Bloodborne Pathogens Exposure Control Plan

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In today's world of AIDS, Hepatitis B, and other such diseases we must be careful. You cannot catch them by being near a person with the disease, but precautions must be taken because they are contracted through contact with contaminated bodily fluids, including blood, saliva, urine, feces, vomit, etc. The purpose of this exposure control plan is to:

  1. Eliminate or minimize employee occupational exposure to blood or certain other body fluids.
  2. Comply with the Cal/OSHA Bloodborne Pathogens Standard, CCR-T8 5193.

Infection Control Representative(s)

Infection Control Representative(s) must be selected to implement the exposure control plan. Claremont McKenna College (CMC) will use the Safety Coordinator named in the Illness and Injury Prevention Program, the Athletics Director and the Associate Dean of Students. These people will be responsible for implementing this plan and for enforcing it.

Exposure Control Plan

The Exposure Control Plan must be in written form, and updated annually, or as needed, taking into account all job classifications where people may be exposed to bloodborne pathogens. A copy of this plan must be made available to employees, their representatives, and Cal/OSHA, if requested. Supervisors will provide all of their employees with a copy during orientation, and also a copy to current employees.

Supervisors must determine the people who have a reasonable risk of exposure regardless of protective equipment. They must list both a) job classifications where all employees may be exposed and b) job classifications where some of the employees may be exposed and the situations in which exposure may occur.

Method Of Implementation:

o Compliance Methods

General/universal precautions will be taken to prevent contact with blood or other potentially infectious material. One of the most basic manners of prevention is careful engineering controls and work procedures and practices. Caution and common sense must always be used when around possibly infectious material.

Hand washing facilities will be made available to the employees who incur exposure to blood or other potentially infectious materials. If hand-washing facilities are not feasible, employee should use antiseptic cleaner provided by employer.

Mouth pipetting and suctioning of blood (e.g., to cure snake bites), and other bodily fluids are not allowed.

o Contaminated Needles and Sharps

Contaminated needles and other sharps shall not be sheared or purposely broken. Cal/OSHA allows recapping, bending or removal of contaminated needles only when the procedure requires it and no alternative is feasible. If such action is required it must be done by the use of a mechanical device.

Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate containers. Containers must be puncture resistant, labeled with a biohazard label and leak proof.

o Work Area Restrictions

Food and drink are not allowed in areas that possibly contain infectious material.

Smoking is prohibited in all work areas.

Application of cosmetics, eye contacts, and removal of these things is also prohibited in areas that possibly contain infectious material.

Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, counters or bench tops where blood or other potentially infectious materials are present.

o Specimens

Specimens of blood or other potentially infectious materials will be placed in a container, which prevents leakage during the collection, handling, storage, processing or transporting of the specimens.

The container for this use will be properly labeled.

o Personal Protective Equipment (PPE)

The employer will provide any necessary personal protective equipment at no cost to the employee.

Each supervisor is responsible for ensuring that employees use such equipment.

Equipment includes, but is not limited to: gloves, lab coats, face shields or masks, other ventilation devices and shoe coverings. All PPE must fit the employee properly. Some people are allergic and the College must provide for their needs. This means, for example, that non-powdered gloves must be available in addition to the standard powdered ones.

The supervisor is also responsible for getting this equipment cleaned thoroughly and properly, and providing repairs and replacements as necessary.

Supervisors are responsible for training all their employees on the proper use of personal protective equipment.

All employees are required to use the employer-provided PPE when in a situation that might expose the employee to possibly infectious material.

o Housekeeping

Another basic precaution is cleaning the work area. Employees are in charge of this. Cleaning and decontaminating the work area must be scheduled regularly. This includes all equipment in the area.

Cleaning and decontaminating must also occur as soon as possible after contact with blood or other possibly infectious material. Protective coverings (plastic wrap, foil, etc.) should be replaced frequently.

Possibly contaminated glass should not be thrown away with regular garbage, but should be stored in secure and labeled containers and disposed of properly, as should all regulated waste. However, some times infectious material makes it into the garbage. That is why caution should be used when taking care of the garbage. For example, wear gloves and don't put a hand underneath to help carry the bag.

While it is unlikely that sharps, etc. are in the laundry, it is highly possible that clothes may have been splattered by infected material, and if you were to touch it directly, contact would occur. This is another situation where gloves are required.

Hepatitis B Vaccine and Post-Exposure Follow-Up

CMC shall make available the Hepatitis B vaccination series to all employees who have occupational exposure, and post-exposure follow-up to employees who have had an exposure incident. The infection control representatives shall ensure that the Hepatitis B vaccine and post exposure follow-up is:

  • Made available at no cost to the employees.
  • Made available to the employee at a reasonable time and place.
  • Performed by or under the supervision of a licensed physician or under the supervision of another licensed healthcare professional.
  • Proved according to the recommendations of the U.S. Public Health Service.

An accredited laboratory at no cost to the employee shall conduct all laboratory tests.

Hepatitis B Vaccinations

  • Hepatitis B vaccinations shall be made available after the employee has received training in occupational exposure and within 10 working days of initial assignment.
  • If an employee initially declines Hepatitis B vaccination but at a later date, while still covered under the standard decides to accept the vaccination, the vaccination shall then be made available.
  • All employees who decline the Hepatitis B vaccination shall sign a Cal/OSHA required waiver indicating their refusal.

Post-Exposure Evaluation

All exposure incidents shall be reported, investigated and documented. When the employee incurs an exposure incident, it shall first be reported to their immediate supervisor.

Following the report of an exposure incident, the exposed employee shall immediately receive a confidential medical evaluation and follow-up, including at least two of the following:

  • Documentation of the route of exposure and the circumstances under which the exposure incident occurred.
  • Identification and documentation of the source individual, unless it can be established that the identification is infeasible or prohibited by State or local law.
  • The source individual's blood shall be tested as soon as feasible and after consent has been obtained.
  • When the source individual is already known to be infected with HBV or HIV, testing need not be repeated.
  • 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.

Information And Training

Each supervisor shall ensure that training is provided to the employee at the time of initial assignment to tasks where occupational exposure may occur. Said training shall be repeated every twelve months. The training will be interactive and cover the following elements:

  • An accessible copy of the standard and explanation of its contents.
  • A discussion of the epidemiology and symptoms of bloodborne diseases.
  • An explanation of the modes of transmission of bloodborne pathogens.
  • An explanation of the CMC Bloodborne Pathogen Exposure Control Plan.
  • The recognition of tasks that may involve exposure.
  • An explanation of the use and limitations of methods to reduce exposure.
  • Information on the types, use, location, removal, handling, decontamination and disposal of PPEs.
  • An explanation of the basis selection of PPEs.
  • Information on the Hepatitis B vaccine.
  • Information on the appropriate actions to take in an emergency involving blood or other bodily fluids.
  • An explanation of the procedures to follow if an exposure incident occurs.
  • In formation on the evaluation and follow-up required after an exposure incident.
  • An explanation of the signs, labels and color-coding systems.

The person conducting the training shall be knowledgeable in the subject matter.

Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employees' occupational exposure.

Labels and Signs

As a method of informing and reminding, Biohazard labels are required in areas where exposure may occur and on containers containing possibly infectious material. Supervisors must make sure that their work area has the appropriate labels. Signs must have the Biohazard picture on them, the name of the infectious agent, specific requirements to enter the area, and the name and phone number of the responsible person. This information must be written in black or some other contrasting color on a fluorescent orange or red-orange background.

Each supervisor shall ensure that biohazard labels are affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials.

Record Keeping

CMC is required to maintain strict records. This is to keep down our liability in the event of an incident, and to help us understand what has been done, who has been covered, where the most accidents occur, and other such information that we can use to make the campus safer for employees.

Accessibility to the records is of equal importance as maintaining them. Employees or a designated representative must have access to the records. Either CMC must provide copies for free to the employee (employee is understood to mean employee or a designated representative), or a copy machine must be easily accessible to the employee. X-ray access is allowed to be restricted, however. Due to the nature of the record, it is difficult to get duplicates. While the x-ray may be loaned out to the employee, it must be returned to CMC. A minimal fee, for searching and handling, may be charged for second requests, unless the request is for information that has been added since the last request, or if the requester is the employee's collective bargaining agent. Otherwise, only one request may be made for free. The employee does have total access for that first request.

o Medical Records

Medical records must all be kept confidential, to be given out only to those who have the permission of the employee. It is suggested, though not required, that a letter from the employee that states who is allowed access to the file be kept on file. These records must be kept throughout the duration of the employment, and an additional thirty years. If an employee works for less than a year, the record may be given to him upon termination of his employment from CMC. CMC would then be absolved of all record keeping requirements pertaining to this employee. The records shall include the following:

  • The name and social security number of the employee.
  • A copy of the employee's HBV vaccination status.
  • A copy of all results of examination, medical testing and follow-up procedures.
  • A copy of the information provided to the healthcare professional, including a description of the employee's duties as they relate to the exposure incident.
  • A confidential copy of the healthcare professional opinion.

o Training Records

The supervisor is responsible for maintaining training records. Records pertaining to bloodborne pathogen exposure training must be kept for three years. The following information shall be documented:

  • The dates of the training session.
  • An outline describing the material presented.
  • The names and qualifications of persons conducting the training.
  • The names and job titles of all persons attending the training sessions.

o Exposure Records

Exposure records will be maintained in the Human Resources Office, along with medical records.

The Director of Human Resources must record all exposure incidents in the OSHA 300 log if a physician administers medical treatment, or if HIV or HBV is a direct result of the exposure.

All exposure records must be kept for thirty years, in addition to the duration of employment. Data about work area quality may be destroyed after one year, as long as the methods and results of the survey are kept the full thirty years.

MSDS's are strongly recommended to be kept for thirty years, but the minimum requirement is the identity of the agent, and when and where it was used.

A basic record of all exposure incidents (who, what, where, when) is the minimum requirement, and must be kept thirty years. Lastly, all analyses must be kept for thirty years.

Program Audits

It isn't enough to just have a plan; we must make regular checks to see that it is being followed. Certain things need to be assessed regularly, and corrected when necessary, to ensure the effectiveness of the program. These things include the need for and availability of engineering controls, the use and quality of personal protective equipment, and the use of proper work practices. The infection control representatives will conduct these audits semi-annually, and record their observations and any actions taken as a result of their discoveries.

Miscellaneous Issues

Companies that supply CMC with contract labor (i.e. outside companies that we pay to pave parking lots, remodel buildings, etc.) must likewise educate their employees. In other words, all people performing work on CMC's campus who may be exposed to bloodborne pathogens must have knowledge of them and be made aware of the vaccination program available. The person responsible for contracting with outside vendors must obtain a letter of commitment stating they have a bloodborne pathogen training program.

December 2003