UVM Biosafety

UVM Environmental Safety Facility

UVM Exposure Control Plan for Bloodborne Pathogens

Last Reviewed and Revised: May, 2011

Table of Contents

1. Policy

2. Program Administration and Responsibilities

3. Determination of Employee Exposure

4. Methods of Implementation and Control:
A. Standard Precautions
B. Exposure Control Plan
C. Engineering and Work Control Practices
D. Personal Protective Equipment
E. Regulated Waste Disposal
F. Handwashing Facilities
G. Needles and Other Sharps
H. Work Area Restrictions
I. Specimen Handling and Transport
J. Contaminated Equipment
K. Housekeeping
L. Laundry
M. Labels

5. Employee Training

6. Hepatitis B Vaccination

7. Post-Exposure Evaluation and Follow-Up

8. Administration Of Post-Exposure Evaluation and Follow-Up

9. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

10. Recordkeeping:
A. Training Records
B. Records Maintained for "At Risk" Employees
C. Medical Records
D. OSHA Recordkeeping
E. Sharps Injury Log

Appendix A: Procedures for Accidents and Exposures to Chemicals, Blood or Biohazardous Material

Appendix B: Description of OSHA Standard

Appendix C: Definitions

Appendix D: Bloodborne Pathogens Information

Appendix E: Forms

Appendix F: Spill Cleanup Procedures

Appendix G: Biowaste Disposal Procedures

Appendix H: Laboratory Employee Specific Procedures

Appendix I: Safer Sharps Program:

1. Policy

The UVM Exposure Control Plan (ECP) implements the UVM Bloodborne Pathogens policy found on the UVM Policy Page. All supervisors and employees are expected to adhere to guidelines established in this document. Questions should be addressed to the supervisor.

2. Program Administration and Responsibilities

A. Departmental supervisors are responsible for the implementation of the Exposure Control Plan. Risk Management staff will review and update the institutional ECP and the Sharps Injury Log at least annually, and whenever necessary to maintain current information including new or modified tasks and procedures.

Supervisors of "at risk employees" will be responsible for ensuring that all required medical actions are performed, that appropriate employee health and OSHA records are maintained, and making the written ECP available to employees. The Risk Management Department will periodically follow-up with departments regarding suggestions for safer sharps made by non-managerial employees and submitted to the departments and/or Risk Management.

You may contact the Environmental Safety staff at esf@uvm.edu with any questions about this plan.

B. Concentra Managed Care (7 Fayette Road, South Burlington, 658-5756) is responsible for administering the vaccination series and titer to UVM employees who present a completed Risk Designation form from their supervisor. This service will be paid for by the UVM Occupational Health budget.

C. Supervisors or Departments (as per Department Policy) are responsible for the following:

  1. exposure determination for all employees, by job title;
  2. documenting that "at risk" employees have been offered and either received or declined the Hepatitis B vaccine series;
  3. training on general background information about OSHA standards. This is provided by online training found at http://esf.uvm.edu/courses. Classroom BBP safety training can also be customized for your group if the on line course does not address specific issues appropriate for your work setting. Contact Environmental Safety staff if you are interested in this service.
  4. training in the specific hazards encountered in the workplace and the controls used to minimize employee risk,
  5. documentation of both supervisor's training and Environmental Safety training,
  6. records maintained for "at risk" employees,
  7. ensuring employees' compliance with this ECP (Methods for Implementation and Control),
  8. soliciting and evaluating suggestions submitted by employees regarding safer devices and implementing these suggestions as warranted, and
  9. providing and maintaining all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red biowaste bags as required by the Standard.

D. Employees who are determined to be "at risk" for occupational exposure to blood or OPIM (see Determination of Employee Exposure, below) must comply with the Methods of Implementation and Control and Employee Training requirements outlined in this ECP. Risk designation, the offer of the Hepatitis B vaccination and initial training must happen within 10 days of assignment to an "at risk" position. If consent was given for receipt of the Hepatitis B vaccination series the appointment for the first shot should also be within that 10 day window. Employees may contact their supervisor with questions about this process.

3. Determination of Employee Exposure

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials (OPIM). UVM has designated the "supervisor" as the person who has the responsibility to make this determination according to the following guidelines. Please contact the Environmental Safety staff if you have any questions about this process.

The "at risk" determination is made solely on the activities for which an employee receives a paycheck from UVM and is made without regard to the use of personal protective equipment (PPE) (i.e. for the purpose of "exposure determination" assume that PPE is not worn.) Employees include all faculty and staff in full, part time, temporary, contract or per diem positions. OSHA excludes Good Samaritan acts from this determination.

The "at risk" determination for exposure to bloodborne pathogens is based on the expected level of risk, as determined by the supervisor, inherent in assigned work duties:

1. High Risk: Those employees who work directly with human blood or OPIM. These employees are designated as "at risk" and fall under the jurisdiction of the OSHA Bloodborne Pathogens Standard. UVM policy this requires use of Standard Precautions, initial and annual training, and being offered the Hepatitis B vaccination series and titer. Initial training and the offer of the Hepatitis B vaccine must occur within 10 days of employment or assignment to a position in which they are considered to be "at risk". If consent is given for the vaccination series, then the first shot must be scheduled within that 10 day window.

2. Low Risk: Those employees who may encounter blood or OPIM in the course of their work and all of the following situations exist:

3. No Risk: Those employees who are not reasonably expected to encounter human blood or OPIM in the course of their assigned duties and if they might inadvertently encounter such a situation there is no expectation that the employee clean it up or handle it in any way. There is no requirement for bloodborne pathogens safety training in this category.

4. Methods of Implementation and Control

A. Standard Precautions

Standard Precautions are the recommended work practices for protection from infection with a bloodborne pathogen or other biological agent in the workplace. This is the work practice of treating all human and primate blood and body fluids (with the exception of sweat) as if they are infectious and avoiding all direct contact with this material.

B. Exposure Control Plan

Employees covered by the Bloodborne Pathogens Standard receive an explanation of the ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting the Environmental Safety or accessing it on a computer at http://esf.uvm.edu/uvmecp free of charge and within 15 days of the request.

The Risk Management 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.

C. Engineering and Work Control Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering and work practice controls to be used are identified by the supervisor. When occupational exposure remains after institution of these controls, personal protective equipment (PPE) will also be used.

Examples of engineering controls are safer sharps devices, sharps disposal containers, biological safety cabinets, enclosed containers, mechanical pipetting devices, secondary leak proof containers for transport of material in biohazard bags for autoclaving, broken glass containers (cardboard) with leak proof liners, and splash shields.

Sharps disposal containers are inspected on a regular basis, maintained, and replaced (whenever necessary to prevent overfilling) by the supervisor or department.

The supervisor identifies the need for changes in engineering controls and work practices. Supervisors and non-managerial employees evaluate new procedures or new products. Front line workers are involved in this process by use of the "Questionnaire for Evaluating Sharps" found in Appendix I. Return a copy of this form to your supervisor.

Your department will ensure effective implementation of these recommendations.

D. Personal Protective Equipment (PPE)

PPE selection, purchase and maintenance are the responsibility of each department. PPE will be chosen based on the anticipated exposure to blood or other biological material. The protective equipment will be considered appropriate only if it does not permit blood or other biological material to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

All PPE will be cleaned, laundered and disposed of through procedures established by the individual department at no cost to employees. Repairs and replacements will be made by the department at no cost to employees. Departments using outside contractors for laundry services must supply appropriately labeled bags for delivery or pickup of soiled laundry.

Training is provided by the supervisor or department in the use of the appropriate PPE for the tasks or procedures employees will perform:

Affected laboratories and all other affected areas on campus will be decontaminated utilizing approved cleaning agents and according to the schedules developed by departments. All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other biological material, as well as the end of the work shift if the surface may have become contaminated since the last cleaning.

Each laboratory should have a "spill kit" as described at http://www.uvm.edu/~esf/emergencyred/biospill.html.

PPE is supplied by your department and may be obtained through your supervisor.

All employees using PPE must observe the following precautions:

The procedure for handling used PPE is determined by the supervisor or department.

E. Regulated Waste Disposal

This policy is established to assure the safe disposal of the University's infectious waste. The key requirement with regard to infectious waste is that the waste be identified as such, that it is segregated from the normal solid waste stream and put into the biowaste stream managed by Environmental Safety staff. This policy governs all University activities which involve any of the types of biological waste listed below:

a) General Waste Procedures

All biological waste must be segregated from regular trash and deposited in the biological waste shipping containers at the Health Science Research Facility (HSRF) loading dock biowaste facility. For details of this procedure, review the Biowaste Management Waste Procedures on line course.

b) Sharps/Physically Dangerous Waste

Sharps which are not chemically-contaminated must be segregated from other wastes and disposed of in leak-proof, rigid, puncture resistant, shatterproof containers and disposed of with other biowaste through UVM's contractor disposal firm.

f) Waste Recordkeeping

UVM Environmental Safety staff will maintain records of biowaste shipments which are dispatched from the HSRF loading dock facility.

F. Handwashing Facilities

Handwashing facilities will be available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. If handwashing facilities are not feasible, the supervisor is required to provide either an antiseptic cleanser in conjunction with a clean cloth/paper towels or antiseptic towelettes. If these alternatives are used then the hands are to be washed with soap and running water as soon as feasible. Supervisors, who must provide alternatives to readily accessible handwashing facilities, should list the location, tasks ,and responsibilities to ensure maintenance and accessibility of these alternatives.

After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin then those areas shall be washed with soap and water for several minutes. If exposure occurs to the mucous membranes the area should be flushed immediately with running water as soon as feasible following contact. Seek medical attention in the case of an exposure incident.

G. Needles and Other Sharps

Sharps are any items which can penetrate the skin including, but not limited to, needles, scalpels, Pasteur pipets, pointed or edged plastic, instruments, and broken glass.

Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one-handed technique.

Containers for Reusable Sharps

Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. The sharps containers should be puncture resistant, labeled with a biohazard label, and leak proof.

Sharps containers are placed in all laboratories deemed appropriate by the supervisor. A supervisor's designee in each laboratory is responsible for checking the integrity of these containers and for disposing of them as needed in the biohazardous waste stream.

H. Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, on counter tops or bench tops, or in the same work area where blood or other potentially infectious materials are present.

All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed to accomplish this goal are determined by each supervisor. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.

I. Specimen Handling and Transport

Specimens of blood or other potentially infectious materials will be placed in a secondary container which prevents leakage during the collection, handling, processing, storage, and transport of the specimen. The container used for this purpose will be labeled with a biohazard label.

J. Contaminated Equipment

Equipment which has become contaminated with blood or other potentially infectious materials shall be decontaminated as soon as possible following contamination. In addition this equipment shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible. If decontamination is not feasible then the equipment must be labeled as contaminated using, as a minimum, the universal symbol for biohazardous material. Decontamination may be done with a disinfectant such as sodium hypochlorite solution (1 part household bleach mixed with 9 parts water, made fresh weekly).

K. Housekeeping

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded, and closed prior to removal to prevent spillage or protrusion of contents during handling.

The procedure for handling sharps disposal containers is to close and dispose of them when they are full. Do not empty the container and do not force or compact the contents in any way as this may cause the container to be punctured. UVM sharps containers are disposed of by incineration. They may be included in a "burn box" or fill out a hazardous waste tag to arrange pick-up of the sharps container by Environmental Safety staff.

Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leakproof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are available at your work area or department and may be ordered through the UVM ChemSource program or through commercial distributors.

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.

See Appendix G: Biowaste Disposal

L. Laundry

Supervisors have the responsibility to arrange for laundering of towels from athletic facilities and laboratory PPE (labcoats).

The following laundering requirements must be met:

M. Labels

The following labeling method is used at UVM:

Biohazardous material needs to be labeled with an appropriately sized (for visibility) biohazard warning symbol (and the word "biohazard" if space allows) in the red or orange red color scheme. In the workplace if such material is in common use, each container need not be labeled; however, if the material leaves the workplace it must have appropriate labeling. Biowaste will be contained in red biohazard bags or clear bags marked with the red biohazard symbol.

Supervisors will ensure warning labels are affixed or red bags are used as required if regulated waste, contaminated equipment or samples are removed from or brought into the facility. Employees are to notify the supervisor if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels.

See Appendix G: Biowaste Disposal

5. Employee Training

All employees who have occupational exposure to bloodborne pathogens receive initial training and annual refresher training conducted by the supervisor. General background training can be found at the Environmental Safety Facility web site at http://esf.uvm.edu/courses. Training specific to the laboratory must still be done by the lab supervisor

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:

6. Hepatitis B Vaccination

Supervisors 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 as "at risk" in the Determination of Employee Exposure section of this plan. Vaccination is encouraged unless: 1)the employee has previously received the series, 2) antibody testing reveals that the employee is immune, or 3) medical evaluation shows that vaccination is contraindicated.

If an employee chooses to decline vaccination, the employee must sign a declination form. (Appendix H of this ECP) Employees who decline may request and obtain the vaccination at a later date at no cost or penalty. Documentation of refusal of the vaccination is kept in the workplace by the supervisor.

Following hepatitis B vaccinations, the health care professional's Written Opinion will be limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was administered.

7. Post-Exposure Evaluation and Follow-Up

FOR EMERGENCIES see Appendix A "Procedures for Accidents and Exposures to Chemicals, Blood or Biohazardous Material". A confidential medical evaluation and follow-up will be conducted by Concentra Health Care, 7 Fayette Road, South Burlington, VT (802) 658-5756.

Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:

8. Administration Of Post-Exposure Evaluation and Follow-Up

The Risk Management 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 the OSHA Bloodborne Pathogens Standard.

The supervisor ensures that the health care professional evaluating an employee after an exposure incident receives the following:

The Risk Management Department provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.

9. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

The Risk Management Department will review the circumstances of all exposure incidents to determine:

10. Recordkeeping

A. Training Records

Training records are completed for each employee upon completion of training. These documents will be kept for an employee by the supervisor or department.

The training records include:

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 the supervisor or department.

B. Records Maintained for "At Risk" Employees

When an employee is designated as "at risk" it is imperative that the appropriate paperwork be kept on file in the workplace:

1. Infectious Materials Risk Designation Form

2. Hepatitis B Vaccination Consent/Dissent Form

3. Training Documentation for both supervisor's training and ESF training

4. Medical records indicating receipt of all three shots for those who consented to have the series.

5. Medical records indicating receipt of the titer if the person consented to have the vaccination series during or after 1999.

C. Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records." (http://www.osha-slc.gov/OshStd_data/1910_1020.html)

D. OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements, 29 CFR 1904, (http://www.osha.gov/FedReg_osha_data/FED19960202.html). This determination and the recording activities are done by the Risk Management Department (656-3242).

E. Sharps Injury Log

In addition to the 29CFR1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log, maintained by the Risk Management Department. All incidents must include at least:

This log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that is covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

If you have any questions about this Exposure Control Plan, the OSHA Bloodborne Pathogens Standard or their applicability to you or your workplace please contact one of the following:

From the UVM ESF web site

http://esf.uvm.edu

esf@uvm.edu

Version 6.0

Last Revised:

May 9, 2011