1.0  INTRODUCTION

More than 5.6 million workers are exposed to bloodborne pathogens in the performance of their jobs. Bloodborne pathogens are microorganisms in human blood that cause disease in humans. Although approximately a dozen diseases are known, the main concern is from exposure to the hepatitis B & C viruses (HBV & HCV) and the human immunodeficiency virus (HIV), which causes AIDS. To prevent illness, chronic infection, and even death, OSHA has developed a Bloodborne Pathogen Standard to protect workers from exposure to blood and other potentially infectious body fluids. OSHA estimates that the Standard will prevent more than 200 deaths and 9,200 infections annually.

Employees are at risk of contacting infectious diseases each time they are exposed to bloodborne pathogens. It is the policy of Radford University to prevent exposure incidents whenever possible. To protect workers and to comply with OSHA's Bloodborne Pathogen Standard, the university has established this Exposure Control Plan. The purpose of the Plan is to identify occupations, tasks, and procedures where exposure to bloodborne pathogens may occur and to implement controls that will reduce the risk of infection. The Plan also includes provisions for affected employees to receive Hepatitis B vaccinations, training, and if necessary confidential medical evaluations.

This plan will be reviewed and updated at least annually by the Safety Manager. Copies of the plan are available in the Safety Office for review by any employee. Employees may obtain a copy of the plan within 15 days by contacting the Safety Manager at 831-7790.

2.0  EXPOSURE DETERMINATION

1. The Safety Manager will evaluate the duties, tasks, and procedures of all employees in each job classification to determine who may have occupational exposure to bloodborne pathogens as part of their job duties. This evaluation and exposure determination will be made without regard to personal protective equipment. Exposure determinations will be reviewed and updated at least annually by the Safety Manager.

2.  Job classifications in which all employees have occupational exposure:

• Police Officers
• Athletic Trainers
• Nursing Faculty
• Lifeguards
• Housekeepers
• Plumbers
• Physicians
• Nurse Practitioners
• Laboratory Technicians
• Speech Language Pathologists
• Audiologists

3. Job classifications in which some employees have occupational exposure and the procedures that cause them to have occupational exposure:

• Recreation Supervisors- first aid (collateral duty)
• Pool Managers- first aid (collateral duty)
• Recreation, Parks, and Tourism Therapists- first aid (collateral duty)
• Dietitians- Phlebotomy (primary duty), first aid (collateral duty)

3.0  UNIVERSAL PRECAUTIONS

1. All workers will observe universal precautions when performing any task which may result in occupational exposure to blood or other potentially infectious body fluid. Universal precautions treat all human blood and certain body fluids as if they were infected with bloodborne pathogens.

2. Universal precautions apply to blood, semen, vaginal secretions, cerebrospinal fluids, synovial fluids, 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 to differentiate between body fluids. Universal precautions also apply to exposure to unfixed tissues or organs other than intact skin from living or dead humans.

4.0  ENGINEERING CONTROLS

1. Engineering controls are devices that isolate or remove the bloodborne pathogens hazard from the worker. Engineering controls shall be used in preference to other control methods to eliminate or minimize exposure to blood or other potentially body fluids. Departments will evaluate the effectiveness of existing controls and review the feasibility of instituting more advanced engineering controls that eliminate or reduce exposure to bloodborne pathogens. 

2.  The following engineering controls will be in place in all areas of occupational exposure:

• Readily accessible handwashing facilities.
• Antiseptic towelettes or antiseptic hand cleanser and towels in areas where it is not feasible to have handwashing facilities.
• Sharps disposal containers.
• Appropriate containers for storage, transport, or shipment of blood or other potentially infectious materials, regulated waste, and contaminated laundry.

3.  Engineering controls will be inspected periodically and repaired or replaced as needed by a designated person appointed by supervision in affected departments.

 4.  Commercially available safer medical devices designed to eliminate or reduce occupational exposure will be evaluated annually and implemented if appropriate. Examples include self-sheathing needles, sharps with engineered sharps injury protections and needleless systems. Documentation of this evaluation will be kept by affected departments.

 5.  In the evaluation and selection of safer medical devices input will be solicited from non-managerial employees who are responsible for direct patient care and potentially exposed to contaminated sharps. Affected departments will maintain documentation of this evaluation.  

5.0  WORK PRACTICES

1. Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed. Handwashing is the most effective means of preventing the spread of infections. Workers shall wash their hands and other skin surfaces with soap and water as soon as possible after contact with blood or other potentially infectious body fluids. Hands will be washed immediately after removing gloves and other personal protective equipment.

2. If handwashing facilities are not readily available an antiseptic hand cleaner and clean towels or antiseptic towelettes will be used. If these alternatives are used, hands shall be washed as soon as feasible with soap and running water.

3. Workers shall flush mucous membranes with copious amounts of water as soon as possible following contact with blood or other potentially infectious body fluid.

4. All procedures will be performed in a manner that minimizes splashing or spraying.

5. Eating, drinking, smoking, applying cosmetics, or handling contact lenses are prohibited in areas of potential exposure to bloodborne pathogens.

6. Food or drinks will not be stored in areas where blood or other potentially infectious materials are present.

7. Mouth pipetting/suctioning of blood or other potentially infectious materials is strictly prohibited.

8. Specimens of blood or other potentially infectious materials will be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping. The container shall be labeled or color-coded and closed prior to being stored or shipped.

9. If outside contamination occurs or the container is punctured it will be placed in a labeled or color coded secondary container which prevents leakage.

6.0  PERSONAL PROTECTIVE EQUIPMENT

1. When engineering controls and work practices are insufficient to control occupational exposure, the university will supply at no cost to employees, appropriate personal protective equipment. This equipment includes gloves, gowns, laboratory coats, face shields or masks, eye protection, mouthpieces, or pocket masks. Employees will wear personal protective equipment when doing procedures in which exposure to the skin, eyes, mouth, or other mucous membranes is anticipated.

2. The Safety Manager will train employees in the proper use of the equipment. Personal protective equipment will be purchased in appropriate sizes, maintained, and distributed by affected departments.

3. Progressive disciplinary actions up to and including discharge will be used by supervision to ensure that employees use assigned personal protective equipment.

4. Personal protective equipment will be readily accessible at the worksite or individually issued to employees.

5. The university will clean, launder, dispose, repair, or replace personal protective equipment at no cost to the employee. Home laundering is not permitted.

6. All personal protective equipment will be removed prior to leaving the work site and placed in an appropriately designated area or container. Areas where employees store contaminated items will be determined by affected departments.

7. Workers will wear gloves when it can be reasonably anticipated that hand contact with blood, other potentially infectious body fluids, mucous membranes, or non-intact skin is possible.

8. Disposable (single use) gloves such as surgical or examination gloves shall be replaced as soon as practical when contaminated, or as soon as feasible when torn or punctured. Single use gloves will not be washed or decontaminated for re-use.

9. Employees will wear disposable gloves made of vinyl, latex, or nitrile when drawing blood. Gloves will be changed between patient contact and disposed in appropriate containers as contaminated waste.

10. Rubber household utility gloves will be used for housekeeping chores that involve handling items or surfaces contaminated with blood or body fluids to which universal precautions apply. Utility gloves may be washed and disinfected for reuse but must be discarded if punctured or torn.

11. Surgical masks, protective eyewear with solid side shields, and/or face shields will be worn whenever splashes, spray, or splatter of blood or other potentially infectious materials are generated. These devices are not required for routine care.

12. Gowns, aprons, and other protective body clothing will be worn in occupational situations in which exposure is reasonably anticipated. Gowns should be made of, or lined with fluid resistant material. If a garment is penetrated by blood or other potentially infective fluid, the garment shall be removed immediately or as soon as feasible.

13. Suitable ventilation devices such as mouthpieces and resuscitation bags that minimize contact with saliva will be provided in strategic locations or to key personnel where the need for resuscitation is likely.

14. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated.

7.0  HOUSEKEEPING

1. The worksite will be maintained in a clean and sanitary condition. An appropriate written schedule for cleaning and decontaminating will be implemented by affected departments for routine and non-routine tasks. Procedures will give the methods, disinfectant used, and frequency of decontamination of various areas within the department.

2. Housekeeping workers will wear appropriate personal protective equipment including general purpose utility gloves during all cleaning of blood or other potentially infectious materials.

3. All equipment and work surfaces shall be properly cleaned and disinfected after completing procedures involving exposure to blood or other potentially infectious materials. Employees will clean equipment and surfaces:

• When surfaces become obviously contaminated.
• After any spill of blood or other potentially infectious material.
• At the end of the work shift if the surface may have become contaminated since the last cleaning.
• When the employee leaves the work area for a period of time.

4. An approved hospital disinfectant that is tuberculocidal or a freshly prepared solution of household bleach diluted 1:10 with water will be used for cleaning surfaces and equipment.

5. Protective coverings used to cover equipment and surfaces will be replaced as soon as feasible when they become grossly contaminated or at the end of the workshift when they become contaminated.

6. All reusable containers such as bins, pails, and trash cans shall be inspected weekly and decontaminated if necessary. Reusable containers will be decontaminated as soon as possible following visible contamination.

7. Broken glassware will be picked up by mechanical means such as a brush and dustpan, or tongs. Broken glassware will not be picked up by hand, even when wearing gloves.

8. Blood spills will be cleaned up by authorized individuals. The following procedures will be used to clean-up spills of blood or other potentially infectious fluids:

• Secure the area.
• Wear appropriate PPE such as rubber gloves, booties, and goggles.
• Place disposable or cloth towels over the spill to soak up gross amounts of fluids.
• Place soaked towels into a red plastic bag.
• Wash the area with soap and water.
• Use towels to complete the clean-up.
• Disinfect the area with an appropriate germicide such as a freshly prepared 1:10 solution of bleach (one cup of bleach to nine cups of water) or a hospital disinfectant labeled as tuberculocidal. Do not mix bleach with other cleaning or disinfecting agents.
• Leave disinfectant on the spill for 10 minutes.
• Place all contaminated materials including gloves into the red plastic bag, seal, and properly label.
• Dispose of the bag as infectious waste.
• Cloth towels may be washed. Mops should be disinfected.
• Dispose of wash water in the sanitary sewer system. Blood on sidewalks or streets may be washed into a sewer or storm drain.  Do not wash bleach into a storm drain.
• Wash hands after removing gloves.

9. Equipment that may be contaminated will be examined prior to servicing or shipping and decontaminated if possible. The equipment will be labeled indicating which portions are still contaminated.

8.0  LAUNDRY PRACTICES

1. Contaminated clothing will be handled as little as possible with a minimum of agitation. Workers who handle potentially infectious clothing will wear appropriate personal protective equipment such as gloves. Gowns and eye protection will be worn if gross contamination is present.

2. Contaminated clothing will be bagged at the location where it was used and transported in leakproof containers labeled with the biohazard symbol or in red plastic bags. Laundry will not be sorted or rinsed at the location of use.

3. Contaminated laundry will be laundered on-site by properly trained personnel or picked up by a commercial laundry service. Washing at a public Laundromat is allowed but not encouraged. Dry cleaning is acceptable. Contaminated laundry shall not be taken home.

9.0  LABELS

1. All containers of contaminated waste, laundry, refrigerators and freezers, and other containers used to store blood and other potentially infectious materials will be properly labeled or color coded. Employees will be informed of labeling requirements during training sessions.

2. Individual small containers are exempt from the labeling requirement provided they are stored in larger labeled containers.

3. Labels will include the universal biohazard symbol and wording. Labels will be fluorescent orange or orange-red with contrasting lettering.

4. Red plastic bags or containers may be used instead of labels if all employees understand the meaning of the color code.

10.0  INFECTIOUS WASTE

1. Regulated infectious waste is defined as:

• Liquid or semi-liquid blood or other potentially infectious materials.
• Contaminated items which could release blood if compressed (discarded feminine hygiene products are exempted).
• Items caked with dried blood that could be released during handling.
• Contaminated sharps.
• Pathological and microbiological waste containing blood or other potentially infectious materials.

2. Disposal of infectious waste shall be in accordance with applicable State regulations for infectious waste management. Solid infectious waste will be steam autoclaved or incinerated prior to disposal. No infectious waste will be disposed of in a landfill. Liquid or semi-liquid infectious waste may be disposed of in the sanitary sewer system.

3. The generator of infectious waste is responsible for the proper packaging, labeling, and management of the waste. Infectious waste shall be placed in closable, leakproof containers or bags that are color-coded, labeled, or tagged.

4. Infectious waste shall be packaged as follows:

• Infectious waste will be contained in two leakproof, plastic bags, each sealed separately, or one leakproof plastic bag inside a double-walled corrugated fiberboard box or equivalent rigid container.
• Sharps will be collected at the point of generation in puncture resistant containers, and placed inside a plastic bag prior to storage or transport.
• All bags will be red in color except bags that are to be steam sterilized. These bags will be orange in color and marked with autoclave tape.
• Prior to transport on a highway all infectious waste will be placed in a double-walled corrugated fiberboard box or equivalent container.
• Infectious waste will not be compacted or subjected to violent mechanical stress.
• Generators will maintain shipping papers from commercial carriers if the waste is sent off-site. The date, type of treatment, type and amount of waste, and the operator's name will be maintained if the waste is treated in-house.

5. All infectious waste will be labeled immediately after packaging. The label will be securely attached to the outer packaging and be clearly legible. The label shall be at three inches by five inches in size and contain the words "INFECTIOUS WASTE" and the biohazard symbol. The label will also contain the name, address, and phone number of the generator and transporter.

6. Contaminated waste not meeting the definition of regulated infectious waste will be properly packaged to prevent exposure to students, workers, and the public. Non-regulated waste will be placed in regular plastic bags (not red or orange). The bag or outside container will be labeled with the biohazard symbol. Bags will be sealed and labels removed prior to disposal in the regular trash.

7. Drop sites on campus for infectious waste are located in the following areas:

• Student Health Services in Moffett Hall
• Dedmon Center Pool
• Waldron Hall
• Athletic Department in the Dedmon Center.

11.0  SHARPS

1. Workers will use appropriate precautions to prevent injuries from needles, scalpels, and other sharp instruments. Contaminated needles shall not be recapped, removed from disposable syringes by hand, or bent as a general practice. Cutting or breaking contaminated needles is prohibited.

2. If no alternative is feasible or such action is required by the procedure, the contaminated needle may be recapped or removed if a mechanical device or a one-handed technique is used. Justifications for these procedures must be in writing and approved by supervision and the Safety Manager.

3. Disposable syringes, needles, scalpel blades, contaminated broken glass, and other sharp items will be placed in puncture resistant containers for disposal immediately or as soon as possible after use. Containers will not be cleaned or reused. Sharps containers shall be:

• Easily accessible to workers & located as close as feasible to the immediate area where sharps are used.
• Constructed of a durable, puncture resistant, high impact plastic such as high-density polyethylene.
• Labeled with the biohazard label or color coded.
• Leakproof on the sides and bottom.
• Closable.
• Maintained upright while in use.
• Replaced when 3/4 full.

4. When moving containers of contaminated sharps the containers will be closed prior to removal and placed in a secondary container if leakage is possible. The secondary container shall be closable, leakproof, and properly labeled or color coded red.

5. Containers for reusable sharps will meet the same requirements as containers for disposable sharps, except that they are not required to be closable. Contaminated reusable sharps will not be stored in a container in such a manner that requires an employee to reach by hand into the container. Containers will include a wire basket liner or the employee will use tongs to withdraw the contents.

12.0  TRAINING

1. Employees who are occupationally exposed to blood or other potentially infectious material will participate in a training and education program. Training will be performed by the Safety Manager or other "knowledgeable" person. The training program shall include the following material:

• Epidemiology and symptoms of exposure to HBV, HCV and HIV.
• Modes of transmission of HBV, HCV and HIV.
• The university's exposure control plan.
• Control methods that may prevent or reduce exposure.
• Personal protective equipment.
• Information on the HBV vaccine.
• Procedures to follow if an exposure incident occurs.
• Signs, labels, color coding system used to denote biohazards.
• Explanation of the Standard and how to obtain a copy.
• Actions to take in an emergency involving blood.
• Post-exposure evaluation.

2. Training will be provided during normal work hours at the time of initial assignment and at least annually thereafter. Additional training will be performed if modifications of procedures affect the employee's possible exposure. Participants will have an opportunity to ask questions during the training session.

13.0  HEPATITIS B VACCINATION

1. Vaccination for hepatitis B will be offered at no cost to employees who have occupational exposure to blood or other potentially infectious fluids. The Safety Manager, in cooperation with supervision, will determine the need for the vaccination. Vaccines will be administered at the Student Health Center in Moffett Hall.

2. Vaccines will not be offered to individuals who perform first aid as a collateral duty to their routine work assignments until after they give aid involving blood or other potentially infectious materials. Vaccines will be offered within 24 hours after exposure. All first aid incidents must be reported to supervision before the end of the work shift in which the incident occurred. The report will include the name of the first aid provider, description of the incident, date, time and a determination of whether an exposure incident occurred.

3. Vaccinations will not be offered to employees who have previously received the complete vaccination series, employees who have immunity as demonstrated through antibody testing, or to employees in which the vaccine is medically contraindicated.

4. Vaccinations will be offered after employees have received training in bloodborne pathogens and within 10 working days of initial assignment.

5. Employees may decline the vaccination but can change their minds at a later date and receive the vaccination. Employees who decline will sign the OSHA Declination Form.

6. The university is not obligated to pay for vaccines that are due after an employee leaves the university. 

7.  The university will pay for postvaccination testing for antibody to hepatitis B for health care workers who are at risk for injuries with sharp instruments or needlesticks. Testing will be done 1-2 months after the vaccine series is completed.   Periodic testing to determine antibody concentrations is not indicated. 

8. The Safety Manager will provide a copy of OSHAs Bloodborne Pathogens Standard to the healthcare professional responsible for the employee's vaccination.

14.0  POST-EXPOSURE EVALUATION

1. Exposure incidents (e.g., needlestick, cut, splash to eye, mouth, or nasal mucosa, splash to non-intact skin) must be reported to supervision immediately. An exposure incident for workers who may be exposed to blood as a collateral duty is defined as any exposure to blood. As soon as possible supervisors will make an appointment with Dr. Daniel Kelly at Carilion Family Medicine (731-3200) for a post-exposure evaluation. Supervisors will complete the First Report of Injury, and Exposure Incident Report and send the reports to the Human Resources Department and the Safety Office. A confidential medical evaluation will be performed by Dr. Kelly as soon as possible following a report of an exposure incident. The duties of the employee, route of exposure, circumstances of the incident, and vaccination status will be provided to Dr. Kelly.

3. If feasible, consent will be obtained from the source patient and the blood tested to determine HIV, HBV and HCV status. Results of the test will be made available to the exposed employee, source individual, and physician in charge of the exposure incident. No one else has a right to know the results of the source individual or exposed employee testing. If consent is not given or if the source is unknown the physician will document this in writing. If a healthcare provider is involved in an exposure incident, the source individual's consent is not needed for HIV testing if blood is available. A court order may be obtained to test the source patient if a police officer is involved.

4. After consent has been obtained from the exposed employee a sample of blood will be drawn as soon as possible after the incident to determine HIV, HBV and HCV status. If the employee does not give consent at that time for HIV testing, the sample will be preserved for 90 days. Testing will be done as soon as feasible if the employee decides to have the blood tested within the 90-day period.

5. Repeat HIV testing will be offered to the exposed employee six weeks after the incident and on a periodic basis as determined by the physician to ensure that the employee is not HIV positive. It is the responsibility of the department to pay for the tests even if the employee leaves the university before all tests are completed.

6. Follow-up of the exposed worker shall include counseling, medical evaluation, and the use of safe and effective post-exposure measures according to recommendations for standard medical practice.

7. An employee who has been exposed to blood from a known HIV patient should report within two hours to Dr. Kelly or to the Emergency Room at the Carilion New River Valley Medical Center.

8. A copy of OSHAs Bloodborne Pathogen Standard will be given to the healthcare professional responsible for evaluating an employee after an exposure incident.

10. Employee medical records will be kept confidential. Contents will not be disclosed to any person within or outside the workplace without the employee's written consent, except as required by law.

15.0 RECORDKEEPING

1. A medical record will be established and maintained for each employee with occupational exposure. Records will be maintained in the Student Health Center, RU Clinic, and the Safety Office. The following information will be included in the file:

• Name and social security number of the employee.
• Copy of the employee's hepatitis B vaccination status including the dates of all hepatitis B vaccinations and declination forms.
• Copy of all examinations, medical testing, and follow-up procedures.
• Employer's copy of the physician's written opinion concerning an exposure incident.

2. The university will ensure that all medical records are kept confidential and not disclosed without the employee's written consent except as required by law.

3. Medical records will be maintained for the duration of employment plus 30 years.

4. Training records will be maintained by the Safety Manager for at least three years. Training records will contain the names and job titles of individuals attending the class, date, contents of the training, and the names and qualifications of the persons conducting the training. Training records will be provided to employees upon request.