Contents

Chapter 1.0 Purpose……………………………………………………………….………2

Chapter 2.0          Scope and Applicability………………………………….……………..2

Chapter 3.0 Responsibilities………………………………………………………..……2

Chapter 4.0          Methods of Compliance…………………………………………….…3

  • 1 Universal Precautions
  • 2 Work Practices and Engineering Controls

4.2.1     Handwashing

4.2.2     Restricted Access

4.2.3     Labeling

4.2.4     Prohibited Practices

4.2.5     Sharps Management

4.2.6     Minimization of Aerosol Generation

4.2.7     Disinfection/Decontamination of Work Areas

4.2.8     Regulated Medical Waste Disposal

4.2.9     Spill Cleanups

  • 3 Personal Protective Equipment

4.3.1     Protective Eyewear

4.3.2     Lab Coats/Aprons

4.3.3     Gloves

Chapter 5.0          Medical Considerations…………………………………………….…7

  • 1 Hepatitis B Vaccinations
  • 2 Post-Exposure Evaluation and Follow-up

Chapter 6.0          Training Requirements…………………………………………………8

 

Appendices

  • Appendix A Exposure Determination Criteria…………………………………………………9
  • Appendix B Exposure Control Job Classification……………………………………………10
  • Appendix C Definitions………………………………………………………………………11
  • Appendix D Post-Exposure Procedures Poster………………………………………………13

 

1.0     Purpose

 

Wichita State University voluntarily complies with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard, 29 CFR 1910.1030. The purpose of the Bloodborne Pathogen Standard is to reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV), and other potentially infectious bloodborne pathogens that employees may encounter in their workplace.

The WSU Exposure Control Plan (ECP) describes how to eliminate or minimize the exposure of University personnel to human blood or blood products and other potentially infection materials (OPIM) that might contain bloodborne pathogens (BBPs).

2.0     Scope and Applicability

 

This bloodborne pathogens program covers all university employees who have occupational exposures with blood or potentially infectious materials during their normal job duties. See Appendix B for the job classifications specifically covered under this program.

3.0     Responsibilities

 

Office of Environmental, Health & Safety (EHS)

  • Develop and maintain the BBP Exposure Control Plan. A copy of this plan is available on the WSU EHS website.
  • Assist departments in training and development of compliance guidelines.
  • Conduct an annual assessment to determine the Exposure Control Plan’s effectiveness.
  • Revise the plan upon regulatory changes or as necessary.

Department Chairs, Deans, Directors, & Administrators

  • Provide the resources necessary to obtain the appropriate safety equipment to reduce the risk of exposure to affected employees.
  • Assist in the annual review and audit of the Exposure Control Plan.
  • Ensure that all employees that may have occupational exposure to BBPs are offered Hepatitis B vaccinations.
  • Ensure that all exposure incidents are reported to Human Resources, Student Health Services, and the Office of Environmental, Health, & Safety.

Principal Investigators (PI), Managers, & Supervisors

  • Provide specific training for personnel within labs and workplaces.
  • Identify tasks and procedures where occupational exposure may occur.
  • Document training.
  • Ensure that employees are wearing the proper personal protective equipment (PPE) and that adequate supplies are available.
  • Ensure that all employees who may have occupational exposure to BBPs are offered Hepatitis B vaccinations.

Employees

  • Review and become familiar with the applicable components of the Exposure Control Plan.
  • Participate in BBP training at the time of initial assignment to tasks where exposure to BBPs may occur, and annually thereafter.
  • Adhere to the practices and procedures of universal precautions.
  • Report any exposure, accident, injury or illness to their supervisor immediately.

4.0     Methods of Compliance

 

4.1 Universal Precautions

Universal precautions is an approach to infection control, and involves behaving under the

assumption that all blood, blood products, and body fluids may be infectious. Based on

this assumption, all workers must utilize good work practices and engineering controls, as

well as protective equipment, to minimize or eliminate exposure to bloodborne pathogens.

Following universal precautions and good work practice requires that all procedures in the

subsequent section of this document be strictly adhered to.

 

  • Work Practices and Engineering Controls

 

  • Handwashing

All personnel must wash their hands with non-abrasive hand soap before and after handling blood, blood products, or other potentially infectious material, and immediately upon any contact with these materials. When handwashing is not feasible, personnel must use an appropriate antiseptic hand cleanser in conjunction with clean cloth or 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.

 

  • Restricted Access

 

  • Access to a laboratory is restricted to authorized personnel by the laboratory supervisor

when work with blood or other potentially infectious materials is in progress.

  • Individuals with reduced immunity who are at increased risk of acquiring infection, or for whom infection may be unusually hazardous (e.g., very young children, patients recovering from surgery), shall not be allowed in the laboratory without prior consultation with a licensed healthcare professional.
  • When work with blood, blood products or other potentially infectious materials is being

performed, non-laboratory personnel, such as maintenance workers, porters, administrative

staff, and personnel not affiliated with the university, are to be discouraged from entering. If it becomes necessary for them to enter a facility, the hazards of the work being performed must be fully explained.

  • Any maintenance and building services personnel visiting the lab may be unfamiliar with

the potential hazards present in a laboratory. They must be fully instructed and carefully

supervised by the laboratory supervisor when working in areas where human blood, blood products, and other potentially infectious materials are handled.

 

  • Labeling

 

  • A biohazard warning sign incorporating the universal biohazard symbol must be posted on the access door to the laboratory work area.
  • All human tissue, body fluid, or other potentially infectious materials must be stored in a

container labeled with a biohazard symbol.

  • Refrigerators, freezers, incubators, or other pieces of equipment where potentially infectious materials are stored or handled must also be labeled with the biohazard symbol.

 

  • Prohibited Practices

 

  • Eating and drinking are not permitted in areas where blood, blood products, or other potentially infectious materials are handled or stored.
  • Food and drink shall not be kept in refrigerators, freezers, shelves, and cabinets or on countertops or benchtops where blood or OPIM are present.
  • Mouth pipetting or suctioning of blood or OPIM is prohibited. Mechanical pipetting devices must be used.
  • Do NOT place head in Biosafety Cabinets.
  • Do not re-cap or alter needles. Used needles and other sharps are not to be sheared, bent, broken, recapped, or re-sheathed by hand. This extra handling increases the potential of needlestick injuries.

 

  • Sharps Management

 

  • The use of syringes, needles, and other sharp instruments must be minimized whenever possible. Extreme caution must be used when handling needles and syringes to avoid accidental needle sticks or the generation of aerosols during use and disposal.
  • To minimize the hazards of injury and infection, sharps must be disposed of, with minimal handling, in appropriate sharps containers.
    • Sharps containers for contaminated sharps:
      • Shall be rigid, puncture resistant, leak-proof, portable, and correctly labeled.
      • Shall be easily accessible to personnel, and located as close as is feasible to where sharps are anticipated to be found.
      • Contaminated sharps are to be placed into sharps containers immediately.
      • The contents of the sharps container shall not be accessed unless properly reprocessed or decontaminated. Sharps containers shall not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of sharps injury.
      • Containers shall be replaced as necessary to prevent overfilling.
    • Sharps containers must be used for the following materials:
      • Needles and syringes with attached needles (contaminated or not), scalpel and razor blades (contaminated or not).
      • Contaminated pipettes and broken glassware
    • Alternatively, these materials may be placed in a hard-sided box which is then closed and placed in a biohazard bag for disposal.

 

  • Minimization of Aerosol Generation

 

  • All procedures must be performed carefully to minimize the creation of aerosols. Biological safety cabinets or other physical containment devices must be used whenever possible while performing operations that might result in aerosolization. Aerosol-generating procedures include, but are not limited to, the following:
    • centrifugation
    • mixing
    • pipetting
    • blending
    • homogenization
    • opening pressurized containers
    • sonication
    • vortexing
    • flow cytometry
    • needle/syringe manipulations
  • Biosafety cabinets shall be used whenever feasible to handle specimens of blood or other potentially infectious materials.
  • If a biological safety cabinet cannot be used, then other recommended means of minimizing exposure to aerosols shall be used. These methods include, but are not limited to, the utilization of closed containers such as centrifuge tubes, sealed centrifuge rotors, and capped test tubes.

 

  • Disinfection/Decontamination of Work Areas

 

  • Blood and other potentially infectious materials must be handled in an area that can be readily decontaminated, such as a biosafety cabinet.
  • The work area must be disinfected before and after handling blood, OPIM or pathogenic microorganisms. All equipment used to contain, inoculate, or transfer hazardous organisms (syringes, media, plates, etc.) must be decontaminated.
  • Non-laboratory personnel should not handle equipment until it has been decontaminated.
  • All disinfectants must be Hepatitis B virucidal and prepared at an effective concentration for use with the appropriate contact time (1:10 solution of bleach and water for 20 minutes).

 

  • Regulated Medical Waste Disposal

 

  • Medical waste must be placed in containers which are constructed to contain all contents and prevent leakage of fluids during handling, storage, transport and shipping.
  • All containers must be labeled with the contents and a biohazard symbol.
  • Prior to removal from the area of use, waste containers must be closed to prevent spillage or protrusion.
  • If a secondary container is used to prevent spillage, it must also be closeable, labeled and closed prior to removal.
  • Containers used for the containment and/or transport of medical waste must be leak resistant, have tight fitting covers, and kept clean and in good repair. The container must be labeled with the words “Biohazard Waste”, or with the international biohazard symbol and the word “Biohazard” on the lid and sides so as to be visible from all sides.
  • All liquid waste (cultures, stocks, and other regulated liquid waste) shall be decontaminated by a 10% solution of household bleach (final concentration) for 15—30 minute minimum contact time prior to disposal down the sink with copious amounts of running water.

 

  • Spill Cleanups

 

  • All spills must be cleaned up immediately and disinfected with an appropriate disinfectant, such as a 1:10 solution of bleach and water. Tools and materials used for cleaning spills must be decontaminated by appropriate decontamination procedures, as determined by the laboratory supervisor.
  • Broken glassware which may potentially be contaminated shall be picked up using tongs, forceps, broom and dust pan, or other such device. At no time will employees pick up potentially contaminated broken glass with their bare hands. Protective clothing shall be worn during the cleanup, such as goggles, a face mask, gloves and a lab coat.
  • The laboratory supervisor or other laboratory personnel must report laboratory accidents (major spills, injuries, illnesses) to EHS within eight working hours.

 

 

 

 

 

 

  • Personal Protective Equipment (PPE)

  4.3.1       Protective Eyewear

Protective eyewear, including safety glasses or goggles, is required during laboratory operations that have the potential for generating splashes or aerosol droplets. Face shields may be substituted when appropriate.

 

  • Lab Coats/Aprons

 

Liquid-impervious laboratory coats, gowns, smocks, or uniforms must be worn while manipulating specimens that include BBP or OPIM. Long pants and closed-toed shoes are required at all times when in the laboratory. Before leaving the laboratory for non-laboratory areas such as a cafeteria, library, or administrative offices, this protective clothing must be removed and left in the laboratory.

 

  • Gloves

 

  • Gloves must be worn by all personnel engaged in activities that may involve skin contact with potentially infectious fluids or tissues.
  • Gloves are required for laboratory workers with dermatitis or other lesions on the hands

who may have direct or indirect contact with potentially infectious materials.

  • Handwashing with non-abrasive hand soap and water must be a routine practice immediately after direct contact with potentially infectious materials and on completion of work, even when gloves are worn.
  • Gloves should be removed before touching common equipment (phone, computer, fax

machines) to prevent contamination.

  • Glove selection shall be appropriate for the materials being handled.

 

5.0     Medical Considerations

 

5.1 Hepatitis B Vaccinations

 

HBV vaccinations will be made available at no cost to all employees and students who are occupationally exposed to blood, blood products or OPIM.

Each identified individual will receive information on the Hepatitis B vaccine, including information on its efficacy, safety, method of administration, and the benefits of being vaccinated. The following provisions apply:

  • HBV vaccinations must be made available to all employees within 10 working days of initial assignment unless the employee has previously received vaccination, antibody testing has shown the employee to be immune, or unless contraindicated for medical reasons.
  • Workers who initially decline the HBV vaccination must sign a declination form to do so. Supervisors are required to keep all declination forms signed by their employees. If any

worker, at a later date, decides to accept the HBV vaccination, it will be provided to the

worker at no cost.

  • University Student Health Services will coordinate and schedule all HBV vaccinations to be given to employees and students.
  • If a routine booster dose for HBV is recommended by the U.S. Public Health Service at a

future date, such booster will be made available to at-risk employees and students.

  • University Student Health Services will maintain records of all those on the Hepatitis B vaccination program.

 

5.2 Post-Exposure Evaluation and Follow-up

 

The exposure incident must be reported to the supervisor, department administrator or department safety coordinator before the end of the workday on which the exposure occurred. EHS must be notified immediately by the employee or department.

The university shall make a confidential medical evaluation and follow-up available to the employee.

 

  • In case of life-threatening conditions, call 911 from any campus landline

 

  • For non-life-threatening incidents, you may seek medical attention at the Student Wellness Center

 

Student Wellness Center
Steve Clark YMCA
2060 N Mid-Campus Drive
Wichita, KS 67208

316-978-4792

6.0     Training Requirements

 

Initial Bloodborne Pathogen training is available in person or online and is required at the time of initial assignment to tasks where occupational exposure to blood and other potentially infectious materials may occur. Training must be repeated every 12 months thereafter. Contact the Office of Environmental, Health and Safety to coordinate training.

 

 

Appendix A: Exposure Determination Criteria

The criteria described below are provided courtesy of the Centers for Disease Control and Prevention:

Criteria for Determining the Risk of Occupational Exposure
to Hepatitis B Virus or other Bloodborne Pathogens

Does the employee ever:

  • work with animals, such as primates, that are infected with Hepatitis B or other bloodborne pathogens OR perform tasks where such animals are housed?
  • work with Hepatitis B virus or other bloodborne pathogens or with preparations, such as liquid solutions or powders containing the Hepatitis B virus?
  • handle human blood products such as whole blood, plasma, serum, platelets, or white cells?
  • handle human body fluids such as semen, cerebrospinal fluid, vaginal secretions, joint fluid, pleural fluid, peritoneal fluid, pericardial fluid, or amniotic fluid?
  • handle unfixed human tissue or organs? (Tissues and organs soaked in chemical preservatives such as alcohol or formaldehyde are “fixed”)
  • handle blood, blood products, body fluids or unfixed tissues or organs of animals infected with the Hepatitis B Virus or other bloodborne pathogens?
  • handle sharp instruments such as knives, needles, scalpels, or scissors, which have been used by others working with human blood, or other potentially infectious materials to include unfixed human organs, tissues or body fluids OR used by others working with similar body parts and fluids from animals infected with the Hepatitis B Virus or other bloodborne pathogens?
  • enter areas where other individuals work with human or animal blood, body fluid, tissues or organs which are infected with the Hepatitis B Virus or other bloodborne pathogens AND perform tasks where any of the aforementioned body substances may come into contact with the laboratory worker’s unbroken skin, broken skin, or mucous membranes?
  • perform tasks which may potentially result in the lab workers exposed skin or mucous membranes coming in contact with human or animal blood, body fluids, organs, or tissues which are infected with the Hepatitis B Virus or other bloodborne pathogens?
  • handle lentiviral vectors (HIV-1), human cell lines known to harbor and propagate HIV or human cells likely to support the replication of HIV and which have not been tested or verified to be free of HIV?
  • respond to medical emergencies as part of assigned tasks

  • IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS “YES”, THEN THE LAB WORKER IS
    CONSIDERED TO BE AT OCCUPATIONAL RISK OF CONTRACTING HBV OR OTHER BLOODBORNE PATHOGENS

 

 

 

Appendix B: Exposure Control Plan Job Classification

Exposure determination is based upon an employee’s reasonable potential for exposure to blood or any other infectious materials that they may contact during their job duties. Exposure determination shall be made without regard to the use of personal protective equipment (employees are considered to be exposed even if they wear personal protective equipment). OSHA requires exposure evaluations based on the potential for job-related tasks leading to exposure. The university program is designed to cover those who are at a higher risk of exposure by establishing high, moderate, or low risk categories. All other employees will be evaluated and determined on an individual basis by Student Health Services and EHS. The three categories and job classifications are as follows:

 

Category 1 – High Risk

Procedures or jobs that involve inherent potential for contact with blood, body fluids, tissues, mucous membranes, or skin contact that could possibly transmit the HBV, HIV or other bloodborne pathogen.

             

High Risk Positions:

  • Physician
  • Registered Nurse
  • Nurse Practitioner
  • Clinical Laboratory Technician
  • Clinical Aids
  • Research and lab personnel working with human and non-human primate materials

 

Category 2 – Moderate Risk

This category has been established for those employees who do not work in situations that routinely involve contact with infectious materials. There is, however, a potential for exposure to these mediums.

             

Moderate Risk Positions:

  • University Police Officers
  • Athletic Trainers
  • EHS Personnel
  • Plumbers
  • First Aid and CPR Responders

 

Category 3 – Minimal Risk

This category involves minimal exposure to blood, body fluids or tissues such as are described in Category 1. Exposure is possible under certain circumstances.

             

Minimal Risk Positions:

  • Housing Personnel
  • Custodial Staff

 

 

 

 

 

 

Appendix C: Definitions

bloodborne pathogens: 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),

hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

 

decontamination: 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.

 

engineering controls: controls that isolate or remove a hazard from the workplace. In the case of

bloodborne pathogens, this includes sharps disposal containers, needleless systems and sharps with

engineered sharps injury protection.

 

exposure incident: eye, mouth, mucous membrane, non-intact skin or parenteral contact with

blood or other potentially infectious materials.

 

exposure control plan: a written plan that includes methods of implementation and procedures

to reduce occupational exposure.

 

exposure determination: identification of job classifications, tasks and procedures where

occupational exposure occurs.

 

HBV: Hepatitis B Virus causes chronic liver disease and strikes 200,000 persons in the US each year.

There is no cure. Prevention is the only way to control this disease.

 

HBV vaccinations: A vaccination program consisting of three inoculations over a six month period.

 

HIV: human immunodeficiency virus; the virus which can eventually cause acquired immune

deficiency syndrome (AIDS).

 

other potentially infectious materials (OPIM): substances other than blood or blood products

which may transmit infection; semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural

fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any other body

fluid that is visibly contaminated with blood such as saliva or vomitus, and all body fluids in situations

where it is difficult or impossible to differentiate between body fluids such as emergency response.

 

occupational exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral

contact with blood or other potentially infectious materials that may result from the performance

of an employee’s duties.

 

parenteral contact: piercing mucous membranes or the skin barrier through such events as

needlesticks, human bites, cuts, and abrasions; or, taken into the body or administered in a manner

other than through the digestive tract, as by intravenous or intramuscular injection.

 

personal protective equipment (PPE): specialized clothing or equipment worn or used by an

employee for protection against a hazard. General work clothes that are not intended to function

as protection against a hazard such as uniforms, pants, shirts or blouses are not considered to be

personal protective equipment.

 

source individual: any individual, living or dead, whose blood or OPIM may be a source of

occupational exposure to the employee. Examples include, but are not limited to, hospital and

clinical 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.

 

sterilize: to use a physical or chemical procedure to destroy all microbial or viral life.

 

universal precautions: approach to infection control whereby all human blood and certain

human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other bloodborne

pathogens.

 

work practice controls: controls that reduce the likelihood of exposure by defining the manner in

which a task is performed (prohibiting recapping of needles by a two-handed technique and use of

patient-handling techniques).

 

Bloodborne Pathogens Safety

Post-Exposure Procedures

 

Immediate action:

 

  • Thoroughly wash the affected area with soap and warm water for several minutes.

 

  • If exposure is by splashes of infectious materials to the nose, mouth, or eyes, the affected area should be flushed extensively with water, saline or sterile irrigating solution.

 

  • Report all exposures to your supervisor and seek medical attention as soon as possible

Follow-up:

 

  • Medical Treatment will be provided at no cost to the student or employee.

 

  • An Exposure Report must be filed with Wichita State University-Student Health Services. Exposure Report (pdf)

 

  • If directed, your physician may prescribe the hepatitis B vaccination.  When given within 24 hours of exposure, it will prevent the Hepatitis B virus.