Table of Contents

• Introduction
  
• Definitions
  
• Responsibility
  
• Review and Update of the Exposure Control Plan
  
• Availability of the Exposure Control Plan
  
• Risk Determination
  
• General Methods of Compliance
  
• Hazard Communication
  
• Training
  
• Obtaining the HBV Vaccine Series
  
• Post Exposure Evaluation and Follow-up
  
• Exposure Determination Record
  
• Records
  
• Appendix 1
  
• Appendix 2
  
• Appendix 3
  

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Introduction

Bloodborne pathogens are infectious microorganisms found in human blood that can cause disease in humans. They include the hepatitis B virus (HBV), hepatitis C virus (HCV) and the human immunodeficiency virus (HIV) which causes Acquired Immune Deficiency Syndrome (AIDS).

At Florida State University, work which exposes employees to bloodborne pathogens is performed in accordance with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (29 CFR 1910.1030). The OSHA Standard requires that the University develop a plan, the Exposure Control Plan, to protect employees from bloodborne pathogens by reducing occupational exposure and providing appropriate treatment and counseling for employees potentially exposed to these pathogens. The plan covers all employees who could reasonably anticipate contact with blood and other potentially infectious materials during the course of their work. These infectious materials include body fluids, such as semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluid; any body fluid where blood is apparent; saliva from dental procedures; body fluid where it is difficult to differentiate body fluids; unfixed human tissues and organs other than intact skin and human cell lines.

Several Schools and Departments have developed their own Exposure Control Plans specific to their facilities; others may decide to use the following generic plan and insert material specific to their needs. If the school or department has a plan in place, it should be submitted to the Biological Safety Office for review to ensure that it covers all the requirements of the OSHA Standard.

Note that this plan does not cover laboratory procedures for employees who work in HBV and HIV laboratories and production facilities. Consult the Biological Safety Office for information on these topics.

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Definitions

Animal contact: direct physical contact with one or more animals used for research at the University.

Assistant Secretary: the Assistant Secretary of Labor for Occupational Safety and Health, or designated representative.

Biological waste: any microorganism containing waste, such as E.coli cloning strains, cell cultures or cell lines. Biological waste includes biomedical waste.

Biomedical waste: any solid or liquid waste that presents a threat of infection to humans, including non-liquid tissue, body parts, blood, blood products and body fluids from human and other primates; laboratory and veterinary waste which contain human disease-causing agents; discarded contaminated sharps; and used, absorbent materials or disposable devices contaminated with regulated waste.

Note; laboratories where any of the above discarded waste that has not been decontaminated is regarded as "biomedical waste".

Biomedical sharps bin: puncture-resistant plastic bin for contaminated glassware or glass sharps.

Biomedical waste box: single corrugated box, supplied by contracted waste disposal company.

Biomedical waste generator: a facility or person that produces biomedical waste.

Blood: human blood, human blood components that include plasma, platelets and wound exudates, and products made from human blood.

Bloodborne pathogens: pathogenic microorganisms present in human blood, which can cause disease in humans. Includes the hepatitis B virus (HBV), hepatitis C virus (HCV) and the human immunodeficiency virus (HIV).

Communication of Hazards to Employees: use of signs, labels, and a training program to employees on Biohazardous safety.

Contaminated: presence or reasonably anticipated presence of blood or other potentially infectious materials (OPIM) on an item or surface.

Contaminated laundry: laundry that has been soiled with blood or other potentially infectious materials or may contain sharps.

Contaminated sharps: any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontamination: use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the item or surface is rendered safe for handling, use, or disposal.

Engineering controls: controls such as sharp disposal containers, or self-sheathing needles that isolate or remove the hazard from the workplace.

Exposure determination: identification of individuals exposed to blood or other potentially infectious materials in the workplace.

Exposure incident: 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.

Glass Sharps: broken glass bottles, containers, pipettes or laboratory ware.

Hand wash facilities: a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

HBV: hepatitis B virus.

HIV: human immunodeficiency virus.

Methods of compliance: engineering controls, practices and procedures that are needed to keep the worksite in a clean and sanitary condition. General methods of compliance, which may include specific instructions for a particular area, may be added.

Needle box: red, puncture-resistant plastic box for metal sharps, such as needle-syringe units, scalpels and razor blades.

Occupational exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Other potentially infectious materials (OPIM): including the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood and all body fluids where it is difficult or impossible to differentiate between body fluids; any unfixed tissue from human and HIV/HBV containing culture medium.

Parenteral: entry into the body by other means than through the digestive tract such as by piercing mucous membranes or the skin by needle sticks, human bites, cuts or abrasions.

Personal protective equipment (PPE): special clothing worn by an employee to protect against a hazard. General work clothes, such as pants, shirts, blouses not provided by the school or department, are not intended to function as protection against a hazard or considered to be personal protective equipment.

Record keeping: maintenance of medical and training records.

Regulated waste: defined in 64E-16.002(2) Florida Administrative Code, Biomedical Waste; any solid or liquid waste that may present a threat of infection to humans.

Examples include:

• Non-liquid or semi-liquid tissue and body parts from humans and other primates; laboratory and veterinary waste which contain disease-causing agents; discarded sharps; and blood, blood products and body parts from humans and other primates;

• 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; and

• Contaminated sharps and pathological and microbiological wastes containing blood or other potentially infectious materials.

Sharps box: any strong corrugated box that can be used to package non-contaminated glass sharps. Must be clearly labeled SHARPS and should not be filled no more than ¾ of the way. Once it is filled it must be tightly sealed and disposed of as regular waste.

Transporter: contracted licensed waste disposal company moves the biomedical waste away for incineration.

Universal precautions: an approach to infection control; a concept that all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV, or other bloodborne pathogens.

Work practice controls: controls that reduce the likelihood of exposure by altering the manner in which a task is performed (for instance prohibiting the recapping of needles by a two-handed technique).

Zoonotic diseases: diseases transmitted from animals to man.

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Responsibility

Responsibility for effective implementation of an Exposure Control Plan (ECP) at the University rests with three groups:

Department of Environmental Health & Safety: The Biological Safety Office investigates incidents involving exposure to bloodborne pathogens, provides technical and general assistance and guidance for schools/departments to develop their individual exposure control plans, and assists with development and presentation of training and education programs. The program representative of Worker's Compensation keeps records of exposed employees.

The supervisory officer of each affected School or Department: Responsible for enforcement of the requirements of the Standard, identification of position descriptions, tasks and procedures in which employees have occupational exposure to blood or other potentially infectious materials. The supervisory officer is responsible for providing of engineering controls, personal protective equipment, for mandating proper work practices and employee participation in a training and education program. The supervisory officer offers the HBV vaccine to exposed individuals, and notifies the Biological Safety Office of any employee exposed to potentially infectious material.

Employees: Employees who have occupational exposure to bloodborne pathogens shall participate in training and education programs annually, observe universal precautions, know the routes of transmission of bloodborne pathogens, report their exposures to potentially infectious materials, and comply with other site-specific requirements.

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Review and Update of the Exposure Control Plan

The Biological Safety Office coordinates a review and update of this generic exposure plans at the beginning of the academic year, and whenever OSHA makes changes to the Bloodborne Pathogen Standard 29 CFR 1910.1030.

Supervisors review the laboratory's or the department's specific plan whenever new or modified tasks are implemented and when jobs are revised that result in changes of occupational exposures. In addition, Schools or Departments will include any modifications to tasks and jobs that results in the reduction or prevention of occupational exposures as recommended by the employee.

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Availability of the Exposure Control Plan

Each School or Department ensures that the Exposure Control Plan is available to all employees. Schools or Departments shall inform employees of the location of their specific exposure control plan. Environmental Health & Safety has a generic plan that is also made available.

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Risk Determination

Risk determination is identified from position descriptions of tasks and procedures where occupational exposure will occur.

Supervisors shall identify positions where (1) all employees have exposure to human blood or other potentially infectious material (OPIM), and (2) where SOME employees have exposure to human blood or other potentially infectious material. When only SOME employees are exposed, the tasks and procedures where occupational exposure occurs must be identified.

Supervisors shall identify employees at risk for occupational exposure to blood or other potentially infectious materials within 10 days of hire or change of responsibility for the employee, offer training for handling bloodborne pathogens and offer the HBV vaccine.

See appendix for Exposure Determination Worksheet.

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General Methods of Compliance

At the University, there are two general methods of compliance: work practices and physical layout (or engineering controls) of a facility.

Compliance can be met through work practices by controlling work procedures. This is accomplished by developing a work task plan that would reduce any hazard. These work practice task plans could be put to use in work areas where a reasonable likelihood of occupational exposure exists. Examples of work practice controls are: washing hands after gloves are removed and as soon as possible after skin contact with blood or other potentially infectious materials, and prohibiting the recapping, removing or bending of needles.

Universal precautions are another form of work practice compliance. Universal precautions are methods of treating all human blood, tissue and other potentially infectious materials as if it is infectious for HBV and HIV. When it is difficult to distinguish among types of body fluid, all materials shall be assumed to be infectious. The concept of Universal Precautions shall be observed throughout the University.

Good housekeeping is another form of work practice. Schools and Departments should develop cleaning schedules that include appropriate methods of decontamination based on the location of potentially infectious sites within the facility, types of surfaces to be cleaned, and types of contamination present.

Physical layout compliance is done through engineering control. Engineering controls are barriers that can be placed between the worker and the hazard. They reduce employee exposure by either removing or isolating the worker from the hazard. Examples are: the sheath on a self-sheathing needle, puncture-resistant sharps containers, and biological safety cabinets.

Engineering and work practice controls are often used together. For instance, needle sticks are a major workplace hazard; their control is based on not recapping needles (work practice) and disposing of them properly in the sharps container (engineering control).

Personal protective equipment (PPE) such as uniforms, protective gloves, and facemasks shall be used as supplemental protection when occupational exposure remains after instituting engineering and work practice controls.

In addition to these primary work practice and general compliance methods, supervisors are advised to insert site-specific information into their own exposure control plan here. Please consult with the Biological Safety Office if you have questions or need assistance.

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Hazard Communication

Labels and signs bearing a red Biohazard warning symbol shall be affixed to locations and containers used to store, transport, and ship blood or other potentially infectious materials.

The Biohazardous Symbol

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Training

Employees occupationally exposed to blood and other potentially infectious materials (OPIM) shall be provided with information and appropriate site-specific training within 10 working days of commencement of employment or reassignment.

Information and training shall be provided by schools/departments initially within 10 working days of employment and then at least annually thereafter. Additional training shall be offered when existing tasks are modified or new tasks introduced which affect the employee's exposure to bloodborne pathogens. It is the Schools' and Departments' responsibility to contact EH&S for the required training. Personnel from EH&S are available to provide information, resources and help.

Training shall cover the following topics:

• How to obtain a copy of the regulatory text and an explanation of its contents;

• Information on the epidemiology and symptoms of bloodborne diseases;

• Ways in which bloodborne pathogens are transmitted;

• Explanation of the Exposure Control Plan and how to obtain a copy;

• Information on how to recognize tasks that might result in occupational exposure;

• Explanation of the use and limitations of work practices, engineering controls and personal protective equipment;

• Information on the types, selection, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;

• Information on the Hepatitis B vaccination such as safety, benefits, efficacy, methods of administration and availability;

• Information on what to do and whom to contact in an emergency;

• Information on how to report an exposure incident and on the post-exposure evaluation and follow-up;

• Information on warning labels and signs, where applicable, and color-coding;

• Opportunity for questions and answers on any part of the training.

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Obtaining the HBV Vaccine Series

Supervisors shall offer the Hepatitis B vaccination to individuals who have occupational exposure to human blood or other potentially infectious material during the course of their work. This must be done within 10 days of hire or change of responsibility for the employee, after the employee has received training and information:

• The employee will be offered the Hepatitis B vaccine and the cost of Hepatitis B vaccination for occupational exposure is the responsibility of each individual school or department.

• For employees involved in sponsored research, EH&S will offer the Hepatitis B vaccine and will pay for the cost of the vaccine.

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Post Exposure Evaluation and Follow-up

If the employee has been exposed to blood or other potentially infectious materials, a healthcare provider should evaluate the exposed employee within 24 hours of the exposure.

Supervisors should offer post exposure evaluation and follow-up to any employee who is exposed to blood or other potentially infectious materials during his/her work.

Following the post-exposure evaluation and follow-up procedure, the supervisor should notify EH&S as soon as possible and ask for the Medical Monitoring Program at 644-5374 or 644-9117 to assist with the procedure.

If the employee has been exposed by a source individual's blood, the source individual's blood shall be tested as soon as feasible, and after consent is obtained, in order to determine HBV and HIV infection, or unless the information is already available. It is the department's responsibility to pay for the source individual's testing.

If possible, the employee will be given confidential information (if obtainable) on the HBV and HIV status of the source individual, and will be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

If applicable, Workers' Compensation Insurance will cover the cost of post-exposure evaluation services for the exposed employees. Procedures and required paperwork for Workers' Compensation can be obtained through the Risk Management and Workers' Compensation section of EH&S. They can be reached at 644-7683 or 644-7684. They can also be reached online at www.safety.fsu.edu/risk.html.

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Exposure Determination Record

The following documents are required for each employee, and can be found in the appendices to determine exposure potential and administrative procedures for employees classified as potentially occupationally exposed to blood and other potentially infectious materials (OPIM).

• Exposure Determination Worksheet, a list of questions to help the supervisor identify the job classifications whose incumbents are included in the Exposure Control Plan. In addition, it also includes a section to outline an individual employee's job description and identify work procedures that may expose the employee to blood or OPIM. This then would require the employee to receive appropriate training and be offered the HBV vaccine.

• Hepatitis B Vaccine Record, a list of questions to help the supervisor identify if the employee has previously received or now wishes to receive or decline the Hepatitis B vaccine. Note that if the employee initially declines the Hepatitis B vaccine, the employee may request it at any time during employment if the employee's duties and responsibilities have not changed.

Supervisors should review the Exposure Determination Worksheet for their School, Department, or group. If the answer to any question is YES, the OSHA Standard applies to the employees.

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Records

Medical records (HBV status, records on post exposure follow up) will be kept by the medical facility performing services, such as workers' compensation contract medical provider, or other health care facility. Records must be kept for 30 years after termination of employment.

EH&S will maintain training records, which include training dates, location, summary of training, qualifications of trainer, name, job titles of trainees, and sign-up sheet. Training records shall be maintained for 3 years from the date of training. All records must be made available to the Assistant Director and Director of OSHA or designee upon request.

An Exposure Determination Worksheet for each employee is to be kept in the Exposure Control Plan by each school, department or group by the individual principal investigator (PI) or supervisor. The employer must keep these documents for 30 years after termination of employment.

A Hepatitis B Vaccine Record for each employee is to be kept in the Exposure Control Plan by each School, Department or group, by the individual principal investigator (PI) or supervisor. The employer must keep these documents for 30 years after termination of employment.

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Appendix 1

Format			Form Number	Form Name
web	doc	pdf
			EHS 7-4	Exposure Determination Worksheet

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Appendix 2

Format			Form Number	Form Name
web	doc	pdf
			EHS 7-3	Hepatitis B Vaccine Record

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Appendix 3

Bloodborne Pathogen Standard-29 CFR 1910.1030

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