in-depth_bbp_a_09-14-11 by Basmulder

Table of Contents Introduction .................................................................................................................................................. 2 The Bloodborne Pathogens Standard ........................................................................................................... 3 Human Immunodeficiency Virus ................................................................................................................... 5 Hepatitis B and C ........................................................................................................................................... 8 Prevention ................................................................................................................................................... 11 Workplace Transmission ............................................................................................................................. 13 Personal Protective Equipment (PPE) ......................................................................................................... 14 Exposure Control Plan ................................................................................................................................. 17 Management of Sharps ............................................................................................................................... 19 Management of Sharps ............................................................................................................................... 19 Blood Spills .................................................................................................................................................. 21 Labeling ....................................................................................................................................................... 22 Hand Washing ............................................................................................................................................. 24 Hygiene ....................................................................................................................................................... 25 Maintenance and Housekeeping ................................................................................................................ 26 HBV Vaccination .......................................................................................................................................... 27 Responding to Emergencies ........................................................................................................................ 28 What if you’re exposed on the job? ........................................................................................................... 30 Bloodborne Pathogens Appendices ............................................................................................................ 33

This In Depth Resource will provide the Instructor with statistics and more detailed information on the instructional content of the course. Although EMS Safety Services has made every effort to ensure that the information provided in this section is current at the time of publication, medical recommendations, standards and statistics are updated regularly. It is the responsibility of the Bloodborne Pathogens Instructor to update the instructional content as needed to reflect changes in standards, accepted medical practice or recommendations.

Bloodborne Pathogens

Introduction Overview The introduction is the opener to warm everyone up to the fact that bloodborne pathogens are dangerous and exposures can occur at work. There were 3.3 million cases of workplace illness and injury in the year 2009. This training will help to minimize the risk of exposure, as well as satisfy the organization’s requirement for annual training in bloodborne pathogens, as described in the Occupational Exposure to Bloodborne Pathogens Standard 29 CFR 1910.1030.1 Lecture on the key points from the introduction in the student text (see below). A discussion may involve someone from your course who can relate a story about an exposure to bloodborne pathogens and give a testimonial to the fact that exposure can occur at work. This training will help to…  Understand what bloodborne pathogens are and why they are dangerous.  Understand basic information regarding HIV, hepatitis B (HBV) and hepatitis C (HCV).  Learn the routes of exposure, techniques to reduce the risk of exposure, and the use of personal protective equipment (PPE).  Understand what resources are available to employees in the workplace.  Respond safely to an emergency at work.  Provide guidelines for postexposure situations.  Satisfy the OSHA annual training requirement in bloodborne pathogen awareness. Discussion: “Who has a story?” Who is willing to share an incident in which a potential exposure to a bloodborne pathogen occurred at work? Ask the student to share his or her story without sharing any specific names or personal information about the victim. It can be about the student or a witnessed event where an exposure occurred. Help keep the story brief and to the point, with just the facts. Key discussion points include: 1. Exposures do occur at work. 2. Training and preparation can make a difference.

Bloodborne Pathogens

The Bloodborne Pathogens Standard Overview2,3,24 Businesses must provide annual awareness training to employees who have the potential for exposure to bloodborne pathogens. This course will satisfy the annual training required by 29 CFR 1910.1030. Anyone can view the Bloodborne Pathogens Standard at www.osha.gov. In 1970, the U.S. Congress enacted the Occupational Safety and Health (OSH) Act to ensure safe and healthful working conditions for men and women. In 1991, the Occupational Safety and Health Administration (OSHA) issued the Occupational Exposure to Bloodborne Pathogens Standard (29 CFR 1910.1030) because of a significant health risk associated with exposure to viruses and other microorganisms that cause bloodborne diseases. In response to the passage of the Needlestick Safety and Prevention Act of 2000, the Bloodborne Pathogens Standard was revised in 2001 to require employers to select safer needle devices as they become available, and to involve employees in identifying and choosing the devices. The updated Standard also requires employers to make additions to the Exposure Control Plan, and maintain a log of injuries from contaminated sharps. Why take this training? This training can help reduce the risk of exposure to bloodborne pathogens in the workplace by providing the employee with awareness to the presence of bloodborne pathogens. This course will also identify how they transmit, as well as the steps to take to reduce the risk of exposure, what to do if exposed, and what the employer has done to provide a safer working environment. Who is covered by the Standard? The bloodborne pathogens standard applies to “all employees who could be anticipated to come into contact with blood or OPIM while performing their jobs.”2,3 Examples of atrisk employees include the following:  First responders, public safety employees, healthcare workers  Custodial or maintenance workers; personnel who clean up after an injury  Workers in labs, tissue or blood banks, laundries, or mortuaries  Workers who handle medical equipment or regulated waste  A co-worker coming to the aid of a bleeding victim What are bloodborne pathogens? Bloodborne pathogens are pathogenic microorganisms that are present in human blood and can transmit from person to person when one is exposed to the blood or certain body fluids of an infected individual. The three bloodborne pathogens of greatest concern in the workplace are the human immunodeficiency virus (HIV), the hepatitis B virus (HBV) and the hepatitis C virus (HCV).

Bloodborne Pathogens

There are many other microorganisms that can be transmitted through contact with human blood and cause diseases such as syphilis, malaria, hepatitis D, and arboviral infections. What are Other Potentially Infectious Materials (OPIM) besides blood? Besides blood, there are other body fluids and tissues that may be infectious. OPIM is to be treated with the same precautions as blood. According to OSHA, OPIM includes:2  Human body fluids  Unfixed tissues or organs from a human  Any cell, culture, fluid, tissue or organ containing the HIV or hepatitis B virus. What is an exposure incident? According to OSHA, an exposure incident is “a specific eye, mouth, 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.”2

Bloodborne Pathogens

Human Immunodeficiency Virus HIV The human immunodeficiency virus (HIV) is a bloodborne pathogen that, after years of infection, causes AIDS. The human body can normally defend itself against most viruses by sending CD4+ T lymphocytes, or “T-cells,” to the site of infection. The T-cells organize the immune system’s fight against an infection. HIV attacks and gradually destroys T-cells, thus weakening the body’s immune system.4

AIDS Acquired immunodeficiency syndrome (AIDS) is the most advanced stage of HIV infection, in which opportunistic infections develop within a weakened immune system.4 Infections that the body could normally fight become progressively more serious. For example, when an uninfected individual is exposed to the common cold, it means a few days of sneezing, tissues and orange juice. However, an HIV infected individual, especially in the later stages, may develop serious or fatal pneumonia when exposed to the common cold. AIDS is diagnosed when an infected person’s T-Cell count falls below a certain level, or when an AIDS-defining disease is present.4 Statistics AIDS was first reported in the U.S. in 1981 and is now a worldwide epidemic. The Centers For Disease Control and Prevention (CDC) estimates that there are more than 1 million cases of HIV in the United States, with 56,000 new cases each year. According to the CDC, 1 in 5 of those infected in the U.S. are not aware they are infected. Worldwide there are more than 33 million people infected with HIV/AIDS, with 2.6 million newly infected each year.4,5,6 Modes of Transmission4,5,7 HIV is transmitted through direct exposure to the blood or certain body fluids of an infected individual. HIV can be found in blood, semen, vaginal secretions, synovial fluid (fluid surrounding the joints), breast milk, pleural fluid (fluid around the lungs), amniotic fluid, peritoneal fluid (fluid in the abdomen), pericardial (fluid around the heart), cerebrospinal fluid (fluid of the spine and brain), and other body fluids containing blood. Exposure to HIV-infected blood or body fluids does not mean certain transmission of the disease. Factors that determine if an exposure results in a transmission include the area exposed, the fluid type, the length and volume of exposure, and the route of exposure. According to the Centers For Disease Control and Prevention, the most common causes of new infections are men having sex with men (53%), heterosexual sex (31%) and injection drug use (12%).18 The risk of HIV infection during unprotected sex is increased substantially when either partner is infected with another sexually transmitted disease (STD).

Bloodborne Pathogens

Although HIV is spread most commonly by having sex with an infected partner or sharing of needles among injection drug users, HIV can be spread through other means of contact with infected blood. Before blood was routinely screened and treated for HIV, the virus was transmitted through transfusions of contaminated blood or blood components. Now the risk of HIV transmission during a transfusion is extremely small. Occupational exposure to HIV rarely results in transmission of the virus. Healthcare workers are exposed to HIV primarily through needlesticks and injuries from other sharp instruments. The risk of HIV transmission for healthcare workers on the job is less than 1%. As of December, 2001, there were 57 documented cases of HIV seroconversion (evidence of antibody response) among healthcare personnel in the United States. This means that approximately 0.3% of exposures to HIV-contaminated sharps resulted in actual transmission. Since 2001, there has been only one confirmed case reported. Women can pass HIV to their babies during pregnancy or birth. If pregnant women receive appropriate treatment during pregnancy and delivery, they can greatly reduce the risk of infecting their babies with HIV. Infected mothers who are breastfeeding can also spread HIV to their babies through their breast milk. Signs and Symptoms4,9 When someone is infected with HIV, the virus may lie dormant for several years. A person newly infected with HIV often experiences flu-like symptoms initially, and then may have no symptoms for more than ten years. During this asymptomatic period, the virus is actively multiplying, infecting and killing CD4+ T cells. As the immune system deteriorates, early signs and symptoms of HIV infection may appear and include the following:  Anorexia, weight loss  Fatigue, weakness  Persistent cough  Swollen lymph nodes  Diarrhea, abdominal discomfort  Mouth lesions, dark skin blemishes  Afternoon fevers, night sweats, chills  Memory loss, neurological disorders  Increased illnesses due to a weakened immune system  Persistent or frequent yeast infections  Pelvic inflammatory disease in women  Shingles, a painful nerve disease There is currently no vaccine or cure for HIV. Reducing the amount of virus in the body with anti-HIV medications can slow the development of AIDS. Other drugs are available to help treat the opportunistic infections and cancers to which people with AIDS are prone. As HIV infection progresses to AIDS, opportunistic infections can cause symptoms, which may include the following: © 2011 EMS Safety

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Coughing and shortness of breath Seizures and lack of coordination Difficult or painful swallowing Mental symptoms such as confusion and forgetfulness Severe and persistent diarrhea Fever Vision loss Nausea, abdominal cramps, and vomiting Weight loss Extreme fatigue Severe headaches Coma

Persons with AIDS may also develop various cancers, such as Kaposi’s sarcoma (tumors in mucous membranes or connective tissues), cervical cancer, or lymphomas (cancers of the immune system). Treatment The only way to know if you are infected is through a blood test for antibodies to HIV. Rapid HIV tests can provide results in as little as 20 minutes. The time between getting infected with HIV and the time it takes for your body to develop antibodies is called the window period. It can take anywhere from two to eight weeks for most people infected with HIV to seroconvert, or develop antibodies to the virus. Very rarely, it can take up to six months.4

Bloodborne Pathogens

Hepatitis B and C Hepatitis B Virus (HBV)10,11,13 Hepatitis B is a serious disease caused by a virus that attacks the liver. According the Centers for Disease Control and Prevention, HBV can cause “lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure and death.” Although HBV is usually not as deadly as HIV, it is more contagious. The hepatitis B virus can cause both acute and chronic hepatitis. Most people who are infected recover completely within 6 months and become immune to the virus. Approximately 5-10% of those infected develop a chronic (longer than 6 months), lifelong infection. Of these HBV carriers, 25% will die as adults from cirrhosis or liver cancer. Approximately 1% of acute hepatitis B cases are fatal. Age is inversely proportional to the risk of becoming a chronic carrier of HBV. The younger a person is when he or she becomes infected, the more likely he or she is to become a chronic carrier. Approximately 5 -10% of adults, 50% of children, and more than 90% of infected infants become chronic carriers. Unfortunately, 90% of all HBV cases occur in adolescents and young adults. Statistics (HBV) Hepatitis B is a serious public health problem. Approximately 1 in 20 American adults have had HBV infections. There are as many as 1.4 million cases of chronic HBV in the United States, with about 38,000 new cases diagnosed each year (2008). This is decreased from an average of 260,000 new cases per year in the 1980s, primarily due to routine HBV vaccination of children, adolescents, and those at risk. Approximately 2,000 - 4,000 die per year in the U.S. from illness caused by HBV.

Hepatitis C Virus (HCV)10,12,15 Hepatitis C is also a serious disease of the liver that can cause chronic infection (7585%), chronic liver disease (70%), and, in some cases, death (<3%). Chronic hepatitis C is a leading indication for liver transplant. Statistics (HCV) Hepatitis C is the most common bloodborne infection in the United States. There are 3.2 million people in the U.S. who suffer from chronic infection and about 18,000 new cases each year (2008). Most infections are due to illegal injection drug use. In U.S. jails and prisons, 1 in 3 people, or about 2.2 million, have HCV.

Mode of Transmission (HBV/HCV)10,11,12 HBV is transmitted when the blood or body fluids of an infected individual enter the body of a person who is not immune to HBV. Any body fluid with visible traces of blood may carry the hepatitis B virus. Like HIV and HBV, HCV is spread through contact with infected blood or body fluids containing blood. Hepatitis infections can also occur during

Bloodborne Pathogens

birth, when an infected mother transmits the virus to her baby, or in healthcare or other settings where there is contact with blood. You are at higher risk for transmission of hepatitis B and C if you:  Have sex with someone infected (rarely for HCV)  Have sex with more than one partner in six months  Are an injection drug user  Are a man and have sex with a man  Live in the same household with someone who has chronic infection  Have a job that involves contact with human blood (healthcare, public safety)  Have hemophilia  Have been on long-term kidney dialysis  Share personal items (razor, toothbrush) with an infected person  Were born to an infected mother  Received a blood transfusion prior to July, 1992  Received blood, blood products, or solid organs from an infected donor  Receive a tattoo or acupuncture with contaminated instruments  Are from an area of the world with high rates of hepatitis B and C infection Those most at risk are people who have multiple sex partners, IV drug abusers (sharing needles), and household members of infected individuals. The risk for occupational transmission of HBV is much higher than the risk for HIV. The risk is primarily related to the degree of contact with blood in the workplace. For an employee who has not had the HBV vaccine, transmission rates range from 6% to 30% after a single needlestick exposure to HBV-infected blood.33 The average incidence of occupational transmission of HCV through accidental exposure from sharps or needlesticks is only 1.8%.33

Acute Signs and Symptoms (HBV/HCV)11,12,13 Nearly all children and infants and 50% of adults with acute hepatitis B have no symptoms at all. In hepatitis C, 80% of infected individuals have no signs or symptoms. The acute stage can last from several weeks to several months. If symptoms are present, they can include any of the following:  Flu-like symptoms (fatigue, diarrhea, sweats, headache)  Jaundice (yellowing of the skin and whites of the eyes) and dark urine due to increased bilirubin  Abdominal pain, nausea/vomiting  Low-grade fever  Decreased appetite, weight loss  Joint or muscle pain  Inability to work or function for long periods of time  Pale or clay-colored stools

Bloodborne Pathogens

Chronic Signs and Symptoms (HBV/HCV) Chronic hepatitis occurs when the liver damage from the acute illness does not completely recover. Many people with chronic hepatitis B or C may have no signs or symptoms for many years after the acute infection. Chronic hepatitis can lead to cirrhosis (scarring) of the liver in which the liver is damaged and cannot effectively cleanse the body of wastes. It can also lead to liver failure and liver cancer. Signs and symptoms can include the following:  Weight loss  Fatigue  Jaundice  Nausea and vomiting  Loss of appetite

Treatment (HBV/HCV) 11,12,13 There is no cure for acute hepatitis B or C. Treatment of the acute condition involves careful monitoring of liver function. Treatment of chronic hepatitis B and C is focused on decreasing inflammation, symptoms, and infectivity. In cases of liver failure, liver transplantation is the only cure. Rest, exercise, a nutritious diet, and plenty of fluids are recommended. Avoid drugs and alcohol, and any potentially liver toxic drugs, since they can exacerbate liver damage. A blood test is the only way to confirm a diagnosis of HBV or HCV infection. Most people do not have symptoms, but can pass the disease to others. If chronic hepatitis is detected early enough, liver damage may be prevented or slowed with appropriate treatment. Anyone who is in a higher risk group for contracting hepatitis B or C should contact their doctor for testing, and for information on the hepatitis B vaccine. Get vaccinated, because hepatitis B is preventable. Vaccination3,11 The HBV vaccination is the best protection against HBV infection. The vaccination is usually a series of 3 injections that creates immunity to HBV. The HBV vaccination is supplied by the employer to employees who are designated as at-risk to exposure. There is more information on the HBV vaccination series under the topic “Reducing the Risk of Exposure.” There is currently no vaccine for HCV.

Bloodborne Pathogens

Prevention Misconceptions about HIV Although HIV has been detected in the saliva and tears of infected individuals, there is no evidence that the virus is spread through saliva, tears, sweat, urine, or feces. Studies have clearly shown that HIV is not spread through casual contact such as sharing of food, drink, eating utensils, towels, bedding, toilet seats, telephones, or swimming pools. HIV is also not spread by mosquitoes or other biting insects. HIV can be transmitted through breast milk; new mothers should abstain from breastfeeding.

Misconceptions about hepatitis B and C There is no evidence that HBV or HCV can be spread through hugging, sneezing, coughing or other casual contact (working, studying, or playing with carriers). Sharing food, drink, or restroom facilities has not been shown to transmit hepatitis B or C. Although household members of HBV and HCV carriers have a higher incidence of infection, it is most likely due to a previous direct exposure to the blood of the infected household member. Breast-feeding alone has not been shown to pass HBV or HCV. It is important that nursing mothers take good care of their nipple areas to prevent cracking and bleeding, and abstain from breast-feeding if the skin is not intact. If a mother has hepatitis B, her baby must receive a shot called H-BIG (hepatitis B immune globulin) and begin the HBV vaccination series within 12 hours of birth in order to safely breast-feed.10,16,37 How can I protect myself? Practice universal precautions when handling blood and body fluids. Do not inject illegal drugs, and especially, do not share needles with anyone. If you inject illegal drugs, seek treatment for substance abuse. Have your sexual partner screened for STDs, HIV and hepatitis. When having sex outside of stable, monogamous relationships, practice safe sex. Avoid sharing personal items that can get contaminated with blood, such as razors, nail clippers, or toothbrushes. Consider the health risks when getting tattoos or body piercings. Only use reputable businesses for body art. Get the HBV vaccination if you are 19 years or younger, or are in a higher risk category for contracting the disease. Exposure to blood during athletic activities poses a very small risk of transmission of bloodborne pathogens, according to the American Academy of Pediatrics. However, since HBV is more easily transmitted than HIV, athletes, coaches, trainers, and equipment personnel should receive the HBV vaccination. An athlete who is actively bleeding should be removed from competition until the bleeding has stopped, and the wound has been cleaned and covered.2

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For More Information: Some students may have many specific questions about HIV, HBV, and HCV, which are beyond the scope of this training course. In order to provide the OSHA required information to the entire class within the allotted time period, you may refer these students to their personal physician, or to one of the resources listed below. 

U.S. Public Health Service: Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm

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MEDLINEplus, U.S. National Library of Medicine, NIH http://medlineplus.gov

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National Center for HIV, STD, and TB Prevention, CDC http://www.cdc.gov/nchstp/od/nchstp.html

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National Institute for Allergy and Infectious Disease, National Institutes of Health http://www.niaid.nih.gov/

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National Institute for Occupational Safety and Health http://www.cdc.gov/niosh/homepage.html

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National Prevention Information Network http://www.cdcnpin.org

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UCSF Center for HIV Information http://hivinsite.ucsf.edu/InSite

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World Health Organization http://www.who.int/en/

Bloodborne Pathogens

Workplace Transmission Overview: Students should understand that potential or confirmed exposure to a bloodborne pathogen does not necessarily mean there is a transmission of disease. The chances of transmission are small, but there is still a possibility.

Modes of Transmission: In the workplace there are many ways employees can be exposed on the job. Common methods of transmission include but are not limited to:  Responding to an emergency involving bleeding: possible exposure to the blood of an infected individual.  Cleaning a contaminated sharp object: possible puncture wound.  Managing a blood spill: possible exposure to BBP via droplets or splashing during overly vigorous cleaning. Routes of Entry7 In order for a disease transmission to occur, there needs to be exposure to the blood or OPIM of an infected individual, commonly known as a source individual. As the source individual’s blood or OPIM enters the blood of a non-infected individual, a transmission can occur. The mixing of the blood of a source individual and a non-infected individual can only occur if there is a route of entry from the source individual to the non-infected individual. Students should know the possible routes of entry for BBP, and how to protect those routes of entry from exposure to blood or OPIM. Routes of entry can be protected though the use of personal protective equipment (see next topic – Personal Protective Equipment) Common routes of entry include:  Mucous membranes: eyes, mouth, and nose. Unprotected sex can also be a route of entry.  Skin breakdown: rashes, cuts, open wounds, and fresh scabs.  Puncture: needlesticks, cleaning contaminated sharp objects, sharing needles (IV drug abuse).

Bloodborne Pathogens

Personal Protective Equipment (PPE) Personal Protective Equipment16 Employers are responsible for providing employees with a plan and the equipment to deal with a possible exposure to bloodborne pathogens in the workplace. One of the responsibilities of the employer is to provide, at no cost to the employee, personal protective equipment (PPE). PPE is protective coverings that are used to reduce risk to exposure to bloodborne pathogens.2 Common examples of PPE include:  Watertight, disposable gloves (latex, or non-latex alternative to avoid latex allergies)  Protective eye shields and facemasks  Splash-resistant gowns, lab coats, aprons, and shoe covers  Ventilation devices and CPR barrier masks PPE requires training for proper use. The first time your students try on PPE should not be during a real-life emergency. PPE should fit correctly and be used appropriately for each situation. Employers should provide a selection of glove sizes to ensure proper fit. Use common sense in discussing good locations for PPE with your students. PPE should be readily available for use by anyone who needs them. Store PPE at each workstation or patient care area, in first aid kits, and any other sites of potential exposure to BBP. Gloves will become brittle over time, especially when removed from their original packing. Glove stock, when not frequently used, should be rotated every six months. Ensure that the proper size glove is available to all employees. Encourage students to practice selecting, donning and removing PPE. Gloves: Gloves are the primary and most common form of PPE. They should be used every time there is a risk of exposure to blood or OPIM. Gloves for the purpose of PPE are usually made of latex, but non-latex alternatives are available for those with latex allergies. In order to properly protect us from exposure to BBP, gloves must fit properly, be watertight, and intact (no punctures, tears or holes). An easy way to ensure that gloves are intact is the “balloon test” – if they hold air, they are watertight. Inflate the glove by blowing into its base, and then twist the base of the glove so that no air can escape. If the glove is airtight, it is watertight. Although gloves are the primary form of protection against BBP exposure, there is no guarantee that they won’t rip during use, or have minute punctures invisible to the naked eye. To ensure maximum protection users should bandage any cuts before © 2011 EMS Safety

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putting on gloves. Avoid handling uncontaminated items such as pens or tools with soiled gloves. Additional protection can be provided by double gloving (wearing two pairs of gloves, one over the other). By double gloving one has an additional layer of protection. If one glove rips, the hand is still protected by a second layer of glove. Also, if the rescuer needs to touch an uncontaminated item, he or she may remove the outer glove, quickly grab the needed item, and return to the scene with PPE still intact. Removal and Disposal: PPE that has been exposed to blood or OPIM should be removed as soon as possible, and before leaving the scene. Taking contaminated PPE out of an emergency scene only increases the possibility of further contamination. Avoid touching any unprotected areas when removing PPE. Soiled gloves should be removed with great care to avoid splashing or aerosolizing (creating airborne droplets). When removing soiled gloves, care should also be given to avoid contaminating other surfaces. Procedure for glove removal: 1. Pinch the base of one glove and slowly peel the glove off so that it is inside out. 2. Place the removed glove in the palm of the gloved hand. 3. Insert a non-gloved finger into the base of the remaining glove. Slowly peel the remaining glove off so that it turns inside out, with the first glove tucked safely inside. Sequence for Donning PPE:19 1. Gown 2. Mask or respirator 3. Goggles or face shield 4. Gloves Sequence for Removing PPE:19 1. Gloves 2. Face shield or goggles 3. Gown 4. Mask or respirator Discard contaminated PPE in a red bag or proper leak-proof container affixed with the biohazard symbol (see labeling requirements). Wash hands thoroughly after removal and disposal of contaminated PPE. Uncontaminated PPE may be discarded in the regular trash. Discussion: “Where is your PPE?” What type of PPE do you have available in this organization? Where is it located? If you need more, who is your resource? © 2011 EMS Safety

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Have a student share his or her thoughts. Open the discussion so that everyone is aware of the location and types of PPE available to them at their workplace. Key discussion points include: 1. Types of PPE available 2. Location of PPE 3. Organizationâ&#x20AC;&#x2122;s process to re-supply PPE if low, inadequate or damaged.

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Exposure Control Plan Overview2,20,21,22 OSHA regulations state that it is the responsibility of the employer to provide a control plan for employees who may come into contact with blood or OPIM. This plan is know as the company’s Exposure Control Plan. The Exposure Control Plan covers every aspect of handling exposure to bloodborne pathogens, including:  Identifying the employees who are “at-risk” for exposure  Sharps management  Spill cleanup  Handling contaminated (regulated) waste  Labeling  Storing, transporting, and cleaning contaminated laundry  Area maintenance, hygiene, and housekeeping  Hepatitis B vaccinations  Postexposure evaluation, treatment, and follow-up care It is the employer’s responsibility to maintain the Exposure Control Plan in writing and make it accessible to all employees. The Exposure Control Plan is reviewed annually and updated as needed. Review of an organization’s Exposure Control Plan should include:  Assessing for new or modified tasks and procedures, which affect occupational exposure.  Changes in technologies that eliminate or reduce exposure to bloodborne pathogens.  New or revised employee positions with risk of occupational exposure.  Incidents from previous year.  Assessment of any deficiencies in the plan. The Exposure Control Plan identifies methods of compliance that help the employer adhere to the standard. Methods of compliance can be broken down into two categories:  Engineering Controls (hardware)  Work-practice Controls (systems) Engineering Controls are hardware that is put into place by the employer to help achieve methods of compliance. OSHA regulations state that engineering controls refer to control systems that isolate or remove the bloodborne pathogens hazards from the workplace.

Bloodborne Pathogens

Engineering controls can include:  Special containers for disposal of contaminated sharps  Needleless injection systems or self-sheathing needles  Specially marked bags for non-sharps contaminated with blood  Blunt-tip suture needles for less-dense tissue, such as muscle and fascia23  PPE Work-practice Controls refer to the every day practices or systems in the workplace that help employees reduce the risk of exposure, and help limit the exposure level should one occur. Common examples of work-practice controls include policies and practices regarding:  Sharps management  Regulated waste  Management of a blood spill  Labeling requirements  Housekeeping and hygiene  Hepatitis B vaccination See appendix A for a Model Exposure Control Plan.24 Discussion: “Where is your Exposure Control Plan?” Every employer is required to have an Exposure Control Plan as mandated by OSHA. As part of this training, review the location of the Exposure Control Plan with the students. Have a student share his or her thoughts. Open the discussion so that everyone is aware of the Exposure Control Plan. It is best to have a copy of the organization’s Exposure Control Plan for this discussion. Key discussion points include: 1. Location(s) of the plan. 2. Who is the designated administrator of the Exposure Control Plan? 3. How are sharps injuries tracked? 4. To whom do you report a potential exposure? 5. When was the Exposure Control Plan last updated? 6. How are employees notified of changes to the Exposure Control Plan?

Bloodborne Pathogens

Management of Sharps Overview2 Caution should be used when handling sharp objects contaminated with blood. A careless individual using poor clean-up technique or an improper container can create a bloodborne exposure. OSHA estimates that 5.6 million workers in the healthcare industry and associated occupations are at risk for exposure to bloodborne pathogens through sharps-related injuries. A needlestick (puncture wound from a contaminated syringe or needle) is the most common cause of occupational exposure to bloodborne pathogens. It is estimated that there are 600,000 to 800,000 needlesticks annually in the United States. Despite the frequency of exposure to BBP through needlesticks, actual transmission of a BBP through this route is extremely rare.25 A contaminated sharp is defined as any object contaminated with blood or OPIM that can penetrate the skin, including needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. When dealing with contaminated sharps, work-practice controls should include a sharps injury log and safe techniques for handing sharps.2 Most needlestick injuries and up to 2/3 of sharps injuries occur during disposal. The CDC estimates that up to 88% of sharps injuries could be prevented by using safer medical devices.26

Sharps Injury Log The sharps injury log is a confidential record maintained by the employer to track sharps injuries. The purpose of the sharps injury log is to track common elements of workrelated sharps injuries, assess for patterns in sharps injuries, and prevent future injuries by eliminating the common causes. Common elements of the sharps injury log include:30  Type and brand of device used in the incident  Location of the incident  Description of the incident Note: OSHA also requires needlestick injuries and cuts from contaminated sharps to be recorded on the OSHA 300 log. Handling Sharps: When handling sharps, there are a few common sense techniques and safeguards that can help prevent exposure to bloodborne pathogens: DO NOT:  Recap needles.  Self-blunt (break/bend) needles.

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DO:     

Follow your state’s needle safety legislation. Use a mechanical means (tongs, broom, dustpan) while wearing PPE to pick up broken glass and other sharps. Dispose of sharps in a leak-resistant, puncture-resistant, closeable container labeled with the biohazard symbol and placed within easy reach of the user. Replace sharps containers when they are 2/3 full.27 Include a sharps provision to the Exposure Control Plan that includes the following: o Annual evaluation of appropriate engineering controls related to sharps and sharps containers (e.g. needleless system, needle with engineered sharps injury protection, or other advanced technology in laboratories and healthcare environments). o Solicitation of non-managerial healthcare workers in evaluating and choosing devices.

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Blood Spills Overview Spills in the workplace should be cleaned immediately. Care should be taken to isolate the spill area to prevent spreading of the contaminate. Disinfect the area and report the spill and any potential exposure to a supervisor at the earliest possible opportunity. Review general spill clean-up guidelines with your students. The goal of cleaning a blood or OPIM spill is to decontaminate the area, killing any particles that could create a bloodborne hazard. 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.

Clean-Up There are commercially available, EPA-registered tuberculocidal disinfectants for decontaminating equipment or working surfaces which have come in contact with blood or OPIM. If no manufactured disinfectant is available, it is recommended to use a solution of chlorinated bleach and water. Depending on the amount and type of spill, use one part household (chlorinated) bleach to 10 - 100 parts water. Mixed bleach and water solutions should be changed daily, since they lose potency over time. The employer’s written schedule for cleaning and decontaminating should identify the type of disinfectant to use for different circumstances.11,20,28,30 General clean-up for blood or OPIM: 1. Follow the Exposure Control Plan. 2. Clear the immediate area to reduce the risk of further contamination/exposure. Isolate the exposure area. 3. Locate the bloodborne pathogen spill kit and PPE. If a germicide is available, follow the manufacturer’s guidelines for use. If a commercial germicide is unavailable, use a chlorinated bleach and water solution as described above. 4. Don personal protective equipment (mask, goggles, gloves, gown, and shoe covers). 5. Thoroughly clean the area of visible blood and OPIM. 6. Follow protocol for decontamination to completely disinfect the area of blood or OPIM. Leave the area wet with disinfectant for at least 10 minutes. 7. Dispose of all materials used in the clean-up process in the properly labeled container according to workplace policy. 8. Wash your hands.

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Labeling Regulated waste requires special clean up, handling and disposal. Regulated waste includes liquid or semi-liquid blood or OPIM; items heavily contaminated with blood or OPIM, and pathological/microbiological wastes containing blood or OPIM.2 Items heavily soiled with blood or OPIM can either be properly cleaned or disposed of as regulated waste. Items that drip blood (i.e. used gauze, bandages, towels used for clean-up) must be disposed of as regulated waste. Regulated waste should be easily identifiable, and stored in a special container that is leak-proof and labeled with a biohazard sticker and/or is bright red in color. Regulated waste is not to be discarded with other regular trash, as there is still potential for exposure.2 Discarded feminine hygiene products used to absorb menstrual flow are not generally considered regulated waste by OSHA. The absorbent material of which they are made normally prevents the release of liquid or semi-liquid blood. These products should be discarded into waste containers properly lined with plastic or wax paper bags to protect people from physical contact with the contents. 2 Contaminated laundry should be cleaned by a professional service that provides pickup and cleaning. It should be handled as little as possible and bagged in the location it was used. Place contaminated laundry in a properly labeled, closeable, leak-proof container. 2 Labeling2, 29 According to most state and federal OSHA guidelines, warning labels shall be affixed to containers of regulated waste, used or contaminated sharps, laundry or any item exposed to blood or OPIM, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport or ship blood or OPIM. Containers carrying blood or OPIM must be labeled using a fluorescent orange or orange red label with the biohazard symbol and lettering in a contrasting color. In the absence of the biohazard warning, red bags or red containers may be substituted for labels. The warning labels should be part of the container or affixed as close as feasible to the containers by string, wire, or other adhesive methods to prevent their loss, or accidental or purposeful removal.1,30 Blood and blood products that are labeled as to their contents and are released for transfusion or other clinical use are exempted from the labeling requirements. Warning signs (the biohazard symbol) must be posted by the employer, as specified by the standard, at the entrance to work areas, as well as HIV and HBV research laboratories and production facilities. Refer to the bloodborne pathogens standard for additional information on research laboratories and production facilities.

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Activity: “Show the Proper Label” 1. Discuss the proper labeling of biohazardous materials. 2. Show the biohazard label to the class; discuss characteristics including proper color and biohazard symbol. 3. Pass the label around so that everyone can see it. 4. Discuss the following: a. What to do in the absence of a proper label. 1. Red bag 2. Red container b. What types of objects need a biohazard label? 1. Refer to the organization’s Exposure Control Plan. 2. Refer to the bloodborne pathogens standard.

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Hand Washing Overview17,18 Proper hand washing techniques can make the difference between exposure and transmission. It can prevent bloodborne pathogens from being transmitted from the hands to the mucous membranes of the eyes, nose, or mouth of the employee. Without proper hand washing, germs can be spread to surfaces, then to other individuals. Hands should be washed before donning gloves and as soon as possible after engaging in tasks that potentially expose the employee to bloodborne pathogens (e.g. rendering first aid or cleaning up a blood spill). Proper hand washing technique: 1. Wet hands with running water and apply soap. a. Place bar soap back on rack to allow it to drain. b. The use of liquid soap reduces the bacteria associated with bar soap. 2. Rub hands together vigorously and scrub all surfaces. Do not forget under nail beds and between fingers. 3. Continue scrubbing for at least 20 seconds. Soap combined with friction (scrubbing action) dislodges and removes germs. 4. Rinse well with warm water and dry. The creation of friction when washing hands is essential to dislodging germs. Rubbing hands together vigorously for 30 seconds, without soap and water, is said to remove 80% of bacteria. By adding soap and water we can eliminate nearly all bacteria. If hand washing facilities are not immediately available, use an alcohol-based hand sanitizer that contains at least 60% alcohol as a temporary method to kill bacteria. Wash hands properly at the earliest opportunity.

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Hygiene Overview The purpose of good hygiene is to further reduce the risk of exposure to BBP. Good hygiene is directly related to using common sense.2 Good personal hygiene in the workplace includes the following: 

Food: do not store food, eat or drink in areas where it may be exposed to blood or OPIM.

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Personal Hygiene: avoid applying makeup or lip balms, smoking, or handling contact lenses in places where BBP are present.

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Creams: avoid the use of petroleum-based creams, as they deteriorate latex gloves, causing exposure.

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Use caution around potentially infectious materials: utilize PPE at all times, and minimize splashing or aerosolization (spattering, spraying or otherwise creating droplets of blood in the air or onto surfaces) of infectious materials.

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Maintenance and Housekeeping Overview Good housekeeping techniques are critical in reducing the incidence of exposure to bloodborne pathogens at work. Although studies have shown that HIV dies when it dries out on environmental surfaces, HBV can survive up to one week.7 Employees are most commonly exposed at the beginning and end of their shifts (when they are tired, distracted or in a hurry). This is when good housekeeping is most important. Follow these general guidelines on good housekeeping practices:2 

Clean and disinfect equipment and work area at the beginning and end of each shift.

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Remove and replace any equipment coverings that have been exposed to BBP.

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Clean spills immediately.

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Pick up sharps properly and dispose of them as soon as possible.

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Use the proper containers for contaminated or used sharps, regulated waste, or contaminated laundry.

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Handle infectious materials and containers as little as possible.

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Ensure containers are labeled properly.

Refer to your company’s Exposure Control Plan for detailed information.

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HBV Vaccination Overview2,11 One of the most effective ways to reduce transmission of Hepatitis B is through the HBV vaccination series. It is recommended that persons who are at higher risk for exposure to HBV, all infants, and children under 19 years of age receive the vaccination. The average number of new infections of HBV was reduced from 260,000 in the 1980’s to about 38,000 in 2008. This dramatic decline in new infections (especially among children and adolescents) was primarily due to routine HBV vaccination. The HBV vaccination works by introducing small amounts of a manufactured protein related to the virus into the body, allowing antibodies (immunity) to the disease to develop. The HBV vaccination provides immunity to the hepatitis B virus 95% of the time. The hepatitis B vaccine has been shown to be safe when administered to both adults and children. Over 20 million people have been vaccinated in the United States. There is no confirmed evidence that the hepatitis B vaccine causes chronic illnesses. Very rarely a person may have a severe allergic reaction (anaphylaxis) to the vaccine. The hepatitis B vaccine is made in yeast cells, so people with known allergies to yeast should not receive the vaccine. When considering the incidence of severe liver disease and death from HBV infection, the benefits of the HBV vaccine far outweigh the risks. Employees who are designated as “at-risk” for coming into contact with a BBP as part of their job are eligible for the Hepatitis B vaccination, a series of shots provided at no cost to all at-risk employees. The vaccination series is given under the supervision of a licensed physician or another licensed healthcare professional. After an exposure incident, post-vaccination testing for continued immunity should be offered. HBV vaccinations should be offered to the employee within 10 days of being classified as “at-risk”. An employee has the right to refuse the vaccination, but at any time may choose to begin the HBV vaccination series. If the employee refuses the vaccination, he or she must sign a HBV vaccination declination form. A post-vaccination titer may be needed. It is recommended by OSHA and the CDC that employees who have “ongoing contact with patients or blood and are at on-going risk of injuries with sharp instruments or needlesticks be tested for antibodies to Hepatitis B surface antigen, one to two months after completion of the three-dose vaccination series.” All testing shall be conducted by an accredited laboratory at no cost to the employee.2,13

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Responding to Emergencies Overview Responding to emergencies in the workplace is a common occurrence. There were 3.3 million cases of workplace illness and injury in the year 2009. A significant percentage of these cases involved a potential occupational exposure to a bloodborne pathogen. When responding to emergencies, having a plan and practicing it can reduce the risk and occurrence of being exposed. The organization’s Exposure Control Plan identifies isolation techniques for exposure to bloodborne pathogens. Having a plan and the supplies needed to execute that plan are essential. Refer to the organization’s techniques for responding to emergencies. Universal precautions and body substance isolation are techniques to limit and prevent exposure on a daily basis and on emergency scenes.

Universal Precautions2,16 Universal precautions are a standard of isolation recommended by the Centers for Disease Control and Prevention. The practice of universal precautions means to treat all blood and body fluids as potentially infectious, even without a diagnosis or known history of infectious disease. Universal precautions apply to: 1. Blood 2. Body fluids (Does not apply to feces, nasal secretions, sputum, sweat, tears, urine, or vomit unless contaminated by visible blood.) 3. Non-intact skin 4. Mucous membranes To utilize universal precautions:  Wash hands before and after each patient contact.  Utilize PPE for every patient contact, every time. Suggested PPE includes the following: o Gloves o Mask/respiratory protection o Goggles/eye protection/face shield o Gowns, shoe covers and other water-resistant protection for clothes and skin.

Body Substance Isolation (BSI) BSI is another standard of isolation techniques recommended by the Centers for Disease Control and Prevention. BSI requires the responder to treat every body fluid as if it is infectious, regardless of whether or not they contain visible blood. If every moist substance that a body produces is considered infectious (except sweat), proper protections (isolation gear) will be used each time.

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Although sweat, tears, saliva, urine, feces, vomit and nasal secretions do not normally present a risk for transmission of BBP, they may contain other infectious microorganisms (i.e. flu virus).

Standard Precautions Standard Precautions are the isolation precautions used in hospitals. For the best protection organizations can follow Standard Precautions, which combine the techniques of universal precautions and BSI, and include airborne, droplet and contact precautions. When responding to emergencies, remember to:  Wash hands before and after each patient contact  Don appropriate PPE prior to rendering first aid  Utilize CPR barrier devices when providing rescue breathing  Consider all moist body fluids as potentially infectious. Follow the organization’s Exposure Control Plan for detailed guidelines on what type of precautions should be taken when one can be reasonably expected to come into contact with blood or OPIM.

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What if you’re exposed on the job? Overview Employees need to understand what steps to take after an exposure occurs on the job. Certain actions aimed at cleaning and disinfecting the exposed area(s) will reduce the possibility of infection or further exposure. Secondary actions include reporting the exposure to a supervisor, and beginning the postexposure evaluation and follow-up. Discuss these actions with your students. If an exposure incident has occurred, take immediate action. Immediate postexposure actions are aimed at cleaning and disinfecting the exposed area(s). By cleaning the exposure sites, one can reduce the possibility of infection or further exposure from contaminating other objects or areas of the skin. Refer to the organization’s Exposure Control Plan for guidelines on immediate postexposure actions. Immediate actions can include:32  Wash hands and other affected/exposed areas. o Flush splashes to nose, mouth or skin thoroughly with water. o Irrigate eyes with water or saline.  Dispose of contaminated PPE, clothing or objects in the appropriately labeled container.  Ensure the clean-up of any spill of blood or OPIM.  Report the exposure to a supervisor immediately.  Seek medical treatment immediately. Report to your supervisor the following information:  Date and time of the exposure  Body part exposed to the BBP  Job classification  Work site location  Engineering controls being used  Work practices being followed  Activity being performed at the time of the exposure incident  Previous training for the activity When a sharp is involved, report:  If the sharp had engineered sharps injury protection.  If the protective mechanism was activated, and if the incident occurred before or after activation.  If there was no engineered sharps injury protection, could engineered protection have prevented the injury?  Could any other engineering control, work practice control, or administrative policy have prevented the injury? The employer is required to provide postexposure evaluation and follow-up. After taking the immediate actions of decontamination, the exposure incident will need to be © 2011 EMS Safety

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reported to a supervisor, who will begin postexposure evaluation and follow-up. The employer should have arrangements in place to provide follow-up within three to four hours of the exposure. The employee should receive the following at no cost:2  Documentation of the routes and circumstances of the exposure.  Identification and documentation of the source individual (unless prohibited by law).  Confidential medical evaluation by a qualified physician.  Laboratory testing of the source and person exposed with follow-up results and retesting as needed.  Treatment of exposure and administration of postexposure medications when appropriate.  Employee counseling  Continued follow-up as needed. Discussion: “What if you’re exposed on the job?” The Exposure Control Plan includes the postexposure actions to be taken. Lead an open discussion on the appropriate postexposure actions within the organization you are teaching. Refer to their Exposure Control Plan when possible. Discuss the following points:  To whom does one report an exposure?  What are the immediate postexposure actions?  Review the postexposure procedures from the Exposure Control Plan.

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Bloodborne Pathogens References 1. 2.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

Department of Labor. “Workplace Injury and Illness Summary, Workplace Injuries and Illnesses in 2009.” United States Department of Labor, Bureau of Labor Statistics. (7/27/11) http://www.bls.gov/news.release/osh.nr0.htm OSHA. “Regulations (Standards-29 CFR) Bloodborne Pathogens – 1910.1030.” 1991. OSHA, U.S. Department of Labor. (7/27/11) http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 CDC. “Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination.” 22 Nov. 1991. Immunizations Practices Advisory Committee, CDC. (7/27/11) http://www.cdc.gov/mmwr/preview/mmwrhtml/00033405.htm CDC. Basic Information about HIV and AIDS.” CDC (5/6/11) http://www.cdc.gov/hiv/topics/basic/index.htm CDC. “HIV in the United States.” CDC. (5/6/11) http://cdc.gov/hiv/resources/factsheets/us.htm WHO. “UNAIDS REPORT ON THE GLOBAL AIDS EPIDEMIC, 2010.” Joint United Nations Programme on HIV/AIDS (UNAIDS). (8/11/11) http://www.unaids.org/globalreport/Global_report.htm CDC. “HIV Transmission.” CDC. (5/7/11) http://www.cdc.gov/hiv/resources/qa/transmission.htm CDC. “Occupational HIV Transmission and Prevention among Health Care Workers.” CDC, National Center for HIV/AEDS, Viral Hepatitis, STD, and TB Prevention. (7/27/11) http://www.cdc.gov/hiv/resources/factsheets/hcwprev.htm MEDLINEplus. “HIV infection.” National Library of Medicine, National Institutes of Health. (7/27/11) http://www.nlm.nih.gov/medlineplus/ency/article/000602.htm CDC. “Surveillance Data for Acute Viral Hepatitis – United States, 2008.” CDC. (7/27/11) http://www.cdc.gov/hepatitis/Statistics/2008Surveillance/ CDC. “Hepatitis B FAQs for the Public.” CDC. (4/13/11) http://www.cdc.gov/hepatitis/B/bFAQ.htm Committee on Sports Medicine and Fitness. “Human Immunodeficiency Virus and Other Blood-borne Viral Pathogens in the Athletic Setting.” American Academy of Pediatrics. Pediatrics 104.6 (1999): 1400-03. CDC. “Hepatitis B FAQs for Health Professionals.” CDC. (4/13/11) http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm CDC. “Hepatitis C and Incarceration.” CDC. (5/11/11) http://www.cdc.gov/hepatitis/HCV/PDFs/HepCIncarcerationFactSheet.pdf CDC. “Correctional Facilities and Viral Hepatitis.” CDC. (7/27/11) http://www.cdc.gov/hepatitis/Settings/corrections.htm Siegel JD et al. “2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.” (5/11/11) http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf CDC. “Wash Your Hands.” CDC. (5/21/11) http://www.cdc.gov/Features/HandWashing CDC. “Handwashing: Clean Hands Save Lives.” CDC. (5/21/11) http://www.cdc.gov/handwashing CDC. “Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings.” (5/21/11) http://www.cdc.gov/ncidod/dhqp/pdf/ppe/PPEslides6-29-04.pdf OSHA. “Most Frequently Asked Questions Concerning the Bloodborne Pathogens Standard.” 1 Feb. 1993. OSHA, U.S. Department of Labor. (5/11/11) http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21010 OSHA. “Needlestick Safety and Prevention Act: Frequently Asked Questions.” OSHA, U.S. Department of Labor. (5/11/11) http://www.osha.gov/needlesticks/needlefaq.html OSHA. “Model Exposure Control Plan.” OSHA, U.S. Department of Labor. (5/11/11) http://www.osha.gov/Publications/osha3186.pdf CDC. “Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to Surgical Personnel: Safety & Health Information Bulletin.” NIOSH, CDC. (5/11/11) http://www.cdc.gov/niosh/docs/2008-101/ OSHA. “Needlestick Safety and Prevention Act.” 2001. Public Law 106-430, 106th Congress. (5/1/11) http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_cong_public_laws&docid=f:publ430.106 OSHA. “Safety and Health Topics: Needlestick Prevention.” OSHA, U.S. Department of Labor. (19 Mar. 2003) http://www.osha-slc.gov/SLTC/needlestick/index.html OSHA. “Bloodborne Pathogens and Needlestick Prevention.” OSHA, U.S. Department of Labor. (5/11/11) http://www.osha.gov/SLTC/bloodbornepathogens/index.html CDC. “Body Art: Prevent Needlestick Injuries.” CDC. (5/11/11) http://www.cdc.gov/niosh/topics/body_art/needlestick.html CDC. “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.” CDC. (7/27/11) http://www.cdc.gov/hicpac/Disinfection_Sterilization/6_0disinfection.html A Best Practices Approach for Reducing Bloodborne Pathogens Exposure. California Department of Industrial Relations, California OSHA (Cal/OSHA), 2001. http://www.dir.ca.gov/dosh/dosh_publications/bbpbest1.pdf USA. OSHA. “Frequently Asked Questions: Bloodborne Pathogens.” 11 Nov. 2001. OSHA, U.S. Department of Labor. (7/27/11) http://www.osha.gov/html/faq-bbp.html CDC. “(Lack of) Universal Precautions.” OSHA, U.S. Department of Labor. (11 July 2003) http://www.osha.gov/SLTC/hospital_etool/hazards/univprec/univ.html CDC. “Bloodborne Infectious Diseases: HIV/AEDS, Hepatitis B, Hepatitis C, Emergency Needlestick Information.” CDC. (7/27/11) http://www.cdc.gov/niosh/topics/bbp/emergnedl.html CDC. “Exposure to Blood: What Healthcare Personnel Need to Know.” CDC, July, 2003. (7/27/11) http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf Morbidity & Mortality Weekly Report, 12-19-03, Vol. 52, N. RR-17 California Code of Regulation, Section 1005. Minimum Standards for Infection Control

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Bloodborne Pathogens Appendices Table of Contents Appendix A: Model Exposure Control Plan Appendix B: Hepatitis B Vaccine Declination (Mandatory) Appendix C: Biohazard Symbol Appendix D: Irrigation Practices for CA Dental Providers

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APPENDIX A: MODEL EXPOSURE CONTROL PLAN The Model Exposure Control Plan is intended to serve as an employer guide to the OSHA Bloodborne Pathogens standard. A central component of the requirements of the standard is the development of an exposure control plan (ECP).22 The intent of this model is to provide small employers with an easy-to-use format for developing a written exposure control plan. Each employer will need to adjust or adapt the model for their specific use. The information contained in this publication is not considered a substitute for the OSH Act or any provisions of OSHA standards. It provides general guidance on a particular standard-related topic. For specific compliance requirements refer to www.osha.gov. POLICY The (Facility Name) __________ is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens." The ECP is a key document to assist our firm in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:  Determination of employee exposure  Implementation of various methods of exposure control, including: o Universal precautions o Engineering and work practice controls o Personal protective equipment o Housekeeping  Hepatitis B vaccination  Post-exposure evaluation and follow-up  Communication of hazards to employees and training  Recordkeeping  Procedures for evaluating circumstances surrounding an exposure incident The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP. PROGRAM ADMINISTRATION  (Name of responsible person or department)__________________ is (are) responsible for the implementation of the ECP. (Name of responsible person or department)_______________ will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Contact location/phone number:____________________________

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Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP. (Name of responsible person or department) _____________________ will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. (Name of responsible person or department) ______________________ will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. Contact location/phone number: ___________________ (Name of responsible person or department) _______________________ will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. Contact location/phone number:________________________ (Name of responsible person or department) _____________________ will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives. Contact location/phone number:_____________________________

EMPLOYEE EXPOSURE DETERMINATION The following is a list of all job classifications at our establishment in which all employees have occupational exposure: JOB TITLE (E.g.: Phlebotomists)

DPEARTMENT/LOCATION (E.g.: Clinical Lab)

The following is a list of job classifications in which some employees at our establishment have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals: JOB TITLE DEPT/LOCATION TASK/PROCUDURE (E.g., Housekeeper) (Ex: EVS) (Handling Regulated Waste)

Part-time, temporary, contract and per diem employees are covered by the standard. How the provisions of the standard will be met for these employees should be described in the ECP. METHODS OF IMPLEMENTATION AND CONTROL Universal Precautions All employees will utilize universal precautions. Exposure Control Plan Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual

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refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting (Name of responsible person or department) __________. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request. (Name of responsible person or department) _______________ is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. Engineering Controls and Work Practices Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used are listed below:   

(e.g.: glass capillary tubes in the clinical laboratory, outpatient clinics, and pediatric units) __________________________________________________________ __________________________________________________________

Sharps disposal containers are inspected and maintained or replaced by (Name of responsible person or department) _____________________ every (list frequency ______________ or whenever necessary to prevent overfilling. This facility identifies the need for changes in engineering control and work practices through (Examples: Review of OSHA records, employee interviews, committee activities, etc.) ______________________________________________________ We evaluate new procedures or new products by (Describe the process) _______ __________________________________________________________________ __________________________________________________________________ The following staff are involved in this process: (Describe how employees will be involved) __________________________________________________________ (Name of responsible person or department)________________will ensure effective implementation of these recommendations. Personal Protective Equipment (PPE) PPE is provided to our employees at no cost to them. Training is provided by (Name of responsible person or department) ______________________ in the use of the appropriate PPE for the tasks or procedures employees will perform. The types of PPE available to employees are as follows:

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(e.g., gloves, eye protection, etc.) _____________________________________ ___________________________________________________________________ PPE is located (List location) _______________________________ and may be obtained through (Name of responsible person or department) _____(Specify how employees are to obtain PPE, and who is responsible for ensuring that it is available.) All employees using PPE must observe the following precautions:  Wash hands immediately or as soon as feasible after removal of gloves or other PPE  Remove PPE after it becomes contaminated, and before leaving the work area  Used PPE may be disposed of in _____________(List appropriate containers for storage, laundering, decontamination, or disposal.)  Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised  Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration.  Never wash or decontaminate disposable gloves for reuse.  Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.  Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface. The procedure for handling used PPE is as follows: (may refer to specific agency procedure by title or number and last date of review) ____________________________________________________________ _________________________________________________________ (e.g., how and where to decontaminate face shields, eye protection, resuscitation equipment) Housekeeping Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling. The procedure for handling sharps disposal containers is: (may refer to specific agency procedure by title or number and last date of review)

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____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ The procedure for handling other regulated waste is: (may refer to specific agency procedure by title or number and last date of review) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak-proof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are available at __________ (must be easily accessible and as close as feasible to the immediate area where sharps are used) Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination. Broken glassware which may be contaminated is picked up using mechanical means, such as a brush and dust pan. Laundry The following contaminated articles will be laundered by this company: ________________________ ________________________ ________________________ ________________________ Laundering will be performed by (Name of responsible person or department) _______________________ at (time and/or location). The following laundering requirements must be met:  Handle contaminated laundry as little as possible, with minimal agitation  Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport.  Use (specify either red bags or bags marked with the biohazard symbol) for this purpose.  Wear the following PPE when handling and/or sorting contaminated laundry: (List appropriate PPE) ______________ , ______________, ______________,______________ Labels The following labeling method(s) is used in this facility: EQUIPMENT TO BE LABELED LABEL TYPE (size, color, etc.) e.g., Specimens, contaminated laundry, etc. Red bag, biohazard label, etc. ___________________________________ ____________________________ ___________________________________ ____________________________

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(Name of responsible person or department) ______________________ will ensure warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify ________________________ if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels. HEPATITIS B VACCINATION (Name of responsible person or department) ________________________ will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability. The hepatitis B vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is encouraged unless any of the following occur: 1) Documentation exists that the employee has previously received the series. 2) Antibody testing reveals that the employee is immune. 3) Medical evaluation shows that vaccination is contraindicated. However, if an employee chooses to decline 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 is kept at _______(List location or person responsible for this recordkeeping). Vaccination will be provided by (List Health care Professional who is responsible for this part of the plan) at (location). Following hepatitis B vaccinations, the healthcare professional's Written Opinion will be limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was administered. POST-EXPOSURE EVALUATION AND FOLLOW-UP Should an exposure incident occur, contact (Name of responsible person) at the following number:____________________________. An immediately available confidential medical evaluation and follow-up will be conducted by (Licenced health care professional) . Following the 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; document

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that the source individual's test results were 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). After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status. If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, 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.

ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOW-UP (Name of responsible person or department) ________________________ ensures that health care professional(s) responsible for employee's hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's bloodborne pathogens standard. (Name of responsible person or department) _____________________ ensures that the health care professional evaluating an employee after an exposure incident receives the following:  A description of the employee's job duties relevant to the exposure incident  Route(s) of exposure  Circumstances of exposure  If possible, results of the source individual's blood test  Relevant employee medical records, including vaccination status (Name of responsible person or department) _______________________provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation. PROCEDURES FOR EVALUATING THE CIRCUMSTANCES SURROUNDING AN EXPOSURE INCIDENT (Name of responsible person or department) ________________________ will review the circumstances of all exposure incidents to determine:  Engineering controls in use at the time  Work practices followed  A description of the device being used

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Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.) Location of the incident (O.R., E.D., patient room, etc.) Procedure being performed when the incident occurred Employee's training

(Name of responsible person) will record all percutaneous injuries from contaminated sharps in a Sharps Injury Log. If it is determined that revisions need to be made, (Responsible person or department) ___________________ will ensure that appropriate changes are made to this ECP. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.) EMPLOYEE TRAINING All employees who have occupational exposure to bloodborne pathogens receive training conducted by (Name of responsible person or department) . (Attach a brief description of their qualifications.) 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 standard  An explanation of our 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  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. © 2011 EMS Safety

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An opportunity for interactive questions and answers with the person conducting the training session.

Training materials for this facility are available at ___________________________. RECORDKEEPING Training Records Training records are completed for each employee upon completion of training. These documents will be kept for at least three years at (Name of responsible person or location of records) ______________________. The training records include:  Dates of the training sessions  Contents or a summary of the training sessions  Names and qualifications of persons conducting the training  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 addressed to (Name of Responsible person or department) ________________________. Medical Records Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.20, "Access to Employee Exposure and Medical Records." (Name of Responsible person or department) is responsible for maintenance of the required medical records. These confidential records are kept at (List location) ________________for at least the duration of employment plus 30 years. Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to (Name of responsible person or department and address) ______________________ OSHA Recordkeeping An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by (Name of responsible person or department) ___________.

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Sharps Injury Log In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:  Date of the injury  Type and brand of the device involved (syringe, suture needle)  Department of work area where the incident occurred  Explanation of how the incident occurred. This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

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APPENDIX B: HEPATITIS B VACCINE DECLINATION (MANDATORY) I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Signed:________________________________ Employee Signature

Name:__________________________________ Print Employee Name

Date:________________________

ÂŠ 2011 EMS Safety

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APPENDIX C: BIOHAZARD SYMBOL

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APPENDIX D: IRRIGATION PRACTICES FOR CA DENTAL PROVIDERS

For: California Dental Providers Re: Irrigation Practices When dealing with irrigation, consider the following practices: 

All containers with blood or saliva (e.g. suctioned fluids) can be inactivated with state-approved treatment technologies or carefully poured down a utility sink, drain or toilet.34

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Be sure to use proper PPE when handling any fluids potentially contaminated with blood.

California regulations require that only sterile coolants and irrigants shall be used for surgical procedures that involve soft tissue or bone. The sterile coolant/irrigant must be delivered with a sterile delivery system.35

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