Bloodborne Pathogens Exposure Control Plan
A. Purpose
1. To define formal infection control procedures to protect Western Michigan University employees, students, and other designated persons from occupational and classroom exposure to blood, bodily fluids, or other potentially infectious material.
2. To ensure Western Michigan University's compliance with State and Federal rules protecting all persons against occupational and classroom exposure to bloodborne pathogens.
3. To define the appropriate evaluation and follow-up procedures to handle accidental injury/exposure for faculty, staff, and students.
B. Definitions
1. Biohazard Symbol: the biohazard symbol and legend in a contrasting color to a fluorescent orange or orange-red background.
2. “Blood” means human blood, human blood components, and products made from human blood.
3. “Bloodborne pathogens” means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
4. “Contaminated” means the presence or the reasonably anticipated presence of blood or other potentially infectious material on an item or surface.
5. “Contaminated Sharps” means any contaminated object that can penetrate the skin, including any of the following: (i) Needles. (ii) Scalpels. (iii) Broken glass. (iv) Broken capillary tubes. (v) Exposed ends of dental wires.
6. “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.
7. “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. “Exposure” does not include incidental exposures that may take place on the job, that are neither reasonably nor routinely expected, and that the worker is not required to incur in the normal course of employment.
8. “Exposure Incident” means a specific eye, mouth, other mucous membranes, nonintact skin, or parenteral contact with blood or other potentially infectious material that results from the performance of an employee’s duties
9. “Other potentially infectious material” means any of the following: (i) Any of the following human body fluids: (A) Semen. (B) Vaginal secretions. (C) Amniotic fluid. (D) Cerebrospinal fluid. (E) Peritoneal fluid. (F) Pleural fluid. (G) Pericardial fluid. (H) Synovial fluid. (I) Saliva in dental procedures. (J) Any body fluid that is visibly contaminated with blood. (K) All body fluids in situations where it is difficult or impossible to differentiate between body fluids. (ii) Any unfixed tissue or organ, other than intact skin, from a living or dead human.
10.Regulated waste is defined as the following:
a. Cultures and stocks of infectious agents and associated biologicals, including laboratory waste, biological production wastes, discarded live and attenuated vaccines, culture dishes, and related devices.
b. Liquid human and animal waste, including blood and blood products and other potentially infectious materials (as defined under Universal Precautions). This includes materials crusted or soaked with blood or bodily fluids but does not include urine or materials stained with blood or bodily fluids.
c. Pathological waste (human organs, tissues, body parts, fluids).
d. Sharps (needles, scalpels, syringes).
e. Contaminated wastes from animals that have been exposed to agents infectious to humans, these being primarily research animals.
11. “Universal precautions” means a method of infection control that treats all human blood and other potentially infectious material as capable of transmitting HIV, HBV, and other bloodborne pathogens.
C. Exposure Determination
1. The potential for occupational exposure to blood-borne pathogens has been classified into the following two categories based on OSHA guidelines.
2. Category A consists of occupations that require procedures or other occupation-related tasks that involve exposure or reasonably anticipated exposure to blood or other potentially infectious material or that involve the likelihood for spills or splashes of blood. This includes procedures or tasks conducted in non-routine situations as a condition of employment. This determination was made without regard to the use of personal protective clothing and equipment.
a. The following are some job classifications or duties that fall into category A.
i. Custodial Services staff
ii. Direct Health Care Providers
iii. Environmental Health and Safety (EHS) Staff
iv. First Aid/CPR/AED providers
v. Maintenance Staff Including: Glaziers, Plumbers/Pipefitters, Carpenters, and Skilled Trades Helpers (STH’s)
vi. Public Safety Police Officers
vii. Others, as reviewed by EHS
b. Environmental Health and Safety has a complete listing of the specific departments that have job classifications with exposure and the departmental standard operating procedures (SOP's) for category A occupations.
3. Category B consists of occupations that do not require tasks that involve exposure to blood or other potentially infectious material on a routine or non-routine basis as a condition of employment. Employees in occupations in this category do not perform or assist in emergency medical care or first aid and are not reasonably anticipated to be exposed in any other way. The areas not listed as Category A above are considered to have job classifications in the B category.
D. Methods of Compliance
1. Universal Precautions
a. Universal precautions shall be observed to prevent contact with blood and other potentially infectious materials. If differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. Infectious materials to which Universal Precautions apply: i. Blood and other bodily fluids, ii. Other potentially infectious materials (OPIM)
b. All persons are expected to use universal precautions, engineering controls, to follow work practice controls, and wear appropriate personal protective equipment when performing a task with potential exposure.
2. Engineering Controls
a. Engineering controls, with work practice controls and personal protective equipment, function together to minimize exposure incidents.
b. Engineering controls are items designed to isolate or keep infectious materials away from staff and others. Where engineering controls will reduce employee exposure, either by removing, eliminating or isolating the hazards, they must be used. All engineering controls must be well maintained. The following are examples of engineering controls: i. Hand-washing facilities must be readily accessible to staff wherever occupational exposure may occur, or approved alternative hand-washing methods i.e., antiseptic towelettes and clean paper or cloth towels followed by soap and water washing as soon as possible must be made available. ii. Containers for used sharps must be puncture-resistant, leakproof, labeled or color-coded, and located as close as possible to the places where sharps are used. iii. Specimen containers must be leak-proof, properly labeled, or color-coded. iv. Appropriate bags and containers for other regulated waste. v. Mechanical pipettes. Pipetting by mouth is prohibited. vi. Laboratory equipment specific to the type of work involved. vii. It is recommended that all departments shall have a first aid kit easily accessible. All departmental first aid kits shall contain a disinfectant. viii. Controls ( e.g. self-sheathing devices, such as sharps with engineered sharps injury protections and needleless systems).
c. Input from non-managerial employees will be solicited and documented regarding consideration of safer medical devices.
3. Work Practice Controls
a. Eating, drinking, smoking, applying cosmetics, and handling contact lenses are prohibited in work areas and/or work surfaces that carry an inherent potential for contamination. Food and drink shall not be stored in refrigerators, freezers, or cabinets where blood or other potentially infectious materials are stored. Such storage equipment must be clearly labeled to prevent this possibility.
b. Hands and other skin surfaces contaminated with blood or other potentially infectious materials shall be washed immediately and thoroughly with soap and water. Mucous membranes, if contaminated, must be washed thoroughly with water. Hands must be washed immediately after gloves are removed, even if the gloves appear to be intact. Handwashing facilities are readily accessible around campus. Employees shall wash their hands immediately or as soon as feasible after the removal of gloves or other personal protective equipment. Those who may not be in close proximity to a handwashing facility (such as landscape service) are supplied with antiseptic hand cleaners (hand sanitizer). Those who use hand sanitizer are still instructed to wash their hands as soon as possible after removing their gloves.
c. Precautions shall be taken to prevent injuries caused by contaminated sharps such as razor blades, broken glass, needles, scalpels, or other sharp instruments. Used needles shall not be bent, broken, reinserted into their original sheaths, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes, needles, scalpel blades, and other sharp items shall be placed in a puncture-resistant container. Puncture-resistant containers shall be located as close as practical to the use area and shall be available to all persons using needles (including diabetic students on campus) and other sharps as indicated above. These containers will not be located in areas open to the public. These containers are to be labeled "Biohazard."
d. New protective device use will be implemented, with employee training as appropriate.
e. All persons who have open wounds or weeping skin rashes shall refrain from all direct patient/client care, potentially hazardous laboratory procedures, and from handling patient-care equipment until the condition resolves. Cuts or abrasions shall be protected with a dressing and gloves prior to performing any procedure involving contact with blood and other potentially infectious materials.
f. Pregnant persons shall be especially familiar with and strictly adhere to Universal Precautions. Infection in the mother places the fetus at risk of acquiring the infection.
g. Blood spills shall be cleaned up promptly with an approved hospital disinfectant. Environmental Health and Safety must be contacted regarding approved hospital disinfectants by calling (269) 387-5590. Germicides vary in their activity against infectious agents and in the time needed for disinfection. The manufacturer's guidelines shall be followed.
h. Medical equipment that requires sterilization or disinfection shall be thoroughly cleaned before disinfecting and care must be taken to follow the manufacturer's guidelines for compatibility with the germicides. This also applies to non-medical equipment.
i. Contaminated laundry, including employee's uniforms, shall be placed in labeled or color-coded, leak-proof containers at the location where it was used. The employer shall ensure that employees who have contact with contaminated laundry wear appropriate personal protective equipment.
j. HBV vaccine shall be offered at Department expense, to all persons whose occupational tasks place them at risk of exposure to blood or other potentially infectious materials.
k. All supervisors/instructors shall be responsible for informing persons of any special precautions pertinent to their area.
l. No Human Immunodeficiency Virus shall be used for research purposes on this campus, without prior approval of the Recombinant DNA Bio-Safety Committee under the auspices of the Vice President for Research. All NIH and CDC guidelines shall be followed.
m. All procedures that involve blood or other potentially infectious material shall be performed in a manner that minimizes splashing, spraying, and aerosolization of blood or other potentially infectious material.
n. Mouth pipetting or suctioning is prohibited.
o. All persons are expected to be knowledgeable about specific operating procedures pertinent to their work area or laboratory.
4. Personal Protective Equipment
a. Protective barriers reduce the risk of exposure of a person's skin or mucous membranes to fluids that require Universal Precautions. Personal protective equipment is appropriate only if it does not permit blood or other potentially infectious material 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 that the protective equipment is used. The following are required protective barriers:
i. Gloves shall be worn for touching human blood, bodily fluids, mucous membranes, or skin with open wounds or weeping rashes; for touching items or surfaces soiled with blood or bodily fluids; for performing venipuncture or other
procedures that enter blood vessels.
ii. Latex, hypoallergenic, or vinyl disposable exam gloves, in suitable sizes, shall be used for all medical and laboratory procedures. Hands shall be washed and gloves changed between patient contacts. Gloves shall not be washed in lieu
of changing. The use of soaps will compromise their ability to be an effective barrier. Employees with a latex allergy are to notify their supervisor. Appropriate accommodations will be made for those persons.
iii. General-purpose utility gloves shall be used for housekeeping chores involving possible blood and other potentially infectious material contact and for instrument and equipment cleanup and decontamination procedures. Gloves extending beyond the wrist are preferable. Gloves must be 0compatible with cleaning and disinfecting chemicals.
iv. Masks, protective goggles, and chin-length face shields shall be worn if aerosolization or splattering of blood or other potentially infectious material is likely to occur.
v. Gowns, fluid-proof aprons, laboratory coats, Tyvek style suits, or other protective clothing shall be worn if blood splattering or the spattering of other potentially infectious material is likely.
vi. Resuscitation devices, including mouthpieces, masks, resuscitation bags, or other ventilation devices shall be strategically located and available for use in areas where the need for resuscitation is predictable. All appropriate personnel shall be trained in their use.
vii. Disposable personal protective equipment shall be disposed of properly into red biohazard bags and not reused.
viii. Reusable equipment shall be cleaned and decontaminated properly soon after use and is proved by WMU.
ix. Personal Protective Equipment is required to be worn by employees. PPE is provided by WMU at no cost to the employees. Employees must tell their supervisor if any PPE or equipment needs replacing as needed to maintain their effectiveness.
5. Standard Operating Procedure (SOP)
a. Task-specific operating procedures shall be written and updated annually by the departments that have employees that are indicated in the Category A definition. These SOPs shall be reviewed with employees at least annually.
6. Regulated Medical Waste Disposal
a. All regulated waste that is being disposed of shall be placed in closable, leakproof containers or bags that are color-coded red or labeled with a biohazard label. If outside contamination of the container or bag is likely to occur, then a second leakproof container or bag that is closable and labeled or color-coded shall be placed over the outside of the first and closed to prevent leakage during handling, storage, and transport.
b. Immediately after use, contaminated sharps shall be disposed of in closable, leakproof, puncture-resistant, disposable containers that are labeled or color-coded red. These containers shall be easily accessible to personnel; shall be located in the immediate area of use or where sharps are likely to be found unless needles are mechanically recapped and transported through nonpublic corridors to the container; and shall be replaced routinely and not allowed to overfill.
c. The Division of Environmental Health and Safety monitors the disposal of all regulated waste in accordance with applicable federal, state, and local regulations.
d. Medical, biological, and other infectious wastes must be disposed of in designated containers or bags that are color-coded, labeled, or tagged as "Biohazard." Sharps containers may be obtained through the Sindecuse Health Center. Biohazard bags may be obtained from Maintenance Stores. Questions regarding safe disposal shall be directed to EHS.
e. WMU students can purchase sharps containers from the Sindecuse Pharmacy.
f. All areas shall contact EHS at (269) 387-5590 for disposal of infectious waste containers.
7. Exposure Incident Protocol
a. All persons are to immediately report an incident of contact with blood or other potentially infectious materials sustained during the course of occupational or classroom duties.
b. The person who receives a potential exposure shall observe the following procedures:
i. Immediately begin thorough cleansing of the exposed body site with soap and water or an approved alternative hand-washing method.
ii. Remove personal protective equipment and wash the exposed site again with soap and water. The exposed site shall be thoroughly disinfected with appropriate skin disinfectant if immediately available (Betadine solution, Hibiclens). Follow precautions to minimize exposure of other persons to blood, blood products, or other potentially infectious material, e.g., inform co-workers to use protective barriers, remove an exposed sharp and place in a sharps container, and isolate the contaminated area.
iii. Notify Supervisor.
iv. Immediately report to Sindecuse Health Center (268) 387-3287 for evaluation, treatment, and follow-up care (Monday-Friday, 8:00 a.m.-5:00 p.m.) After hours report to the Bronson Methodist Hospital Emergency Room (269) 341-6386.
c. The supervisor of a potentially exposed person shall observe the following procedures:
i. Ensure the individual receives medical attention as soon as possible.
ii. Ensure that other persons remain out of the area to minimize potential exposure to blood, blood products or OPIM.
iii. Barricade any heavily contaminated area until disinfected.
iv. Notify Custodial Services when clean up of a contaminated area is required. Ensure that custodians are aware of the potential for contamination and take every precaution to prevent contamination of themselves or other persons by using appropriate personal protective equipment and decontamination procedures.
v. Ensure that the contaminated area is adequately disinfected.
vi. Complete a WC210 Form and provide the physician with:
1. A description of the exposed employee's duties as they relate to the exposure incident
2. Documentation of the route of exposure and circumstances under which exposure occurred
3. Identity of the source individual, if available
4. Complete an EHS 311 Form.
d. The Sindecuse Health Center shall observe the following procedures:
i. Make a rapid initial determination if the person presented with exposure to blood or OPIM.
ii. If an immediate referral is not made, perform medical evaluation and treatment
iii. Record the circumstances of the injury/exposure in the person's confidential medical record. Relevant information shall include the following:
1. Date and time of exposure
2. Job duty being performed by the person at the time of exposure
3. Details of exposure including the amount and type of fluid or material, severity of exposure, and whether or not the person was using personal protective equipment
4. Description of the source of exposure including whether the source material contains HIV, HBV, or HCV if known.
5. Details about counseling, post-exposure management, and follow-up.
iv. Perform blood analysis for HIV (with informed consent), HBV, or HCV on the exposed person as soon as feasible. If the employee consents to baseline testing, but not HIV testing, the specimen shall be saved for at least 90 days. If within 90 days of exposure, the employee elects to have the specimen tested for HIV, it shall be tested as soon as possible.
v. Follow the CDC guidelines for post-exposure treatment if the source is unknown.
vi. Reevaluate the exposed person at 6 weeks, 12 weeks, and 6 months after exposure to determine whether HIV infection has occurred if the source individual is unknown, refuses HIV testing, or is HIV positive. If the source individual is HIV negative, no further testing is necessary unless past personal history suggests that the individual may have recently been exposed to HIV.
vii. All exposed employees, whether seen in the community or Sindecuse, will be asked to return to Sindecuse for Hepatitis B test results for follow-up testing and evaluation.
viii. Provide a copy of the written opinion to the employee at the time of evaluation.
ix. Ensure that person's medical information and records are kept confidential except as required by law.
x. Complete WC 210 form by the WMU Occupational Medicine physician.
e. Environmental Health and Safety shall observe the following procedure:
i. EHS maintains a file of all EHS 311 and WC 210 forms as well as the physician's opinion regarding an employee's occupational exposure to blood or other potentially infectious materials.
ii. EHS maintains a sharps injury log separate from the OSHA 300 Log. The sharps injury log will record percutaneous injuries from contaminated sharps. The information in the log is recorded so that it protects in the confidentiality of the injured employee.
iii. Update policies and operating procedures reflecting changes in technology reducing/eliminating exposure to blood, body fluids, or other potentially infectious material.
8. Hepatitis B Vaccination Program
a. Western Michigan University provides an HBV vaccination program at the Sindecuse Health Center for the employees in Category A occupations at no cost to the employee.
b. EHS maintains files of the Hepatitis B declination forms and the confirmation of completion of the vaccination series.
9. Training and Education
a. Western Michigan University shall provide initial and annual formal training and education programs for employees with potential exposure to blood or other potentially infectious material (Category A occupations) at no cost to the employee and during working hours. Material appropriate in content and vocabulary to the education level, literacy, and language background of persons shall be used
b. The training program shall contain the following elements:
i. Discuss the basis of the standard.
ii. A general explanation of the epidemiology of HBV, HIV, and HCV and symptoms associated with clinical illness from these two viruses.
iii. An explanation of the modes of transmission of HBV, HIV, and HCV.
iv. An explanation of Western Michigan University's Bloodborne Pathogen Exposure Control Plan. This will include an explanation of Universal Precautions, Engineering and Work Practice Controls, and the use of Personal Protective Equipment.
v. A detailed explanation of protective barriers and other personal protective equipment, the basis of which these are selected, and the limitations of these methods of control in preventing exposure.
vi. An explanation of the signs, labels, tags, and color-coding used to denote biohazards.
vii. Information on the HBV vaccine, including the indications, safety, efficacy, and benefits.
viii. An explanation of the procedure to follow if potential exposure occurs and the medical follow-up that will be made available.
ix. Question and answer period.
c. The Division of Environmental Health and Safety shall maintain files documenting employee training on the Bloodborne Pathogen Standard and the Western Michigan University Exposure Control Plan.
Reviewed and Updated 8/6/2021