Conversation
Feedback

We want to hear from you!

BYU-Idaho values suggestions and ideas that can improve the university.
Use our Feedback Form to let us know what you think.

Conversation
Feedback
Brigham Young University Logo

Bloodborne Pathogen Policy

Bloodborne Summary
Hepatitis B Vaccine Refusal Form


Bloodborne Pathogens Policy
Compliance with 29 CFR 1910.1030
Drafted November 30, 1999

Table of Contents
1.0 Introduction
2.0 Definitions
3.0 College Departmental Responsibilities
4.0 Exposure determination
5.0 General Work Practices and Procedures
6.0 Personal Protective Equipment
7.0 Housekeeping
8.0 Regulated Waste
9.0 Laundry
10.0 HIV and HBV Research Laboratories and Production Facilities
11.0 Hepatitis B vaccination and post-exposure evaluation and follow-up
12.0 Communication of Hazards to Employees
13.0 Recordkeeping

 

Bloodborne Pathogens Exposure Control Plan

1.0 Introduction

The purpose of this Exposure Control Plan is to reduce the probability of college employees contracting serious illness due to pathogenic microorganisms while working at BYU-Idaho or participating in academic or volunteer programs associated with the university.

2.0 Definitions

2.1 Blood means human blood, human blood components, and products made from human blood.

2.2 Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

2.3 Clinical Laboratory means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

2.4 Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

2.5 Contaminated Laundry means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

2.6 Contaminated Sharps means 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.

2.7 Decontamination means the 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 surface or item is rendered safe for handling, use, or disposal.

2.8 Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.

2.9 Exposure Incident means a 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.

2.10 Handwashing Facilities means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

2.11 Licensed Healthcare Professional is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by section 11 dealing with Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.

2.12 HBV means hepatitis B virus.

2.13 HIV means human immunodeficiency virus.

2.14 Occupational Exposure means 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.

2.15 Other Potentially Infectious Materials means

2.15.1 The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;

2.15.2 Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and

2.15.3 HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

2.16 Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

2.17 Personal Protective Equipment is specialized clothing or equipment worn 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.

2.18 Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

2.19 Research Laboratory means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

2.20 Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

2.21 Sterilize means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

2.22 Universal Precautions is 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 other bloodborne pathogens.

2.23 Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Table of Contents

 

3.0 Department Exposure Control Plan.

Each department or center at BYU-Idaho shall write and review a supplementary safety policy for their area. This document, shall be titled the A (Name of Department or Center) Exposure Control Plan (for example, The College of Nursing Exposure Control Plan). The Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

3.1 Exposure Control Plan.

Each department or center should write a former plan detailing the proper protocols for handling potential occupational exposures or contamination involving biohazardous substances for their individual area as well as provide training for employees who are at risk for occupational exposure.

3.1.2 Protocol for handling biohazardous wastes.

3.1.2.1 The BYU-Idaho Health Center will oversee the shipping of all biohazardous waste to the proper off-campus waste handling facilities. Each department or center's protocol must include proper packaging, labeling, and delivery of biohazardous wastes to the College Health Center.

3.1.2.1.1 Each department or center on campus which produces biohazardous waste is required to deliver such waste for shipment to the campus Health Center.

3.1.2.1.2 Each department or center will be charged a fee by the health center for the purchase of biohazardous containers and for the shipping of those containers to the necessary waste disposal facilities.

3.1.3 Provide Biohazard Exposure training for all employees whose line of work may present risk of occupational exposure (see section 12 and 13).

3.1.4 Provide information on benefits and risks for Hepatitis B vaccination shots (see section 11).

3.1.5 Include a copy of the department list from section 4.0 of this document to the Campus Safety Office.

3.1.6 A copy of this policy shall be submitted to the Campus Safety Office for documentation and review.

Table of Contents

 

4.0 Exposure determination.

Each department with employee's who have occupational exposure shall prepare an exposure determination. This exposure determination shall be made without regard to the use of personal protective equipment and shall contain the following:

4.1 Job List Defined. A list of all job classifications in which all employees in those job classifications have occupational exposure;

4.2 Job List(some exposure) Defined. A list of job classifications in which some employees have occupational exposure, and

4.3 Task List Defined. A list of all tasks and procedures or groups of closely related task and procedures in which occupational exposure occurs and that are performed by employees in job classifications listed in accordance with the provisions of items 4.1 and 4.2 of this standard.

4.4 List of job classifications in which all employees have occupational exposure. (include list here)

4.5 List of job classifications in which some employees have occupational exposure. (include list here)

4.6 List of tasks and procedures involving occupational exposure. (including enclosed list)

Table of Contents

 

5.0 General Work Practices and Procedures.

5.1 Universal Precautions. Universal precautions shall be observed to prevent contact with blood or 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.

5.2 Engineering and work practice controls.

5.2.1 Use. Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used.

5.2.2 Maintenance. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.

5.3 Hand-washing. BYU-Idaho shall provide hand-washing facilities which are readily accessible to employees in jobs listed in 4.4 and 4.5 above.

5.3.1 Exception. When provision of hand-washing facilities is not feasible, BYU-Idaho shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible after an exposure.

5.3.2 Removal of Gloves. Supervisors shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.

5.3.3 Contact with Infectious Materials. Supervisors shall ensure that employees wash hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.

5.4 Eating in Contaminated Areas. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.

5.5 Food and Drink. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.

5.6 Aerosols. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

5.7 Pipetting. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.

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

5.8.1 Labeling. The container for storage, transport, or shipping shall be labeled or color-coded according to section 12.1 and closed prior to being stored, transported, or shipped. If Universal Precautions are used in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility using Universal Precautions. Labeling or color-coding in accordance with section 12.1 is required when such specimens/containers leave the facility.

5.8.2 Contaminated Primary Containers. If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping and is labeled or color-coded according to the requirements of this standard.

5.8.3 Puncture Resistance. If the specimen could puncture the primary container, the primary container shall be placed within a secondary container which is puncture- resistant in addition to the above characteristics.

5.9 Servicing and Shipping Equipment.

5.9.1 Decontamination. Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless the it can be demonstrated that decontamination of such equipment or portions of such equipment is not feasible.

5.9.2 Labeling. A readily observable label in accordance with section 12.1.5 shall be attached to the equipment stating which portions remain contaminated.

5.9.3 Informing. The area supervisor shall ensure that information concerning contaminated equipment is conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken.

Table of Contents

 

6.0 Personal Protective Equipment.

6.1 Availability. When there is occupational exposure, BYU-Idaho shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered Aappropriate@ only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

6.2 Use. Department supervisors shall ensure that College personnel use appropriate personal protective equipment unless the supervisor shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee's professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgement, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

6.3 Accessibility. BYU-Idaho shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.

6.4 Cleaning, Laundering, and Disposal. BYU-Idaho shall clean, launder, and dispose of personal protective equipment required by this plan at no cost to the employee.

6.5 Repair and Replacement. BYU-Idaho shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.

6.6 Inner Contamination. If a garment(s) is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed immediately or as soon as feasible.

6.7 Removal All personal protective equipment shall be removed prior to leaving the work area.

6.7.1 Storage. When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

6.8 Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph section 6.8.4; and when handling or touching contaminated items or surfaces.

6.8.1 Disposable Glove Replacement. Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

6.8.2 Disposable Glove Re-use. Disposable (single use) gloves shall not be washed or decontaminated for re-use.

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

6.8.4 Phlebotomy. If a supervisor judges that routine gloving for all phlebotomies is not necessary then the supervisor shall:

6.8.4.1 Periodically reevaluate this policy;

6.8.4.2 Make gloves available to all employees who wish to use them for phlebotomy;

6.8.4.3 Not discourage the use of gloves for phlebotomy; and

6.8.4.4 Require that gloves be used for phlebotomy in the following circumstances:

6.8.4.4.1 When the employee has cuts, scratches, or other breaks in his or her skin;

6.8.4.4.2 When the employee judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual; and

6.8.4.4.3 When the employee is receiving training in phlebotomy.

6.9 Masks, Eye Protection, and Face Shields. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

6.10 Gowns, Aprons, and Other Protective Body Clothing. Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.

6.10.1 Anticipated Gross Contamination. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopedic surgery).

Table of Contents

 

7.0 Housekeeping.

Departments shall ensure that their work areas are maintained in a clean and sanitary condition. The department shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.

7.1 Cleaning Schedule. (insert cleaning schedule here)

7.2 Cleaning Equipment, Disinfectants, and Equipment.(insert list here)

7.3 Equipment and Working Surfaces. All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.

7.4 Disposable Protective Coverings. Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the workshift if they may have become contaminated during the shift.

7.5 Contaminated Bins, Pails, and Cans. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.

Table of Contents

 

8.0 Regulated Waste.

8.1 Sharps.

8.1.1 Bending and Recapping. Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted in paragraphs 6.1.1 below. Shearing or breaking of contaminated needles is prohibited.

8.1.1.1 Contaminated needles and other contaminated sharps shall not be recapped or removed unless the director or supervisor can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure.

Such recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique.

8.1.2 Contaminated Reusable Sharps. Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers shall be

8.1.2.1 Puncture resistant

8.1.2.2 Labeled or color-coded

8.1.2.3 Leakproof on the sides and bottom

8.1.3 Reusable Sharps Storage. Reusable sharps that are contaminated with blood or other potentially infectious materials 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.

8.1.4 Broken glassware. 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.

8.1.5 Contaminated Sharps Discarding and Containment.

8.1.5.1 Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:

8.1.5.1.1 Closable;

8.1.5.1.2 Puncture resistant;

8.1.5.1.3 Leakproof on sides and bottom; and

8.1.5.1.4 Labeled or color-coded in accordance section 12.1 of this plan.

8.1.5.2 During use, containers for contaminated sharps shall be:

8.1.5.2.1 Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries);

8.1.5.2.2 Maintained upright throughout use; and

8.1.5.2.3 Replaced routinely and not be allowed to overfill.

8.1.5.2.4 When moving containers of contaminated sharps from the area of use, the containers shall be:

8.1.5.2.5 Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;

8.1.5.2.6 Placed in a secondary container if leakage is possible. The second container shall be:

8.1.5.2.6.1 Closeable;

8.1.5.2.6.2 Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and

8.1.5.2.6.3 Labeled or color-coded according to section 12 of this plan.

8.1.5.3 Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury.

8.2 Other Regulated Waste Containment. Regulated waste shall be placed in containers which are:

8.2.1 Closable;

8.2.2 Leakage. Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;

8.2.3 Labeling. Labeled or color-coded in accordance with section 12.1 of this plan; and

8.2.4 Closing. Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

8.3 Outside Contamination of Waste Container. If outside contamination of the regulated waste container occurs, it shall be placed in a second container. The second container shall be:

8.3.1 Closable;

8.3.2 Leakage. Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;

8.3.3 Labeling. Labeled or color-coded in accordance with section 12.1 of this plan; and

8.3.4 Closing. Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

8.4 Disposal. Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, States and Territories, and political subdivisions of States and Territories.

Table of Contents

 

9.0 Laundry.

9.1 Handling. Contaminated laundry shall be handled as little as possible with a minimum of agitation. (1) Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use.

9.2 Containers. Contaminated laundry shall be placed and transported in bags or containers labeled or color-coded in accordance with section 12.1 of this plan. When a facility utilizes Universal Precautions in the handling of all soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with Universal Precautions.

9.3 Wet Contaminated Laundry. Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.

9.4 Personal Protective Equipment. The supervisor shall ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment.

9.5 Labels and Marking. When contaminated laundry is sent to a second facility which does not utilize Universal Precautions in the handling of all laundry, the department generating the contaminated laundry must place such laundry in bags or containers which are labeled or color-coded in accordance section 12 of this plan.

Table of Contents

 

10 HIV and HBV Research Laboratories and Production Facilities.

This section applies to research laboratories and production facilities engaged in the culture, production, concentration, experimentation, and manipulation of HIV and HBV. It does not apply to clinical or diagnostic laboratories engaged solely in the analysis of blood, tissues, or organs. These requirements apply in addition to the other requirements of this plan.

Research laboratories and production facilities shall meet the following criteria:

10.1 Standard microbiological practices. All regulated waste shall either be incinerated or decontaminated by a method such as autoclaving known to effectively destroy bloodborne pathogens.

10.2 Special practices.

10.2.1 Doors. Laboratory doors shall be kept closed when work involving HIV or HBV is in progress.

10.2.2 Contaminated Materials. Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a durable, leakproof, labeled or color-coded container that is closed before being removed from the work area.

10.2.3 Access. Access to the work area shall be limited to authorized persons. Written policies and procedures shall be established whereby only persons who have been advised of the potential biohazard, who meet any specific entry requirements, and who comply with all entry and exit procedures shall be allowed to enter the work areas and animal rooms.

10.2.4 Signs. When other potentially infectious materials or infected animals are present in the work area or containment module, a hazard warning sign incorporating the universal biohazard symbol shall be posted on all access doors. The hazard warning sign shall comply with section 12.2 of this plan.

10.2.5 Use of Safety Cabinets. All activities involving other potentially infectious materials shall be conducted in biological safety cabinets or other physical-containment devices within the containment module. No work with these other potentially infectious materials shall be conducted on the open bench.

10.2.6 Protective Clothing. Laboratory coats, gowns, smocks, uniforms, or other appropriate protective clothing shall be used in the work area and animal rooms. Protective clothing shall not be worn outside of the work area and shall be decontaminated before being laundered.

10.2.7 Gloves. Special care shall be taken to avoid skin contact with other potentially infectious materials. Gloves shall be worn when handling infected animals and when making hand contact with other potentially infectious materials is unavoidable.

10.2.8 Decontaminating Waste. Before disposal all waste from work areas and from animal rooms shall either be incinerated or decontaminated by a method such as autoclaving known to effectively destroy bloodborne pathogens.

10.2.9 Vacuum Lines. Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters or filters of equivalent or superior efficiency and which are checked routinely and maintained or replaced as necessary.

10.2.10 Needles. Hypodermic needles and syringes shall be used only for parenteral injection and aspiration of fluids from laboratory animals and diaphragm bottles. Only needle-locking syringes or disposable syringe-needle units (i.e., the needle is integral to the syringe) shall be used for the injection or aspiration of other potentially infectious materials. Extreme caution shall be used when handling needles and syringes. A needle shall not be bent, sheared, replaced in the sheath or guard, or removed from the syringe following use. The needle and syringe shall be promptly placed in a puncture-resistant container and autoclaved or decontaminated before reuse or disposal.

10.2.11 Spills. All spills shall be immediately contained and cleaned up by appropriate professional staff or others properly trained and equipped to work with potentially concentrated infectious materials.

10.2.12 Accidental Exposures. A spill or accident that results in an exposure incident shall be immediately reported to the laboratory director or other responsible person.

10.2.13 Biosafety Manual. A biosafety manual shall be prepared or adopted and periodically reviewed and updated at least annually or more often if necessary. Personnel shall be advised of potential hazards, shall be required to read instructions on practices and procedures, and shall be required to follow them.

10.3 Containment equipment. Certified biological safety cabinets (Class I, II, or III) or other appropriate combinations of personal protection or physical containment devices, such as special protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotors, and containment caging for animals, shall be used for all activities with other potentially infectious materials that pose a threat of exposure to droplets, splashes, spills, or aerosols.

10.3.1 Certification. Biological safety cabinets shall be certified when installed, whenever they are moved and at least annually.

10.4 Facilities. HIV and HBV research laboratories shall meet the following criteria:

10.4.1 Eye and Hand Wash. Each laboratory shall contain a facility for hand washing and an eye wash facility which is readily available within the work area.

10.4.2 Autoclave. An autoclave for decontamination of regulated waste shall be available.

Table of Contents

 

11.0 Hepatitis B vaccination and post-exposure evaluation and follow-up.

11.1 Availability. BYU-Idaho shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to all employees who have had an exposure incident.

11.2 Procedure. BYU-Idaho shall ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis, are:

11.2.1 Cost. Made available at no cost to the employee;

11.2.2 Convenience. Made available to the employee at a reasonable time and place;

11.2.3 Performed By. Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional; and

11.2.4 Protocol. Provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place, except as specified by section 11.4.

11.3 Laboratory Tests. BYU-Idaho shall ensure that all laboratory tests are conducted by an accredited laboratory at no cost to the employee.

11.4 Hepatitis B Vaccination. Hepatitis B vaccination shall be made available after the employee has received the training required in section 12.3 of this plan and within 10 working days of initial assignment to all employees who have occupational exposure 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 participation in a prescreening program shall not be a prerequisite for receiving hepatitis B vaccination.

11.4.1 Employee Refusal. If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, BYU-Idaho shall make available hepatitis B vaccination at that time.

The employees who decline to accept hepatitis B vaccination shall sign the statement in appendix A.

11.4.2 Boosters. If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available in accordance with section 11.2.

11.5 Post-exposure Evaluation and Follow-up. Following a report of an exposure incident, BYU-Idaho shall make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:

11.5.1 Documentation. Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred;

11.5.2 Identification of Source. Identification and documentation of the source individual, unless it can be established that identification is infeasible or prohibited by state or local law;

11.5.2.1 The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, BYU-Idaho shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.

11.5.2.2 When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.

11.5.2.3 Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

11.5.3 Employee Serology.

11.5.3.1 The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.

11.5.3.2 If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.

11.5.4 Prophylaxis. Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service;

11.6 Counseling and Evaluation of Reported Illnesses.

11.6.1 Information Provided to the Healthcare Professional. BYU-Idaho shall ensure that the healthcare professional responsible for the employee's Hepatitis B vaccination is provided a copy of the Bloodborne Pathogen Standard.

In addition the healthcare professional evaluating an employee after an exposure incident shall be provided with the following information:

11.6.1.1 A description of the exposed employee's duties as they relate to the exposure incident;

11.6.1.2 Documentation of the route(s) of exposure and circumstances under which exposure occurred;

11.6.1.3 Results of the source individual's blood testing, if available; and

11.6.1.4 All medical records relevant to the appropriate treatment of the employee including vaccination status which are the employer's responsibility to maintain.

11.7 Healthcare Professional's Written Opinion. BYU-Idaho shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

11.7.1 Hepatitis B Vaccination. The healthcare professional's written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination.

11.7.2 Evaluation and Followup. The healthcare professional's written opinion for post-exposure evaluation and follow-up shall be limited to the following information:

11.7.2.1 That the employee has been informed of the results of the evaluation; and

11.7.2.2 That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written report.

11.8 Medical recordkeeping. Medical records required by this plan shall be maintained in accordance with section 13.1 of this plan.

Table of Contents

 

12.0 Communication of Hazards to Employees.

12.1 Labels.

12.1.1 Required Labeling. Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in sections 12.1.7 through 12.1.9.

12.1.2 Required Legend. Labels required by this section shall include the legend as demonstrated in figure 1 in appendix 2.

12.1.3 Color. These labels shall be fluorescent orange or orange-red or predominantly so, with lettering or symbols in a contrasting color.

12.1.4 Location and Attachment. Required labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.

12.1.5 Contaminated Equipment. Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated.

12.1.6 Color Coding In Place of Labels. Red bags or red containers may be substituted for labels.

12.1.7 Exemption for Blood Products. Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the these labeling requirements.

12.1.8 Exemption for Inner Packaging. Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from these labeling requirements.

12.1.9 Exemption for Decontaminated Waste. Regulated waste that has been decontaminated need not be labeled or color-coded.

12.2 Signs.

12.2.1 Location. Signs shall be posted at the entrance to HIV and HBV Research Laboratory and Production Facilities, which shall bear the legend BIOHAZARD (see figure 1 in appendix 2). In addition the following information shall be included on the sign:

12.2.1.1 The name of the Infectious Agent

12.2.1.2 Special requirements for entering the area

12.2.1.3 The name and telephone number of the laboratory director or other responsible person.

12.2.2 Color. These signs shall be fluorescent orange-red or predominantly so, with lettering or symbols in a contrasting color.

12.3 Information and Training. All employees with occupational exposure shall participate in a training program which must be provided at no cost to the employee and during working hours.

Training shall be provided as follows:

12.3.1 When. At the time of initial assignment to tasks where occupational exposure may take place; or within 90 days after the effective date of the standard.

12.3.2 Refresher Training. Followup training shall be provided at least annually.

12.3.3 New Tasks. Additional training shall be provided when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee's occupational exposure. The additional training may be limited to addressing the new exposures created.

12.3.4 Content. Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be used. The training program shall contain at a minimum the following elements:

12.3.4.1 An accessible copy of the regulatory text of the Bloodborne Pathogen Standard and an explanation of its contents;

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

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

12.3.4.4 An explanation of the exposure control plan and the means by which the employee can obtain a copy of the written plan;

12.3.4.5 An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials;

12.3.4.6 An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment;

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

12.3.4.8 An explanation of the basis for selection of personal protective equipment;

12.3.4.9 Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;

12.3.4.10 Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;

12.3.4.11 An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available;

12.3.4.12 Information on the post-exposure evaluation and follow-up that BYU-Idaho is required to provide for the employee following an exposure incident;

12.3.4.13 An explanation of the signs and labels and/or color coding used at Ricks;

12.3.4.14 An opportunity for interactive questions and answers with the person conducting the training session.

12.3.5 Trainer. The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address.

12.3.6 Additional Training in Research Laboratories. Additional Initial Training for Employees in HIV and HBV Laboratories and Production Facilities. Employees in HIV or HBV research laboratories and HIV or HBV production facilities shall receive the following initial training in addition to the above training requirements.

12.3.6.1 BYU-Idaho shall assure that employees demonstrate proficiency in standard microbiological practices and techniques and in the practices and operations specific to the facility before being allowed to work with HIV or HBV.

12.3.6.2 BYU-Idaho shall assure that employees have prior experience in the handling of human pathogens or tissue cultures before working with HIV or HBV.

12.3.6.3 BYU-Idaho shall provide a training program to employees who have no prior experience in handling human pathogens. Initial work activities shall not include the handling of infectious agents. A progression of work activities shall be assigned as techniques are learned and proficiency is developed. The supervisor shall assure that employees participate in work activities involving infectious agents only after proficiency has been demonstrated.

Table of Contents

 

13.0 Record Keeping.

13.1 Medical Records. BYU-Idaho shall establish and maintain an accurate record for each employee with occupational exposure, in accordance with 29 CFR 1910.20. This record shall include:

13.1.1 Identification. The name and social security number of the employee;

13.1.2 Vaccination Status. A copy of the employee's hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination as indicated in 11.4;

13.1.3 Examinations. A copy of all results of examinations, medical testing, and follow-up procedures as required by section 11;

13.1.4 Written Opinion. The employer's copy of the healthcare professional's written opinion.

13.1.5 Information Provided to Health Care Professional. A copy of the information provided to the healthcare professional as required by section 11.

13.1.6 Confidentiality. BYU-Idaho shall insure that Employee medical records required by this section:

13.1.6.1 Are kept confidential; and

13.1.6.2 Are not disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by this section or as may be required by law.

13.1.7 Maintenance of Records. BYU-Idaho shall maintain the records required by this section for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.20.

13.1.8 Availability. Employee medical records required by this section shall be provided upon request for examination and copying to the subject employee, and to anyone having written consent of the subject employee.

13.2 Training Records.

13.2.1 Required Information in Training Records. Training records shall include the following information:

13.2.1.1 The dates of the training sessions;

13.2.1.2 The contents or a summary of the training sessions;

13.2.1.3 The names and qualifications of persons conducting the training; and

13.2.1.4 The names and job titles of all persons attending the training sessions.

13.2.2 Record Retention. Training records shall be maintained for 3 years from the date on which the training occurred.

13.2.3 Availability of Records. Employee training records required by this section shall be provided upon request for examination and copying to employees, to employee representatives, to the Director, and to the Assistant Secretary in accordance with 29 CFR 1910.20.

Table of Contents