Exposure Control Plan for Bloodborne Pathogens

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Scope and Purpose

California State University, Dominguez Hills (CSUDH) is dedicated to protecting the health, safety and wellbeing of students, employees, visitors, and the surrounding community. The Exposure Control Plan for Bloodborne Pathogens is established to protect employees from infectious disease resulting from exposure to blood or other potentially infectious materials (OPIM).  Environmental Health & Safety (EHS) administers and oversees implementation of the program.

The program complies with Cal/OSHA’s requirement for CSUDH to develop and implement a written exposure control plan to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with the following regulation:


California Code of Regulations (CCR) Title 8 Section 5193

Definitions

Blood – human blood, human blood components, and products made from human blood.

Bloodborne Pathogens – pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

Contaminated – the presence or the reasonably anticipated presence of blood or other potentially infectious materials on a surface or in or on an item.

Decontaminated – 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. Decontamination includes procedures regulated by California Health and Safety Code Section 118275.

Engineering Controls – controls (e.g., sharps disposal containers, needleless systems and sharps with engineered sharps injury protection) that isolate or remove the bloodborne pathogens hazard from the workplace.

Exposure Incident – 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.

Occupational Exposure – reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Other Potentially Infections Material (OPIM) – the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and other body fluid that is visibly contaminated with blood such as saliva or vomitus, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids such as emergency response;

Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and

Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV: cell, tissue, or organ cultures from humans or experimental animals; blood, organs, or other tissues from experimental animals; or culture medium or other solutions.


Parenteral Contact – piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.


Regulated waste – waste that is any of the following:

  • Liquid or semi-liquid blood or OPIM;
  • Contaminated items that:
    • Contain liquid or semi-liquid blood, or are caked with dried blood or OPIM; and
    • Are capable of releasing these materials when handled or compressed.
  • Contaminated sharps.
  • Pathological and microbiological wastes containing blood or OPIM.
  • Regulated Waste includes “medical waste” regulated by California Health and Safety Code Sections 117600 through 118360.


Sharp – any object used or encountered in the industries covered by subsection (a) that can be reasonably anticipated to penetrate the skin or any other part of the body, and to result in an exposure incident, including, but not limited to, needle devices, scalpels, lancets, broken glass, broken capillary tubes, exposed ends of dental wires and dental knives, drills and burs.

Source Individual – any individual, living or dead, whose blood or OPIM may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinical patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

Universal Precautions – an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other bloodborne pathogens.

Exposure Determination


CSUDH shall determine and list employee job classifications and tasks that have occupational exposure to blood or OPIM. Exposure determination must be made without regard to the use of personal protective equipment (PPE).

Job Classifications

The following job classifications have some, or all, employees in which occupational exposure could occur:

  • Athletics Trainers
  • Custodians
  • Laboratory Instruction Support Technicians (Biology, Chemistry, Health Sciences
  • Police Officers
  • Clinical Aids
  • Laboratory Assistants (Student Health Center)
  • Licensed Vocational Nurses
  • Nurse Practitioners
  • Pharmacists
  • Physicians
  • Registered Nurses
  • Designated EHS staff

Tasks and Procedures

The following tasks and procedures in which occupational exposure could occur:

  • Administering care to students, patients, and athletes
  • Using sharps such as needles and razor blades
  • Encountering sharps that have been improperly disposed in the trash or other places on campus
  • Emergency response or apprehending of individuals by law enforcement
    Handling of medical waste including sharps waste, biological waste, and pathological waste
  • Clean-up of blood or OPIM
  • Removal of dead animals from campus property
Proper Work Practices

Universal precautions (see definition) shall be observed at the University to prevent contact with blood or OPIM. All blood and OPIM shall be considered infectious regardless of the perceived status of the source individual.

The following work practice controls shall be used to minimize employee exposure:

  • Employees shall wash their hands immediately, or as soon as feasible, after removal of gloves or other PPE.
  • Employees shall wash their hands and other skin surfaces with soap and water, or flush mucous membranes with water immediately, or as soon as feasible, following contact of such body areas with blood or OPIM.
  • Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed. Shearing or breaking of contaminated needles is prohibited.
  • Immediately, or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly processed. These containers shall be:
    • Puncture resistant;
    • Leak-proof on the sides and bottom; and
    • Appropriately labeled.
  • Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
  • Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops in the same room where blood or OPIM are present.
  • All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
  • Mouth pipetting/suctioning of blood or OPIM is prohibited.
  • Specimens of blood or OPIM shall be placed in a container, which prevents leakage during collection, handling, processing, storage, transport, or shipping.
  • If outside contamination of the primary container occurs, the primary container shall be placed within a second container, which prevents leakage during collection, handling, processing, storage, transport, or shipping.
  • If the specimen could puncture the primary container, the primary container shall be placed within a secondary container, which is puncture-resistant in addition to the above characteristics.
  • Equipment which may become contaminated with blood or OPIM shall be decontaminated as necessary, unless decontamination of such equipment or portions of such equipment is not feasible. If decontamination is not feasible:
    • A readily observable label shall be attached to the equipment stating which portions remain contaminated.
    • The appropriate administrator shall inform all affected employees, the servicing representative, and/or the manufacturer, in writing, prior to handling, servicing, or shipping so that appropriate precautions will be taken.
  • Sharps containers shall not be opened, emptied, or cleaned manually or in any other manner that could expose employees to the risk of sharps injury.
Personal Protective Equipment (PPE)

Employees shall be provided, at no cost, PPE necessary to prohibit blood or OPIM from passing through or reaching the employees' work clothes, street clothes, undergarments, 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.

Employees shall use appropriate PPE unless the employee temporarily and briefly declines to use PPE, under rare and extraordinary circumstances, when the employee believes that in a specific instance its use will prevent the delivery of health care or public safety services or would have posed an increased hazard to the safety of the employee or other employees.

Cleaning, laundering, disposal, repair, and replacement of PPE shall be the responsibility of the University.

All PPE shall be removed prior to leaving the work area. If a piece of garment is penetrated by blood or other potentially infectious materials, the garment shall be removed immediately, or as soon as feasible.

When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.

Hand Protection

Gloves shall be worn when it can be reasonable anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, non- intact skin, and when handling or touching contaminated items or surfaces.

Disposable (single use) gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Disposable (single use) gloves shall not be washed or decontaminated for re-use.

Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Latex gloves used in a wet procedure shall be replaced after one hour of use. Nitrile or other (vinyl, neoprene, etc.) gloves will be made available to employees as a substitute to latex gloves.

Eye and Face Protection

Masks, Eye Protection, and Face Shields

Masks in combination with eye protection devices such as goggles or glasses with solid side shields or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

Body Protection

Appropriate protective clothing (gowns, aprons, and other protective body clothing) shall be worn in occupational exposure situations.

Laundry

Contaminated laundry shall be handled as little as possible with a minimum of agitation. Contaminated laundry shall be bagged and shall not be sorted or rinsed by university personnel.

Contaminated laundry shall be placed in red bags that prevent soak through and/or leakage of fluids to the exterior. If contaminated laundry is sent to a facility, which does not utilize Universal Precautions in the handling of all laundry, the university shall ensure that the red bags are labeled with the universal biohazard symbol and the legend BIOHAZARD.

Employees having contact with contaminated laundry shall wear protective gloves and other appropriate PPE.

Housekeeping

All equipment and exposed work surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

  • Contaminated work surfaces shall be cleaned and decontaminated with an appropriate disinfectant immediately upon completion of procedures; immediately, or as soon as feasible, when surfaces are overtly contaminated or after any spill of blood or OPIM; and at the end of the work shift if the surface may have become contaminated since the last cleaning.
  • Protective coverings, such as plastic wrap, aluminum foil, or imperviously backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.
  • All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or OPIM shall be inspected and disinfected on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination
  • Broken glassware, which may be contaminated, shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps.
  • Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
Medical Waste

See the CSUDH Medical Waste Management Plan for additional information.

Sharps Waste

Sharps Waste is any needle/device having acute ridged corners, edges, or perturbances capable of cutting or piercing.

  • Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:
    •  Rigid;
    • Closable and sealable;
    • Puncture resistant;
    • Leak-proof on sides and bottom; and
    • Labeled with the words "Sharps Waste" below the international biohazard symbol and the word "BIOHAZARD".
  • REUSABLE CONTAINERS SHALL NOT BE USED
  • During use, containers for contaminated sharps shall be:
    • Easily accessible to employees and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found;
    • Maintained upright throughout use; and
    • Replaced as necessary to avoid overfilling.
  • When moving containers of contaminated sharps from the area of use, the containers shall be:
    • Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;
    • Placed in a secondary container if leakage is possible. The secondary container shall be:
      • Closable;
      • Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping;
      • Labeled with the words "Sharps Waste" below the international biohazard symbol and the word "BIOHAZARD".
    • Placed in containers located in the designated medical waste accumulation area.

Other Regulated Waste

  • Medical waste shall be placed in containers which are:
    • Closable;
    • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;
    • Labeled (see “Labels and Signage” section);
    • Closed prior to removal from the area of use to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;
    • Placed in containers located in the designated medical waste accumulation area.
  • If outside contamination of the medical waste container occurs, it shall be placed in a second container. The second container shall be:
    • Closable;
    • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;
    • Labeled (see “Labels and Signage” section);
    • Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

Handling, Storage, Treatment and Disposal

CSUDH does not treat any medical waste on-site.  Medical waste generated by CSUDH is removed by a licensed medical waste hauler for off-site disposal.

Medical waste shall not be stored above 0 degrees Centigrade (32 degrees Fahrenheit) for more than seven calendar days.

  • Containers used for the containment and/or transport of medical waste must be leak resistant, have tight fitting covers, and kept clean and in good repair. The appropriate container shall be labeled with the words “Biohazard Waste", or with the international biohazard symbol and the word "BIOHAZARD" on the lid and sides so as to be visible from any lateral direction. Containers labeled with the words "Infectious Waste" or with the international biohazard symbol and the word "Biohazard" on the lid and sides may also be used until the replacement of containers is necessary or existing stock has been depleted.

Medical waste is stored in the following locations on campus:

  • Student Health Center
  • James L. Welch Hall, WH B-365
  • Social & Behavioral Sciences, 1st Floor
  • Natural Sciences & Mathematics, 1st and 3rd Floors
  • Athletics Building, Sports Medicine Clinic, B-106



     
Hepatitis B Vaccination

Hepatitis B vaccinations shall be offered free of charge to employees who have occupational exposure to bloodborne pathogens. Vaccinations shall be administered in amounts and at times prescribed by standard medical practice. Each identified employee shall receive information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, and the benefits of being vaccinated and be offered the Hepatitis B vaccination within 10 working days of appointment or assignment.

An employee declining a Hepatitis B Vaccination must sign a Hepatitis B declination form, provided in Appendix A.  Signed declination forms shall be provided to and maintained by Human Resources Management.

An employee who initially declines hepatitis B vaccination but, at a later date, decides to accept the vaccination, shall receive that hepatitis B vaccination at that time.

If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available to identified employees.

If the employee is unsure if the Hepatitis B vaccine is still active, an antibody test can be performed at the Student Health Center.

Hepatitis B Vaccination: Post-Exposure Evaluation and Follow-up

An employee who experiences an exposure incident (see definition) must report it immediately to their supervisor and EHS. The completion of an "Employees Claim for Workers' Compensation Benefits" must be filed with the University’s Human Resources department. The claim must document the route(s) of exposure, and the circumstances under which the exposure incident occurred. If known, the identification of the source individual shall be made.

The source individual's blood shall be tested as soon as feasible and after consent is obtained to determine HBV and HIV infectivity. If the source individual is known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.

Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Upon receipt of the source testing or if consent for blood testing has not been given, the employee should be given the opportunity to:

  • Receive the Hepatitis B vaccine
  • Receive the Hepatitis B Immune Globulin
  • Consent to a baseline blood collection and Hepatitis B Vaccine serological testing
  • Consent to a baseline blood collection and HIV serological testing
  • Consent to baseline blood collection, but not consent to blood testing at that time. In these cases, the blood sample will be preserved for 90 days. If within the 90 days of the exposure incident, the employee elects to have the baseline sample tested for HBV or HIV, such testing shall be done as soon a feasible.
Collection and Testing of Blood for HBV and HIV Serological Status

Performed by the University’s designated Industrial Medical Clinic.

  • A copy of the Cal/OSHA standard 8 CCR §5193 - Bloodborne Pathogens - shall be provided to the healthcare professional responsible for the employee's hepatitis B vaccination.
  • The healthcare professional evaluating an employee after an exposure incident shall be provided with the following:
    • A description of the exposed employee's duties as they relate to the exposure incident;
    • Documentation of the route(s) of exposure and circumstances under which exposure occurred;
    • Results of the source individual's blood testing, if available;
    • All medical records relevant to the appropriate treatment of the employee including vaccination status.
  • EHS shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.

  • The healthcare professional's written opinion for HBV vaccination and post-exposure follow up shall be limited to the following information:

    • Whether vaccination is indicated for employee and if employee has received such vaccination.
    • A statement that the employee has been informed of the results of the evaluation; and
    • A statement that the employee has been told about any medical conditions resulting from exposure to blood or other potential infectious materials which require further evaluation or treatment.
Labels and Signage

Labeling Requirements


Labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport or ship blood or other potentially infectious materials.

The label shall include the universal biohazard symbol and the legend BIOHAZARD.

  • For regulated waste, the words BIOHAZARD WASTE shall be presented below, or may be substituted for, the BIOHAZARD legend.
  • For sharps waste the words SHARPS WASTE shall be presented below, or may be substituted for, the BIOHAZARD legend.

The label shall be fluorescent orange or orange-red or predominately so with lettering in contrasting color. Red bags or red containers may be substituted for labels except for sharp containers or regulated waste biohazard bags. Biohazard bags used to contain regulated waste shall be color-coded red and shall be labeled in accordance with this section. Lettering and hazard symbol on labels should be black in color.

Labels required for contaminated equipment shall be in accordance with this section and state which portions of the equipment remain contaminated.

Blood products that have been released for transfusion or other clinical use are exempted from these labeling requirements.

Labels for Infectious Waste:

Signage Requirements

Medical waste storage areas, including areas used for temporary storage, shall have the following signage:

English:

“Caution – Biohazardous Waste Storage Area Unauthorized Persons Keep Out”

B n W BioHaz Sign Orange BioHaz Waste

Spanish:

“Cuidado – Zona de Residuos Biologicos Peligrosos Prohiba La Entrada a Personas No Autorizadas”

B n W BioHaz Sign

 

Training

Appropriate administrators shall ensure that training is provided to employees at the time of initial assignment to tasks where occupational exposure may occur and ensure that training be repeated within twelve months of the previous training.

Training will be interactive and cover the following elements:

  • An accessible copy of the Cal/OSHA standard 8 CCR §5139 – Bloodborne Pathogens – and an explanation of its contents;
  • A discussion of the epidemiology and symptoms of bloodborne diseases;
  • An explanation of the modes of transmission of bloodborne pathogens;
  • An explanation of the CSUDH Exposure Control Plan for Bloodborne Pathogens, and a method for obtaining a copy;
  • The recognition of tasks that may involve exposure;
  • An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices and PPE:
  • Information on the types, use, location, removal, handling, decontamination, and disposal of PPE;
  • An explanation of the basis of selection of PPE;
  • Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge;
  • Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;
  • An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up;
  • Information on the evaluation and follow-up required after an employee exposure incident;
  • An explanation of the signs, labels, and color-coding systems.

Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employee's occupational exposure.

Recordkeeping

Medical Records

Medical records for patients treated at the Student Health Center (SHC) are maintained at the SHC and records for patients seen at university contracted Employee Health/Workers’ Compensation Clinics, are maintained by those facilities, in accordance with Title 8, California Code of Regulations, Section 3204. These records shall be kept confidential, and not disclosed without the employee's written consent and must be maintained for a least the duration of employment plus 30 years.

The records shall include the following:

  • The name of the employee;
  • A copy of the employee's HBV vaccination status, including the dates of the Hepatitis B vaccination and ability to receive vaccination;
  • A copy of all results of examination, medical testing, and follow-up procedures;
  • A copy of the information provided to the healthcare professional, including a description of the employee's duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure;
  • A confidential copy of the healthcare professional’s opinion.

Hepatitis B Vaccine Request/Declination Form

Completed Hepatitis B Vaccine Request/Declination forms shall be maintained by Human Resources Management for at least the duration of employment.

Training Records

Training records shall be maintained for three years from the date of training. EHS is responsible for maintaining the following training records:

  • The dates of the training sessions;
  • An outline describing the material presented;
  • The names and qualifications of persons conducting the training; and
  • The names and job titles of all persons attending the training sessions.

Upon written request, the employee's records shall be made available to the employee or to their designated representative for examination and copying.

All employee records shall be made available to the Chief of the Division of Occupational Safety and Health (DOSH) and the National Institute for Occupational Safety and Health (NIOSH).

Sharps Injury Log

Affected University departments shall establish and maintain a Sharps Injury Log, which is a record of each exposure incident involving a sharp.  A blank Sharps Injury Log is presented in Appendix B.  The following information shall be recorded by the injured employee on the log if known or reasonably available:

  • Date and time of the exposure incident;
  • Type and brand of sharp involved in the exposure incident;
  • A description of the exposure incident, which shall include:
    • Job classification of the exposed employee;
    • Department or work area where the exposure incident occurred;
    • The task/procedure that the exposed employee was performing at the time of the incident;
    • How the incident occurred;
    • The body part involved in the exposure incident;
    • If the sharp had engineered sharps injury protection, whether the protective mechanism was activated, and whether the injury occurred before the protective mechanism was activated, during activation of the mechanism or after activation of the mechanism, if applicable;
    • If the sharp had no engineered sharps injury protection, the injured employee's opinion as to whether and how such a mechanism could have prevented the injury; and
    • The employee's opinion about whether any engineering, administrative or work practice control could have prevented the injury.

Each injured employee shall complete a Sharps Injury Log form and provide it to EHS within 14 working days of the date the incident is reported to the employer. EHS shall maintain a record of the log for at least five years from the date the exposure incident occurred.  The information in the Sharps Injury Log shall be recorded and maintained in such a manner as to protect the confidentiality of the injured employee.

Review and Update

EHS shall review and update this Plan at least annually and whenever necessary as follows:

  • To reflect new or modified tasks and procedures which affect occupational exposure;
  • To reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens;
  • To document consideration and implementation of appropriate commercially available needleless systems and needle devices and sharps with engineered sharps injury protection;
  • To include new or revised employee positions with occupational exposure;
  • To determine the frequency of use of the types and brands of sharps involved in the exposure incidents documented on the Sharps Injury Log;
  • To review and evaluate the exposure incidents which occurred since the previous update; and
  • To review and respond to information indicating that the Plan is deficient in any area.

The current version of this Plan shall be made available on the CSUDH website.  Affected employees will be notified of updates to the Plan by EHS via email.

Appendix

Appendix A - Hepatitis B Vaccine Request/Declination [PDF]

Appendix B - Sharps Injury Log [PDF]

Appendix C - Student Health Center Cleaning Procedures [PDF]