Policies

Policies

Blood-Borne Pathogen Exposure Control Plan

Table of Contents

  1. Introduction (HIV, HBV General Information)
  2. Purpose
  3. Exposure Determination
  4. Methods of Compliance
    1. Universal Precautions
    2. Engineering Controls
    3. Work Practice Controls
    4. Personal Protective Equipment
    5. Standard Operating Procedures
    6. Infectious Waste Disposal
  5. Responsibilities of Employees/Students/Other Designated Persons
  6. Exposure Incident Protocol
  7. Person's Responsibilites
  8. Supervisor Responsibilities
  9. Sindecuse Health Center Responsibilities
  10. Office of Environmental Safety and Emergency Management Responsibilities
  11. Hepatitis B Vaccination
  12. Treaining and Education
  13. Appendicies

Introduction

Human Immunodeficiency Virus (HIV) is a blood-borne and sexually transmitted virus that ultimately causes Acquired Immune Deficiency Syndrome (AIDS). AIDS develops after HIV invades and destroys the body's immune system making it vulnerable to life-threatening infections, rare forms of cancer and deterioration of the nervous system. Current information suggests that the vast majority of persons infected with HIV will progress to AIDS. Current medications appear to slow the progression of the disease, but are not a cure. HIV infection has reached epidemic proportions in the United States. It is currently estimated that 1,039,000 to 1,185,000 people are HIV infected. For every diagnosed case of AIDS there are seven HIV positive cases. Most have not been tested and are unaware of their infection. There is currently no cure for HIV infection.

Hepatitis B Virus (HBV) is also a blood-borne and sexually transmitted virus, which generally causes a self-limited liver infection (hepatitis). Some persons, however, will develop life-threatening liver diseases (chronic hepatitis, cirrhosis) and carry an increased risk for liver cancer. Some will become chronic carriers of the virus, retaining the ability to infect others. The United States contains an estimated 1 million HBV carriers.

Most persons infected with HIV, and some infected with HBV, are unaware of their infection. Since the medical history, the physical examination and laboratory testing cannot reliably identify all persons infected with HIV/HBV or other blood-borne pathogens, precautions shall be used consistently for handling blood and blood products from all persons. This approach is referred to as "Universal Precautions."

Purpose

  1. To define formal infection control procedures to protect Western Michigan University employees, students, and other designated persons from occupational and classroom exposure to blood, bodily fluids, or other potentially infectious material.
  2. To ensure Western Michigan University's compliance with State and Federal rules protecting all persons against occupational and classroom exposure to blood-borne pathogens.
  3. To define the appropriate evaluation and follow-up procedures to handle accidental injury/exposure for faculty, staff, and students.
  4. To update policies and operating procedures reflecting changes in technology reducing/eliminating exposure to blood, body fluids, or other potentially infectious material.

Exposure Determination

The potential for occupational exposure to blood-borne pathogens has been classified into the following two categories based on OSHA guidelines.

  1. Category A consists of occupations that require procedures or other occupation related tasks that involve exposure or reasonably anticipated exposure to blood or other potentially infectious material or that involve a likelihood for spills or splashes of blood. This includes procedures or tasks conducted in non-routine situations as a condition of employment.
    1. The following are some job classifications or duties that fall into category A.
      • Child care providers
      • Custodial Services staff
      • Direct Health Care Providers
      • Environmental Safety and Emergency Management(ESEM) Staff
      • First Aid/CPR/AED providers
      • Glaziers
      • Plumbers/Pipefitters
      • Public Safety Police Officers
      • Others, as approved by (ESEM)

      Environmental Safety and Emergency Management has a complete listing of the specific departments that have job classifications with exposure. For information on standard operating procedures (SOP's) for category A occupations see Appendix A.

  2. Category B consists of occupations that do not require tasks that involve exposure to blood or other potentially infectious material on a routine or non-routine basis as a condition of employment. Employees in occupations in this category do not perform or assist in emergency medical care or first aid and are not reasonably anticipated to be exposed in any other way. The areas not listed above in #1 are considered to have job classifications in the B category.

Methods of Compliance

  1. Universal Precaution
    1. The term "Universal Precautions" refers to an approach to infection control developed by the Centers for Disease Control and the National Institutes of Health in which blood and bodily fluids of all people are handled as if they contain blood-borne pathogens.
      1. Body fluids to which Universal Precautions apply:
        1. Blood and other bodily fluids containing visible blood (Blood is the single most important source of HIV, HBV, and other blood-borne pathogens in the occupational setting.)
        2. Semen and vaginal secretions. (These have been implicated in sexual transmission but have not been implicated in occupational transmission.)
        3. Bodily fluids. (Spinal fluid, joint fluid, fluid surrounding the heart and lungs, or amniotic fluid.)
        4. Any undetermined bodily fluid.
        5. These materials are called other potentially infectious materials (OPIM)
      2. Body fluids to which Universal Precautions may not apply:
        1. Urine
        2. Nasal Secretions
        3. Feces
        4. Sputum, Phlegm, (Lung Secretions)
        5. Sweat
        6. Tears
        7. Vomitus
        8. Saliva
        9. (Unless any of the above contain visible blood)
      3. All standard infection control procedures regarding these body fluids still apply and must be followed.
  2. Engineering Control
    1. Engineering controls, with work practice controls and personal protective equipment, function together to minimize exposure incidents. The use of all three controls is mandated by MIOSHA.
    2. Engineering controls are items designed to isolate or keep infectious materials away from staff and others. Where engineering controls will reduce employee exposure, either by removing, eliminating, or isolating the hazards, they must be used. All engineering controls must be well maintained. The following are examples of engineering controls.
      1. Hand-washing facilities must be readily accessible to staff wherever occupational exposure may occur, or approved alternative hand-washing methods i.e., antiseptic towelettes and clean paper or cloth towels followed by soap and water washing as soon as possible must be made available.
      2. Containers for used sharps must be puncture resistant, leak-proof, labeled or color-coded, and located as close as possible to the places where sharps are used.
      3. Specimen containers must be leak-proof, properly labeled or color-coded.
      4. Appropriate containers for other regulated waste.
      5. Mechanical pipettes. Pipetting by mouth is specifically prohibited by OSHA.
      6. Laboratory equipment specific to the type of work involved.
      7. It is recommended that all departments shall have a first aid kit easily accessible. All departmental first aid kits shall contain a disinfectant.
    3. Engineering controls also includes controls ( e.g., self-sheathing devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogen hazard from the workplace. Input from non-managerial employees will be solicited regarding consideration of safer medical devices.
  3. Work Practice Controls
    1. Eating, drinking, smoking, applying cosmetics, and handling contact lenses are prohibited in work areas and/or work surfaces that carry an inherent potential for contamination. Food and drink must not be stored in refrigerators, freezers, or cabinets where blood or other potentially infectious materials are stored. Such storage equipment must be clearly labeled to prevent this possibility.
    2. Hands and other skin surfaces contaminated with blood or other potentially infectious materials shall be washed immediately and thoroughly with soap and water. Mucous membranes, if contaminated, must be washed thoroughly with water. Hands must be washed immediately after gloves are removed, even if the gloves appear to be intact.
    3. Precautions shall be taken to prevent injuries caused by contaminated sharps such as razor blades, broken glass, needles, scalpels, or other sharp instruments. Used needles shall not be bent, broken, reinserted into their original sheaths, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes, needles, scalpel blades, and other sharp items shall be placed in a puncture resistant container. Puncture resistant containers shall be located as close as practical to the use area and shall be available to all persons using needles (including diabetic students on campus) and other sharps as indicated above. These containers will not be located in areas open to the public. These containers are to be labeled "Biohazard."
    4. New protective device use will be implemented, with employee training as appropriate.
    5. All persons who have open wounds or weeping skin rashes shall refrain from all direct patient/client care, potentially hazardous laboratory procedures, and from handling patient-care equipment until the condition resolves. Cuts or abrasions shall be protected with a dressing and gloves prior to performing any procedure involving contact with blood and other potentially infectious materials.
    6. Pregnant persons shall be especially familiar with and strictly adhere to Universal Precautions. Infection in the mother places the fetus at risk of acquiring the infection.
    7. Blood spills shall be cleaned up promptly with an approved hospital disinfectant. ESEM must be contacted regarding approved hospital disinfectants. Germicides vary in their activity against infectious agents and in the time needed for disinfection. Manufacturer's guidelines shall be followed.
    8. Large work areas contaminated by blood or bodily fluids must be thoroughly cleaned, flooded with a liquid germicide, cleaned again, and de-contaminated with fresh germicide.
    9. Medical equipment that requires sterilization or disinfection shall be thoroughly cleaned before disinfecting and care must be taken to follow manufacturer's guidelines for compatibility with the germicides. This also applies to non-medical equipment.
    10. Contaminated laundry, including employee's uniforms, shall be placed in labeled or color-coded, leak-proof containers at the location where it was used. The employer shall ensure that employees who have contact with contaminated laundry wear appropriate personal protective equipment.
    11. HBV vaccine shall be offered at Department expense, to all persons whose occupational tasks place them at risk of exposure to blood or other potentially infectious materials.
    12. All supervisors/instructors shall be responsible for informing persons of any special precautions pertinent to their area.
    13. No Human Immunodeficiency Virus shall be used for research purposes on this campus, without prior approval of the Recombinant DNA Bio-Safety Committee under the auspices of the Vice President for Research. All NIH and CDC guidelines shall be followed.
  4. Personal Protective Equipment
    1. Protective barriers reduce the risk of exposure of a person's skin or mucous membranes to fluids that require Universal Precautions. The following are required protective barriers:
      1. Gloves shall be worn for touching human blood, bodily fluids, mucous membranes, or skin with open wounds or weeping rashes; for touching items or surfaces soiled with blood or bodily fluids; for performing venipuncture or other procedures that enter blood vessels.
      2. Latex, hypoallergic, or vinyl disposable exam gloves, in suitable sizes, shall be used for all medical and laboratory procedures. Hands shall be washed and gloves changed between patient contacts. Gloves shall not be washed in lieu of changing. Use of soaps will compromise their ability to be an effective barrier. Employees with a latex allergy are to notify their supervisor. Appropriate accommodations will be made for those persons.
      3. General-purpose utility gloves shall be used for housekeeping chores involving possible blood and other potentially infectious material contact and for instrument and equipment cleanup and decontamination procedures. Gloves extending beyond the wrist are preferable. Gloves must be compatible with cleaning and disinfecting chemicals.
      4. Masks, protective goggles, and face shields shall be worn if aerosolization or splattering of blood or other potentially infectious material is likely to occur.
      5. Gowns, fluid-proof aprons, laboratory coats, tyvek suits, or other protective clothing shall be worn if blood splattering or spattering of other potentially infectious material is likely.
      6. Resuscitation devices, including mouth-pieces, masks, resuscitation bags, or other ventilation devices shall be strategically located and available for use in areas where the need for resuscitation is predictable. All appropriate personnel shall be trained in their use.
      7. Disposable personal protective equipment shall be disposed of properly and not reused. Reusable equipment shall be cleaned and de-contaminated properly soon after use (see Work Practice Controls C.8).
  5. Standard Operating Procedure (SOP)
    1. Task specific operating procedures shall be written and updated annually by the departments that have employees that are indicated in the Category A definition. These SOPs shall be reviewed with employees at least annually.
  6. Infectious Waste Disposal
    1. Infectious waste is defined as the following:
      1. Cultures and stocks of infectious agents and associated biologicals, including laboratory waste, biological production wastes, discarded live and attenuated vaccines, culture dishes, and related devices.
      2. Liquid human and animal waste, including blood and blood products and other potentially infectious materials (as defined under Universal Precautions, pg. 3). This includes materials crusted or soaked with blood or bodily fluids, but does not include urine or materials stained with blood or bodily fluids.
      3. Pathological waste (human organs, tissues, body parts, fluids).
      4. Sharps (needles, scalpels, syringes).
      5. Contaminated wastes from animals that have been exposed to agents infectious to humans, these being primarily research animals.
    2. The Division of Environmental Safety and Emergency Management monitors the disposal of all infectious waste. The disposal of infectious waste shall be in accordance with applicable federal, state, and local regulations.
    3. Medical, biological, and other infectious wastes must be disposed of in designated containers or bags that are color-coded, labeled, or tagged as "Biohazard." Sharps containers may be obtained through the Sindecuse Health Center or Environmental Safety and Emergency Management. Biohazard bags may be obtained from University Stores. Questions regarding safe disposal shall be directed to ESEM.
    4. Residence Hall members shall notify ESEM when sharps containers need to be replaced.
    5. All areas shall contact ESEM for disposal of infectious waste containers.

Responsibilities of Employees and Other Designated Persons

    1. All persons are expected to be knowledgeable about specific operating procedures pertinent to their work area or laboratory.
    2. All persons are expected to use universal precautions, engineering controls, to follow work practice controls, and wear appropriate personal protective equipment when performing a task with potential exposure.
    3. All persons are to immediately report an incident of contact with blood or other potentially infectious materials sustained during the course of occupational or classroom duties, according to the Exposure Incident Protocol which follows. Supervisors are responsible for posting this procedure.

Exposure Incident Protocol

    1. The person who receives a potential exposure shall observe the following procedures:
      1. Immediately begin thorough cleansing of the exposed body site with soap and water or approved alternative hand-washing method. (See Methods of Compliance B.1)
      2. Remove personal protective equipment and wash exposed site again with soap and water. The exposed site shall be thoroughly disinfected with appropriate skin disinfectant if immediately available (Betadine solution, Hibiclens). Follow precautions to minimize exposure of other persons to blood, blood products, or other potentially infectious material, e.g., inform co-workers to use protective barriers, remove an exposed sharp and place in a sharps container, isolate the contaminated area.
      3. Notify Supervisor.
      4. Immediately report to Sindecuse Health Center (387-3287) for evaluation, treatment, and follow-up care (Monday-Friday, 8:00a.m.-5:00p.m.; Saturday, 9:00-11:30a.m. except during summer session.) After hours report to the Bronson Methodist Hospital Emergency Room (341-6386).
    2. The supervisor of a potentially exposed person shall observe the following procedures:
      1. Ensure the individual receives medical attention as per 1.d. above.
      2. Ensure that other persons remain out of the area to minimize potential exposure to blood, blood products or OPIM.
      3. Barricade any heavily contaminated area until disinfected.
      4. Notify Custodial Services when clean up of a contaminated area is required. Ensure that custodians are aware of the potential for contamination and take every precaution to prevent contamination of themselves or other persons by using appropriate personal protective equipment and decontamination procedures.
      5. Ensure that the contaminated area is adequately disinfected.
      6. Complete an WC P-210 Form and provide the physician with:
        1. A description of the exposed employee's duties as they relate to the exposure incident;
        1. Documentation of the route of exposure and circumstances under which exposure occurred;
        2. Identity of the source individual, if available; and
        3. Complete an EHS 311 Form.

      3. The Sindecuse Health Center shall observe the following procedures:

        1. Following the CDC guidelines, make a rapid initial determination if the person presented with exposure to blood or OPIM should be referred immediately to Bronson ProHealth.
        2. If immediate referral is not made, perform medical evaluation and treatment
        3. Record the circumstances of the injury/exposure in the person's confidential medical record. Relevant information shall include the following:
            • date and time of exposure
            • job duty being performed by the person at time of exposure
            • details of exposure including the amount and type of fluid or material, severity of exposure, and whether or not the person was using personal protective equipment
            • description of source of exposure including whether the source material contains HIV or HBV if known.
            • Details about counseling, post exposure management and follow-up.
        4. Perform blood analysis for HIV (with informed consent) and HBV on exposed person. If the employee consents to baseline testing, but not HIV testing, the specimen shall be saved for at least 90 days. If, within 90 days of exposure, the employee elects to have the specimen tested for HIV, it shall be done as soon as possible.
        5. Follow the CDC guidelines for post-exposure treatment if unknown source.
        6. Reevaluate the exposed person at 6 weeks, 12 weeks, and 6 months after exposure to determine whether HIV infection has occurred if source individual is unknown, refuses HIV testing, or is HIV positive. If source individual is HIV negative, no further testing is necessary unless past personal history suggests that the individual may have recently been exposed to HIV.
        7. If a Health Center employee is exposed to blood and a specimen of the blood is available, the properly labeled specimen can be taken with the exposed employee to Bronson ProHealth without expressed written consent of the source patient. If the source is available and a blood specimen is needed, the specimen may be obtained in the Sindecuse Lab, with the consent of the patient, and the specimen taken with the exposed employee to Bronson (otherwise the source patient can accompany the employee to Bronson).
        8. All exposed employees, whether seen at Bronson or Sindecuse, will be asked to return to Sindecuse for Hepatitis B test results and final evaluation approximately one week after the initial visit.
        9. Provide a written opinion to ESEM stating that the employee has been informed of the results of the evaluation, and about any exposure related medical conditions that will need further evaluation and treatment.
        10. Provide a copy of the opinion to the employee at the time of evaluation.
        11. Ensure that person's medical information and records are kept confidential except as required by law.
        12. Complete WC P-210 Form.
        13. A sharps injury log has been established that is separate from the OSHA 200 Log. The sharps injury log will record percutaneous injuries from contaminated sharps. The information in the log is recorded so that it protects in confidentiality of the injured employee.
        14. Record any cases of clinical hepatitis or any HIV related illness on the OSHA 200 Log if the illness can be traced back to an occupational injury or exposure incident.
    3. The Division of Environmental Safety and Emergency Management (387-5590) shall observe the following procedure:
      1. Maintain files documenting employee training in the Bloodborne Pathogen Standard and the Western Michigan University Exposure Control Plan.
      2. ESEM maintains a record of all 311 Forms covering BBP exposures.

Hepatitus B Protocol

    1. Western Michigan University shall provide an HBV vaccination program for the employees in Category A occupations at the Sindecuse Health Center at no cost to the employee.

Training and Education

    1. Western Michigan University shall provide initial and annual formal training and education program for employees with potential exposure to blood or other potentially infectious material (Category A occupations) at no cost to the employee and during working hours. Material appropriate in content and vocabulary to the education level, literacy, and language background of persons shall be used
    2. The training program shall contain the following elements:
      1. Discuss the basis of the standard.
      2. A general explanation of the epidemiology of HBV and HIV and symptoms associated with clinical illness from these two viruses.
      3. An explanation of the modes of transmission of HBV and HIV.
      4. An explanation of Western Michigan University's Bloodborne Pathogen Exposure Control Plan. This will include an explanation of Universal Precautions, Engineering and Work Practice Controls, and the use of Personal Protective Equipment.
      5. A detailed explanation of protective barriers and other personal protective equipment, the basis of which these are selected, and the limitations of these methods of control in preventing exposure.
      6. An explanation of the signs, labels, tags, and color-coding used to denote biohazards.
      7. Information of the HBV vaccine, including the indications, safety, efficacy, and benefits.
      8. An explanation of the procedure to follow if potential exposure occurs and the medical follow-up that will be made available.
      9. Question and answer period.

Appendicies

    1. S.O.P. for departments having job classifications that fall into category A are located in the Office of Environmental Safety and Emergency Management.
    2. Following is a list of forms used to comply with the blood-borne pathogen standard.
      1. Hepatitis B vaccination ticket form.
      2. Hepatitis B vaccination declination forms.
      3. Physician opinion regarding employee with occupational exposure to blood or blood products (or other potentially infectious materials).
      4. WC P-210, EHS:311, for medical treatment for on the job injury (potential) exposure, and accident/injury reporting.
      5. Employee sign-in sheet for blood-borne pathogen training sessions.
    3. Pertinent phone numbers
      1. WMU Public Safety- 387-5555
      2. Emergency Calls- 911
      3. Sindecuse Health Center- 387-3287
      4. Bronson Methodist Hospital Emergency Room- 341-6386
      5. Borgess Medical Center Emergency and Trauma Center-226-4815
      6. WMU Environmental Safety and Emergency Management-387-5590

 

print Printer Friendly Version

 

Environmental Safety and Emergency Management
Western Michigan University
Kalamazoo MI 49008-5418 USA
(269) 387-5590
patricia.holton@wmich.edu