I. EXPOSURE CONTROL PROGRAM
Wittenberg University recognizes that employees may encounter routine or non-routine occupational exposure to bloodborne pathogens including hepatitis B virus (HBV) and human immunodeficiency virus (HIV). This written exposure control program has been developed by the University to minimize employee exposure to blood or other potentially infectious materials and is intended to comply with the requirements of OSHA standard 29 CFR 1910.1030, Bloodborne Pathogens.
The Director of Operations, Safety & Environment has been designated as the exposure control program coordinator and will be responsible for enforcement, review (annually or more frequently when determined necessary) and maintenance of this program.
Important Definitions:
Blood: Human blood, human blood components, and products from human blood.
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) and human immunodeficiency virus (HIV).
Contaminated: The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Contaminated Laundry: Laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.
Contaminated Sharps: Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tube, and exposed ends of dental wires.
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 not longer capable of transmitting infectious articles and the surface or items are rendered safe for handling, use, or disposal.
Engineering Controls: Controls (e.g. sharps disposable containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.
Exposure Incident: A specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.
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.
Other Potentially Infectious Materials: (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs or other tissue from experimental animals infected with HIV or HBV.
Parenteral: Piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Personal Protective Equipment: Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g. uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.
Regulated Waste: Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed, items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.
Universal Precautions: An approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Work Practice Controls: Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g. prohibiting recapping of needles by a two-handed technique).
II. EXPOSURE DETERMINATION
The following exposure determination has been made without regard to the use of personal protective equipment:
A. The following are job classifications in which all employees have occupational exposure to blood or other potentially infectious materials:
Biology Department
- Lab Coordinator
Security Department
- Director
- Police/Security/Patrol Officers
- Student Escorts
Athletic Department
- Coaches/Faculty
- Athletic Trainers
- Assistant Athletic Trainers
- Lifeguards
- Athletic Equipment Managers
Wellness Center Staff
- Nurses
- Receptionists
- Physicians
Grounds Department
- Refuse Truck Operator
- Waste Removal
Housekeeping
- Custodian
- Custodial Supervisor
B. The following are job classifications in which some employees have occupational exposure to blood or other potentially infectious materials:
Biology Department
- Faculty
- Staff Members
Security Department
- Secretary
Athletic Department
- Student Employee
Wellness Center Staff
- Nurses
- Receptionists
- Physicians
- Psychologist
- Student Employees
Grounds Department
- Grounds keeper
- Refuse Truck Operator
Physical Plant/ Skilled Trades
- Plumber, Carpenter, Electrician, HVAC, General Maintenance
Tasks and procedures or groups of closely related tasks and procedures in which occupational exposure occurs that are performed by employee(s) in this job classification.
Biology Department
- cleaning and autoclaving laboratory glassware used for culturing specific human pathogens, human normal flora, or bacteria that may opportunistically infect an immunocompromised worker.
- sub-culturing, experimentation, collection, storage and transport of microbiological or mycological cultures.
- handling laboratory rodents or tissues thereof may expose workers to zoonoses.
Security Department
- effecting arrest of infested or infectious suspects
- transporting injured suspects or students to emergency department
- providing first aid/CPR to accident victims
- lawful search of a subject's person or property for evidence collection
Athletic Department
- rendering first aid to the injured
- pre-game and post-game care of players
- rehabilitation of the injured
- collecting soiled linens and equipment
Wellness Center Staff
- Providing health care services to patients
Grounds /Physical Plant Department
- Removing unlabeled refuse from campus properties
- Various repairs
Housekeeping Services
- Removing or cleaning items contaminated with bodily fluids or other potentially infectious materials
III. SCHEDULE AND METHOD OF IMPLEMENTATION
Methods of Compliance:
A. Universal Precautions:
Effective immediately, universal precautions shall be observed at Wittenberg University to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. Supervisors of employees working in job classifications who encounter occupational exposure to blood or other potentially infectious materials (listed in the Exposure Determination section) are responsible for ensuring that employees observe universal precautions at all times.
B. Engineering and Work Practice Controls:
Engineering and work practice controls shall be utilized at Wittenberg University as a primary method for eliminating or controlling exposure to blood or other potentially infectious materials. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness. The following work practice controls will be utilized at Wittenberg and enforced by department chairs/supervisors:
1. Employees MUST wash their hands and any other exposed skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact with such body areas with blood or other potentially infectious materials.
2. Employees MUST wash their hands immediately or as soon as possible after removal of gloves or other personal protective equipment.
3. Employees are required to wash their hands with soap and running water as soon as feasible after using an appropriate antiseptic hand cleaner or towelette. Antiseptic hand cleaners or towelettes are acceptable only where hand washing facilities are not feasible.
4. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
5. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.
6. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.
7. Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(I) of the standard and closed prior to being stored, transported, or shipped. If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping and is labeled or color-coded according to the requirements of this standard. If the specimen could puncture the primary container, the primary container shall be placed within a secondary container which is puncture-resistant in addition to the above characteristics.
8. Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed.
9. Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and decontaminated as necessary. If decontamination is not feasible, a readily observable label in accordance with 29 CFR 1910.1030(g)(1)(I)(H) must be attached to the equipment stating which portions remain contaminated. The Director of Operations, Safety & Environment is responsible for informing affected employees, the servicing representative, and/or the manufacturer prior to handling, servicing, or shipping so that appropriate precautions can be taken.
10. All reusable glassware and other laboratory apparati will be sterilized using appropriate germicidal and virucidal solutions followed by autoclaving prior to being returned to service for Departmental use. If autoclaving is not possible the item(s) will be disinfected with germicidal and virucidal solutions then washed per usual protocol prior to being returned to general service.
11. All security personnel, lifeguards, and athletic trainers shall be issued CPR "pocket masks" and latex examination gloves to carry while on duty to provide immediate barrier protection during CPR and/or first aid administration.
C. Personal Protective Equipment: Where occupational exposure remains after instituting engineering and work practice controls, appropriate personal protective equipment will be used. Personal protective equipment will be considered "appropriate" only if it does not permit blood or other potentially infectious materials to pass through to reach employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use. Personal protective equipment is provided by the University at no cost to the employee. The following job classifications and/or tasks or procedures require personal protective equipment:
Gloves:
- Biology Department Student Lab Assistant -Stockroom
- Biology Department Faculty
- Department of Biology Lab Coordinator
- Student Animal Caretaker
- Security Department Personnel
- Athletic Trainers
- Lifeguards
- Student Employees
Masks, Eye Protection, & Face Shields:
- Biology Department Student Lab Assistant - Stockroom
- Biology Department Faculty
- Biology Department Lab Coordinator
- Student Animal Caretaker
- Student Employees
Gowns, Aprons, & Other Protective Body Clothing:
- Biology Department Faculty
- Biology Department Lab Coordinator
- Student Animal Caretaker
- Student Employees
Other Personal Protective Equipment - CPR Pocketmask:
- Security Department personnel
- Biology Department Lab Coordinator
Wittenberg University shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powder less gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided. In addition, the following also applies to personal protective equipment and is the responsibility of the employee using the personal protective equipment:
Personal protective equipment MUST be cleaned, laundered, repaired, and/or replaced as needed to maintain its effectiveness.
If a garment is penetrated by blood or other potentially infectious material, this garment MUST be removed immediately or as soon as feasible.
All personal protective equipment MUST be removed prior to leaving the work area.
When personal protective equipment is removed, it MUST be placed in an appropriately designed container for storage, washing and decontamination, or disposal.
D. Housekeeping: The University will require that the contracted housekeeping service provider, ISS Service Systems, Inc., will maintain campus facilities in a clean and sanitary condition. ISS Service Systems will follow their own "Guidelines for Controlling Occupational Exposure to Bloodborne Pathogens" plan to comply with 29 CFR 1910.1030 mandates.
Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-Up:
A. The Hepatitis B vaccine and vaccination series shall be made available to all employees with occupational exposure, based on the completed exposure determination, at no cost to the employee. The Director of Operations, Safety & Environment is responsible for ensuring that all employees who may be working in areas with occupational exposure are allowed the chance to receive the Hepatitis B vaccination after the employee has received the training required (see Section F, below) and within 10 working days of initial assignment. Any employee with occupational exposure who initially declines the Hepatitis B vaccination series may request these immunizations at a later date. The University will then provide the Hepatitis B vaccination series to the employee at no cost. The University shall require any employee who declines to accept Hepatitis B vaccination to sign a statement to that effect which accords with 29 CFR 1910,1030 Appendix A. Due to potentially severe consequences resulting in exposure incidents, the circumstances regarding these incidents will be investigated with the utmost priority. Employees MUST notify their supervisor immediately following any exposure incident. The Director of Human Resources will be responsible for conducting an investigation into the circumstances of exposure incidents immediately following each incident. The Post Exposure Evaluation and Follow-Up Procedure as outlined in Appendix F &mmp; G (29 CFR 1910.1030) must be adhered to. In all cases, the University must be guided by the Health Care Professional's (HCP) evaluation and opinion.
B. Following a report of an exposure incident, the University shall make immediately available to the exposed employee a confidential medical evaluation and follow-up which will include the following items:
1. Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred.
2. Identification and documentation of the source individual, unless infeasible or prohibited by state or local law. If consent is obtained (where required), the source individual's blood shall be tested and results documented. If the source individual is known to be infected with HIV or HBV, this shall be documented without repeat test.
3. Results of the source individual's testing shall be made available to the exposed employee, along with applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
4. The exposed employee's blood shall be tested as soon as feasible after consent is obtained.
5. If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the sample shall be preserved for 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
6. When medically indicated, Post-exposure prophylaxis will be provided, as recommended by a health care professional.
7. Counseling will be made available to the employee upon request.
8. Evaluation of reported illness(es).
C. The Director of Human Resources is responsible for providing the following information to the health care professional following an exposure incident and prior to medical evaluation:
- A copy of 29 CFR 1910.1030.
- A description of the exposed employee's duties as they relate to the exposure incident.
- Documentation of the route(s) of exposure and circumstance under which exposure occurred.
- Results of the source individual's blood testing, if available.
- All medical records relevant to the appropriate treatment of the employee including vaccination status.
D. Within 15 days of completion, a copy of the evaluating health care professional's written opinion shall be obtained by the Director of Human Resources and provided to the employee. This written opinion will be limited to the following information:
- That the employee has been informed of the results of the evaluation.
- That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. (OTHER FINDINGS OR DIAGNOSES SHALL REMAIN CONFIDENTIAL AND NOT BE INCLUDED IN THE WRITTEN REPORT).
Communication of Hazards to Employees:
A. Labels and Signs:
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. Labels required for this section shall include the following legend:
These labels shall be florescent orange or orange-red or predominately so, with lettering or symbols in a 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. Red bags or red containers may be substituted for labels.
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.
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 requirement.
Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated. Regulated waste that has been decontaminated need not be labeled or color-coded.
B. Information and Training:
All employees with occupational exposure will be expected to participate in a training session that will be provided at the time of initial assignment to tasks where occupational exposure takes place, every year thereafter, and whenever changes such as modifications of tasks or procedures or institution of new tasks or procedures affect the employee's exposure. The Director of Operations, Safety & Environment will be responsible for coordinating training sessions, which will consist of the following:
1. An explanation of the bloodborne pathogens standard (29 CFR 1910.1030) and the fact that a copy of the text of this standard will be accessible to employees at all times.
2. A general explanation of the epidemiology and symptoms of bloodborne diseases.
3. An explanation of the modes of transmission of bloodborne pathogens.
4. An explanation of Wittenberg's exposure control plan and the means by which employees can obtain a copy of the written plan.
5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
6. An explanation of the use and limitations of methods that will prevent or reduce exposure including engineering controls, work practice, and personal protective equipment.
7. Information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment.
8. An explanation of the basis for selection of personal protective equipment.
9. Information on the Hepatitis B vaccine and a statement that the vaccine will be offered free of charge.
10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
11. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
12. Information of the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
13. An explanation of the signs and labels and/or color coding that is used in the facility.
14. An opportunity for interactive questions and answers with the person conducting the training session.
The Director of Operations, Safety & Environment will keep a record on file concerning all training sessions.
IV. RECORD KEEPING
The Director of Human Resources is responsible for maintaining records regarding the exposure control plan at Wittenberg University, and for ensuring that all medical records are kept confidential. The following records will be kept on file:
A. A file for each employee with occupational exposure to blood or other potentially infectious materials including the name and social security number of the employee, a copy of the employee's hepatitis B vaccination status and any medical records relative to the employee's ability to receive vaccination.
B. A copy of all results of examinations, medical testing, and follow-up procedures following an exposure incident.
C. The University's copy of the health care professional's written opinion regarding post-exposure evaluation and follow-up.
D. A copy of the information provided to the health care professional regarding post-exposure evaluation and follow-up.
E. Wittenberg University shall ensure that all records required to be maintained by the standard shall be made available upon request to the Assistant Secretary and the Director for examination and copying.
F. Employee training records shall be provided upon request for examination and copying to employees, to employee representatives, to the Director and to the Assistant Secretary. Training records shall include the dates of training sessions. The contents or a summary of the training sessions. The names and qualifications of persons conducting the training and the names, job titles of all persons attending the training sessions. Training records shall be maintained for 3 years from the date on which the training occured.
G. Wittenberg University shall comply with the require involving transfer of records set forth in 29 CFR 1910.20(h).
The above records will not be disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by the bloodborne pathogens standard or by law. Additionally, these records will be maintained for at least the duration of employment plus thirty (30) years.