PPE becomes contaminated.
5. If a garment is penetrated, workers must remove it immediately or as soon as feasible.
6. When removed, PPE shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.

9.1 Gloves

1. If an employee is expected to have direct hand contact with blood or OPIM or contaminated surfaces, gloves must be worn.
2. Single use gloves cannot be washed or decontaminated for reuse.
3. Disposable gloves shall be properly disposed of if visibly soiled, torn, or damaged.
4. Gloves are not to be removed or worn outside the work area.

9.2 Masks, Eye Protection, Face Shields

This PPE will be worn singularly or in combination as guidelines specify. They will be worn when the potential exists for spattering, spraying, splashing droplets or aerosols of blood or any other potentially infectious materials may be present. Use of this PPE applies when the employees eyes, nose, or mouth are potentially exposed to contamination.

10.0 HIV, HBV, HCV Research

CSU Channel Islands is not currently involved in HIV, HBV or HCV research. Professors wishing to conduct such research in the future should submit their proposal to the campus Biosafety Committee.

11.0 Hepatitis B Vaccination

The hepatitis B vaccination series shall be made available to all employees whose exposure determination is identified as being in Category I (Section 6.0), 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 hepatitis vaccination program consists of the following:

1. Made available at no cost to eligible employees.
2. Made available to the employee at a reasonable time and location.
3. Performed under the supervision of a licensed physician or healthcare professional.
4. Provided according to the recommendations of the U.S. Public Health Services.
5. Made available after the employee has received the training in occupational exposure and within 10 working days of initial assignment to all employees who have occupational exposure.
6. If an employee initially declines the hepatitis B vaccination, but at a later date chooses to receive the vaccination while still eligible and employed by CSU Channel Islands, the vaccination shall then be made available.
7. All employees who decline the hepatitis vaccination shall sign the Hepatitis B Vaccination Declination Form (Section 15.0).

12.0 BBP Post-Exposure Evaluation and Follow-up

12.1 Procedures

All exposure incidents shall be reported, investigated, and documented. Following a report of an exposure incident, the following procedure must be performed.  The first response is time critical and certain actions must be completed within 24 hours.

1. The exposure incident must be reported immediately to your supervisor, and the Environment, Safety and Risk Management Office (extension 8847).
2. The" Exposure Incident Report Form" (Section 15.0) must be filled out immediately.
3. A full HBV vaccination series will be made available within 24 hours to affected employees that have not received the pre-exposure vaccination series.
4. The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained. If the employee consents to blood collections, but does not give consent for testing, the sample must be preserved for 90 days. The employee may elect, during that time, for testing to be done. Additional testing and collection will be made available as recommended by the U.S. Public Health Service.
5. A confidential medical evaluation and follow-up will be made available to the employee.
6. A "Supervisor's Injury or Illness Report" must be filed with the Environment, Safety and Risk Management Office (extension 8847). (Section 15.0)
7. The employee and his/her immediate supervisor will complete the "Sharps Injury Log" (Section 15.0) within 14 days for a sharps injury; defined as injury caused by a sharp, including but not limited to, cuts, abrasions or needle sticks. This information will be collected in such a manner as to protect the exposed employee's confidentiality.
8. A Post-Exposure Evaluation and Follow-up form (Section 15.0) must be completed.
9. Identification of the source individual must be made, if possible. The source individual's blood must be tested if consent can be obtained. Source testing is not needed if it is already known that the individual is infected with HBV or HIV. Results of the test must be made available to the exposed employee.

12.2 Information Provided to the Healthcare Professional

The following information shall be provided to the attending physician:

1. A copy of the Bloodborne Pathogen Standard CCR Title 8, 5193
2. Description of the affected employee's job duties and history regarding the occupational exposure.
3. Documentation of the route of exposure and circumstances under which exposure occurred (Exposure Incident Report Form, Section 15.0).
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.

12.3 Healthcare Professional's Written Opinion

The attending physician shall provide the University with the following information in writing within 15 days from completion of the evaluation:

1. An opinion whether or not a vaccination for Hepatitis B is indicated and the series has been initiated.
2. That the employee has been informed of the results of the evaluation.
3. That the employee has been told about any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment.

13.0 Communication of Hazards to Employees

Communicating hazards to employees who may potentially come into contact with bloodborne pathogens is a vital component of this program in order to eliminate or minimize exposure.

13.1 Signs and Labels

1. The proper biohazard labels shall be affixed to all collection or storage containers of potentially infectious materials. This includes any containers or equipment (e.g. refrigerator) used to store, transport or ship blood or other potentially infectious materials.
2. The labels shall include the universal biohazard symbol and the legend BIOHAZARD. In the case of regulated waste BIOHAZARDOUS WASTE may be substituted.
3. The labels shall be fluorescent orange or orange-red.

13.2 Information and Training

Employee training will be conducted prior to assignment of tasks where the potential for occupational exposure to bloodborne pathogens is present. In addition, these employees will be retrained at least annually on the following elements:

1. An accessible copy of Title 8, California Code of Regulations, Section 5193, "Bloodborne Pathogens" and an explanation of its contents.
2. A general explanation of the epidemiology and symptoms of bloodborne diseases.
3. Information regarding the modes and methods of transmission of bloodborne disease.
4. An explanation and an accessible copy of the campus Exposure Control Plan.
5. Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
6. Use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, administrative or work practice controls, and personal protective equipment.
7. Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
8. The basis for selection of personal protective equipment.
9. Information on the hepatitis B vaccine, including information on its efficiency, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
10. Appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
11. Procedures to follow if an exposure incident occurs, including the method of reporting the incident, the medical follow-up that will be made available, and the procedure for recording the incident on the Sharps Injury Log. (Section 15.0)
12. Information on the post-exposure evaluation and follow-up that is provided following an exposure.
13. An explanation of the signs, labels, and color coding requirements.
14. An opportunity for interactive questions and answers.
15. All training shall be documented and maintained for a period of at least 3 years.

14.0 Recordkeeping

1. All records should be maintained on the forms provided in the appendices of this document.
2. Training records will be maintained by the applicable department and overseen by EHS.
3. Medical records and exposure incident reports shall be maintained in Human Resources.
4. All medical records shall be confidential and will not be disclosed to any person except where regulation requires. Each record will be maintained for the duration of employment plus 30 years in accordance with Section 3204. The records shall include the following:

• The name and social security number of employees.
• A copy of the employee's HBV vaccination status, including the dates of vaccination and ability to receive vaccination.
• A copy of all results of examinations, medical testing, and follow-up procedures.
• A copy of the information provided to the healthcare professional.
• A confidential copy of the healthcare professional's written opinion.

Revisions

15.0 Links to Forms

• Exposure Incident Report Form (PDF)
• Hepatitis B Vaccination Form (PDF)
• Post-Exposure Evaluation and Follow-up Form (PDF)
• Sharps Injury Log
  (PDF)
• Reporting of Injury or Illness