Bloodborne Pathogens Program

The ECTC Environmental Health and Safety Coordinator (EHSC) has full authority to make necessary decisions to ensure success of the program, and is authorized to halt any operation where there is danger of serious personal injury and is responsible for all facets of this program, including the following:

• Is responsible for coordinating the implementation of the ECP in accordance with the requirements of applicable federal, state and local bloodborne pathogen regulations
• Shall maintain and update the written ECP at least annually and whenever necessary to include new or modified tasks and procedures, new safety devices, or when an exposure incident indicates the need for a revision in the plan
• Shall ensure that safety audits are conducted to maintain an up-to-date ECP
• Shall assist in coordination of training, documentation of training and making the written ECP available to employees
• Shall assist departments in identifying the appropriate personal protective equipment (PPE), engineering control supplies, labels and other supplies as required by the standard
• Shall assist in arranging and coordinating the disposal of potential infectious waste with an off-site facility
• Shall assist supervisory personnel in writing standard operating procedures pertinent to their needs
• Shall develop suitable education/training programs for employees and instructors 
• Shall schedule periodic training seminars for employees and review seminars for instructors
• Shall review the training programs, at least annually, to include appropriate new information.

The following is a list of all job classifications at ECTC in which employees may have occupational exposure:

It will be the policy of ECTC to utilize Universal Precautions. Universal Precautions are a system of infection controls which assumes that all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens. Universal Precautions shall be consistently used for all individuals. Implementation of Universal Precautions does not eliminate the need for other category or disease-specific isolation precautions. Implementation of Universal Precautions will be accomplished as follows:

1. Gloves shall be worn when direct contact with blood and visibly blood-tinged bodily substances can reasonably be expected including contact with blood and body fluids, mucous membranes, non-intact skin of individuals, handling of items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Gloves shall be changed after contact with each patient or victim.
2. Gloves must be worn if the hands of the caregiver are not intact. Employees who have exudative lesions or weeping dermatitis shall refrain from all direct contact with patients or victims and from handling patient care equipment until the condition resolves.
3. Gloves should be put on prior to beginning a task and removed when the task is complete. Hands must be washed after removal of gloves or other personal protective equipment.  It is not acceptable to wash gloves instead of removing gloves, washing hands, and applying clean gloves.
4. Gloves shall be worn for all procedures where a potential exists for exposure to blood or body fluids. The procedures will include, but not be limited to:  perineal care, catheter care, oral care, suctioning, treatment/dressing changes, venipuncture, handling of contaminated trash, handling of soiled laundry/linens, cleaning body fluids spills, or cleaning blood spills.
5. Handwashing with soap and water is mandatory between each patient or victim contact and should be done whenever hands are visibly soiled. Hand cleanser and clean cloth/paper towels or antiseptic towelettes will be provided by the employee’s department. When antiseptic hand cleanser or towelettes are used, hands must be washed with soap and running water as soon as feasible.
6. Gowns and disposable aprons are only needed when it is likely that blood and visibly blood substance will soil clothing or skin.
7. Masks are only needed when it is likely that nose and mouth will be splashed with moist body substances or when personnel are working directly in or around areas of large open wounds.
8. Eye shields, goggles, or face shields are only needed when there is a likelihood that the eyes may be splashed with body fluids.
9. Personal protective equipment shall be examined by the supervisor on at least a monthly basis and shall be maintained or replaced on at least an annual basis to ensure their effectiveness. 
10. In the event that unexpected splashing occurs in an unprotected situation, a change of clothing and shower facilities shall be made available for the employee.
11. Contaminated needles or other sharps must not be bent, sheared, broken or recapped by hand. Needles and other sharps must be discarded in rigid, leak proof, puncture-resistant containers for disposal. The puncture-resistant sharps container should be located as close as practical to the use area and identified as bio-hazardous. To prevent recapping by hand, re-sheathing of needles may be accomplished with the aid of re-sheathing instrument, self-sheathing needles or forceps.
12. Linen soiled with blood or blood tinged body fluids must be gathered without undue agitation and placed in a leak-proof bag for transportation to the laundry soiled linen area. Bagging should occur at the location where it was used, however double bagging is not necessary.
13. Containers used for waste containment must be large enough to hold all contents and must prevent leakage of fluids during handling, storage, transport or shipping. If outside contamination of the container occurs, a second container shall be used to encase the first.
14. Housekeeping - Environmental surfaces such as walls, floors, and other surfaces are not associated with transmission of infections to either patients/victims or employees, therefore, attempts to disinfect or sterilize is not necessary. However, changing and removal of soil should be done routinely using products that, according to the manufacturer’s instructions are effective for the required sanitation outcome and are registered with the EPA.
15. Laundry- Because the risks of disease transmission from soiled linen is negligible, hygienic and common-sense storage and processing of clean and soiled linen is recommended. Soiled linens should be handled as little as possible. Linens should be washed with detergent and hot water (at least 60 degrees C for 25 minutes) or if lower temperature cycles are used, with chemicals suitable for low temperature washing at proper use concentration.
16. If an employee has an exposure incident, the employee shall file an accident report with his/her supervisor as soon as feasible and the individual shall be encouraged to be tested for HBV and HIV as soon as possible and then at intervals of six (6) weeks, twelve (12) weeks, and six (6) months following the incident.
17. An evaluation of any incident that exposed or potentially exposed an employee (or student or volunteer) to infection with bloodborne pathogens shall be undertaken by the Environmental Health and Safety Coordinator and a description of the corrective action taken to prevent recurrence of similar exposures shall be recorded and included in incident/injury file.
18. For each incidence of mucous membrane or parenteral exposure to body fluids or tissue, a description of the exposure and any corrective action taken to prevent recurrence shall be documented by the Environmental Health and Safety Coordinator. Progressive discipline will occur for any employee that fails to comply with Universal Precautions. Documentation will include the employee infraction and the corrective action taken by the facility to bring the employee into compliance. Standard disciplinary procedures will be followed.

Engineering controls are physical or mechanical means of isolating or removing bloodborne hazards from the work area. Engineering and work practice controls are used to eliminate or minimize exposure to employees. Where occupational exposure remains after institution of these controls, personal protective equipment will be used. 
The following engineering controls are used:

• Hand-washing facilities with appropriate hand cleaners and disposable towels are readily available in the work area, such as the laboratory, procedure room, or patient care area.
• Sharps containers are available where sharps are used. Appropriate containers are puncture resistant, labeled with a biohazard label or color coded, and leak proof on the sides and bottom. Sharps containers are located as close to the point of use as possible, preferably at eye level. Sharps containers may not be allowed to overfill.  Re-usable Sharps Containers will not be opened, emptied, or cleaned manually; or in any other manner that would expose employees to the risk of percutaneous injury. 
• Biological Safety Cabinets (Class II) will, in appropriate situations (i.e. labs), provide worker protection during aerosol generating procedures with human blood and other potentially infectious material (OPIM) including human cells, tissue cultures, and blood products and blood components. 
• Infectious waste is discarded into biohazard containers, lined with a red plastic bag and covered. If the waste could puncture the bags, it must first be placed in a Sharps container. 
• Mechanical Pipettes must be used; mouth pipetting is prohibited. 
• Containers for blood or OPIM: Specimens of blood or other potentially infectious material will be placed in a container that prevents leakage during collection, handling, processing, storage, transport and shipping. 
• Autoclaves are available in some labs, clinics or units for decontamination. Proper use of equipment is essential to ensure sterilization. 
• Plastic or Mylar Coated Capillary tubes will be used instead of glass capillary tubes. 

Personal protective equipment (PPE) are barriers designed to prevent employees from having direct contact with blood or other potentially infectious materials.

Personal protective equipment must also be used if occupational exposure remains after instituting engineering and work practice controls, or if controls are not feasible. Baseline information will be provided during the initial training, in the use of the appropriate personal protective equipment. PPE training for employees' specific job classifications or tasks and procedures will be provided by the supervisor or project director for work they will perform.

Employees must be trained regarding the use of the appropriate PPE for their job classification and the tasks/procedures they perform. Training must be documented as part of employee’s initial and annual training sessions for Bloodborne Pathogens. Additional training will be provided, whenever necessary, such as if an employee takes a new position or if new duties are added to their current position.

Where there is a potential for occupational exposure, the supervisor shall provide and ensure that the employee uses appropriate personal protective equipment such as, but not limited to the following:  gloves, gowns, aprons, laboratory coats, head coverings, foot coverings, utility gloves, eye protection, face shields, masks, mouth pieces, resuscitation bags, pocket masks, or other ventilation devices.

Supervisors shall provide, at no cost to the employee, appropriate personal protective equipment when there is anticipated occupational exposure. Personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. General work clothes or eyeglasses not intended to function as protection against a hazard are not considered to be an acceptable form of PPE.

The required PPE in the appropriate sizes will be readily accessible at the worksite or issued to employees by the project supervisor. 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.

• Each campus laboratory that contains blood or bodily fluid shall have a written schedule for cleaning and disinfection of equipment and work surfaces, which contaminates are appropriate to the facility and the type of tasks being performed. 
• Any laboratory where blood, bodily fluids, or OPIM is routinely handled shall have an appropriate biohazard sign posted at the entrance(s). 
• Housekeeping personnel must be instructed in proper precautionary measures appropriate to each laboratory area. 

EPA registered tuberculocidal disinfectants are appropriate for the cleaning of blood or OPIM. A list of EPA approved disinfectants is provided at the following website: https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-bloodborne

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 for in this section below in the case of red bags or red containers, blood products released for clinical use, and individual containers placed within labeled containers.

Labels required by this Section shall follow these guidelines:

• These labels shall be fluorescent orange or orange-red or predominantly so, with lettering or symbols of contrasting color. 
• 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. 
• 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 labeling requirements of this section. 
• 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 the labeling requirements of this section. 
• Regulated waste that has been decontaminated need not be labeled or color-coded.

Supervisory personnel will provide training to employees on Hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of administration and availability.

The Hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the exposure determination section of this plan. Vaccination is encouraged unless: 1) documentation exists that the employee has previously received the series; 2) antibody testing reveals that the employee is immune; or 3) medical evaluation shows that vaccination is contraindicated.

However, if an employee declines the vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination must be submitted to the Human Resources Department.

Departments with employees who are at risk of occupational exposure to bloodborne pathogens must provide the name and location of the clinic where employees can obtain a medical evaluation to receive a Hepatitis B vaccination.

Following the medical evaluation, a copy of the health care professional's written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the Hepatitis vaccine and whether the vaccine was administered.

Should an exposure incident occur, employees must contact their supervisor.  An immediately available confidential medical evaluation and follow-up will be conducted.  Following initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:

• Document the routes of exposure and how the exposure occurred
• Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law)
• Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity. If consent is not obtained, the employer 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. Document that the source individual's test results are conveyed to the employee's health care provider.  If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed
• Assure that the exposed employee is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality)
• If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, provider must preserve the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

All employees who have occupational exposure to bloodborne pathogens receive initial and annual training coordinated by the Environmental Health and Safety Coordinator.

All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

• A copy and explanation of the OSHA bloodborne pathogen standard
• An explanation of this ECP and how to obtain a copy
• An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
• An explanation of the use and limitations of engineering controls, work practices, and PPE
• The option to decline the vaccination and the declination form to complete and sign.
• An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
• An explanation of the basis for PPE selection
• Information on the Hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
• Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
• 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
• Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
• An explanation of the signs and labels and/or color-coding required by the standard and used at this facility
• An opportunity for interactive questions and answers with the person conducting the training session.

Training materials for this facility are available through the ECTC Environmental Health and Safety Coordinator.  

Training Records are completed for each employee upon completion of training. These documents will be kept for at least three years with the Environmental Health and Safety Coordinator.
The training records include:

• The dates of the training session
• The contents or a summary of the training sessions
• The names and qualifications of persons conducting the training
• The names and job titles of all persons attending the training sessions.

Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be submitted to the Environmental Health and Safety Coordinator.

Students are, strictly speaking, not covered by the Bloodborne Pathogens Rule. However, it is the mission of the ECTC to provide students with adequate training so they may pursue their studies and eventually their careers safely and knowledgeably. Therefore, ECTC has identified those curricula which involve reasonably anticipated exposure of students to blood or other potentially infectious materials.

The use of blood must be evaluated in light of its risk to students and the fulfillment of each department's academic mission. When possible, alternatives to the use of blood and other potentially infectious materials must be adopted. Alternatives include the use of non-infectious animal blood, synthetic blood or computer simulations. (Note that "Screened Blood" from a blood bank is not 100% safe, must be handled using Universal Precautions and requires the same training, precautions and protective equipment as unscreened blood). For curricula where alternatives are not feasible, the policies of this section (see below) must be followed.

Exposure Control Plan: Departments which require students to work with blood or other potentially infectious materials must follow the ECTC Bloodborne Pathogens Exposure Control Plan.

Training: Departments which require students to work with blood or other potentially infections materials must provide at least the same level of training as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. For students in laboratory or clinical settings (on campus or off) advanced training must be provided by qualified instructors.

Personal Protective Equipment (PPE): Departments which require students to work with blood or other potentially infectious materials must provide at least the same level of personal protective equipment as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. Students may be required to purchase the equipment and should be advised of this requirement well in advance. Moreover, students must be provided training in the proper use of personal protective equipment in advance of its use.

Hepatitis B Vaccination: Departments which require students to work with blood or other potentially infections materials must make available to students a Hepatitis B vaccination as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. Students may be required to pay for the vaccination and should be advised of this requirement well in advance, as well as where they may obtain the vaccination and what it will cost.

Post Exposure Follow Up: Departments which require students to work with blood or other potentially infections materials must advise students that they should notify their health insurance carriers of their academic activities involving bloodborne pathogenic materials. ECTC cannot assure students that it will fund post-exposure follow up procedures should the student become exposed to bloodborne pathogens.

Management of Infectious Wastes and Contaminated Laundry: Students who are not employees of ECTC must not handle, treat or sewer dispose of infectious wastes, other than to immediately containerize infectious waste generated by their laboratory procedures. Students who are not employees are also prohibited from handling contaminated laundry for ECTC-related purposes. Strict regulations govern the handling, treatment and disposal of infectious wastes; therefore, these activities are restricted to designated employees of ECTC.

Volunteers are not covered by the Bloodborne Pathogens Exposure Control Plan. Therefore, because of their unofficial status, it is expected that volunteers will not be placed in situations where they would be exposed to bloodborne pathogens. However, in rare circumstances where a volunteer may possess special skills or knowledge and where it would be impossible to utilize this expertise without the risk of exposure to blood or other potentially infectious materials, exceptions may be permitted. In these situations, the use of blood must be evaluated in light of its risk to the volunteer and the academic mission which requires the volunteer's expertise.

When possible, alternatives to the use of blood and other potentially infectious materials must be adopted. Alternatives include the use of non-infectious animal blood, synthetic blood or computer simulations. (Note that "Screened Blood" from a blood bank is not 100% safe, must be handled using Universal Precautions, and requires the same training, precautions and protective equipment as unscreened blood).

"Good Samaritans" are considered to be employees, students, volunteers, and members of the general public who are not expected to provide first aid or CPR but who may have had first aid or CPR training and wish to provide first aid or CPR services in an emergency. These individuals are not included in the Bloodborne Pathogens Plan and are not considered eligible for post exposure follow up or HBV vaccination. It is recommended that if these individuals are exposed to blood or other potentially infectious material in the course of rendering first aid or performing CPR that they seek follow up medical attention from a qualified health care provider.

Exposure Control Plan: Volunteers approved to work with blood or other potentially infectious materials must follow the ECTC Bloodborne Pathogens exposure control plan.

Training: Volunteers approved to work with blood or other potentially infections materials must receive at least the same level of training as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. For volunteers in laboratory or clinical settings advanced training must be provided by qualified instructors.

Personal Protective Equipment: Volunteers approved to work with blood or other potentially infections materials must be provided with at least the same level of personal protective equipment as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. Volunteers may be required to purchase the equipment and should be advised of this requirement well in advance. Moreover, volunteers must be provided training in the proper use of personal protective equipment in advance of its use.

Hepatitis B Vaccination: Volunteers approved to work with blood or other potentially infections materials must obtain a Hepatitis B vaccination as outlined in the ECTC Bloodborne Pathogens Exposure Control Plan. Volunteers will be required to pay for the vaccination and should be advised of this requirement well in advance. Volunteers must consult with their personal physician and health insurance carrier as to where they may obtain the vaccination and what it will cost. Proof of vaccination or refusal of vaccination must be on file with the Human Resources Director.

Post Exposure Follow Up: Volunteers approved to work with blood or other potentially infectious materials must be advised that they should notify their health insurance carriers of their academic activities involving bloodborne pathogenic materials. ECTC will not fund post-exposure follow up procedures should the volunteer become exposed to bloodborne pathogens.

Management of Infectious Wastes and Contaminated Laundry: Volunteers who are not employees of ECTC must not handle, treat or sewer dispose of infectious wastes, other than to immediately containerize infectious waste generated by their laboratory procedures. Volunteers who are not employees are also prohibited from handling contaminated laundry for ECTC-related purposes. Strict regulations govern the handling, treatment and disposal of infectious wastes; therefore, these activities are restricted to designated employees of ECTC.