Bloodborne Pathogens Program
- Scope and Application
- Exposure Control Procedures
- Exposure Determination
- Methods of Compliance
- Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-Up
Scope and Application
This section applies to all employees at Keene State College that have the potential for exposure to blood or other potentially infectious substances.
The purpose of this section is to minimize or eliminate exposure to blood or other potentially infectious materials that may be encountered during response to medical emergencies at Keene State College.
Blood. Human blood, human blood components and products made from human blood.
Blood Pathogen. Pathogenic micro organisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV), the etiologic agent which causes acquired immunodeficiency syndrome (AIDS).
Contaminated. The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Decontamination. The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.
Exposure Incident. A specific eye, mouth, other mucous membrane, non-intact skin, or through the skin contact with blood or other potentially infectious materials that results from the performance of an employees duties.
Other Potentially Infectious Materials
- The following human body fluids: semen, vaginal secretions, and cerebrospinal, synovial, pleural, amniotic fluids, saliva, and any body fluid that is visible contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids
- any unfixed tissue or organ (other than intact skin) from a human (living or dead).
Personal Protective Equipment. The specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g. uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. Sterilize means the use of a physical or chemical process to destroy all microbial life including highly resistant bacterial endospore.
Universal Precautions. An approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Exposure Control Procedures
Universal Precautions shall be observed in order to prevent contact with blood or other potentially infectious materials. In circumstances which make it difficult or impossible to differentiate between body fluids, all body fluids shall be considered potentially infectious materials.
Engineering and Work Practice Controls.
Engineering controls reduce exposure by either removing or isolating the hazard or isolating an individual from a known hazard. Examples include, but are not limited to, puncture resistant disposal containers for sharps or resuscitation bags/shields. Engineering controls must be inspected and maintained or replaced on a scheduled basis.
Work practice controls alter the way in which a task is performed. For the purposes of this section, work practice controls include:
- Responders with non-intact skin should perform tasks which preclude contact with blood or other potentially infectious materials, such as paperwork
- Hands, face and other exposed skin are thoroughly washed with soap and water immediately or as soon as possible upon removal of gloves and other personal protection equipment, regardless if there was contact with blood or other potentially infectious materials.
- Immediately or as soon as possible after contact with blood or other potentially infectious materials, hands, face or and other skin should be washed with soap and water for a least 15 minuets. Deluge mucous membranes with water.
- In the event suitable washing facilities are not available, waterless soap or antiseptic towelettes should be used to cleanse hands, face, or any other skin that may have been exposed to blood or other potentially infectious materials, this should be followed by a thoroughly washing affected skin with soap and water once these facilities become available.
- Sharps used during the treatment of a patient should be placed in a suitable rigid, leak proof, shatterproof container immediately on completion of use.
Personal Protective Equipment (PPE)
Personal protective equipment (PPE) is considered appropriate if it does not allow blood or other potentially infectious materials to pass through or reach an employees work clothes, street clothes, under garments, skin, eyes, mouth, or mucous membranes under normal conditions or use. Appropriate PPE includes, but is not limited to, impervious gloves, gowns and lab coats, eye protection, face shields or masks, and respiratory protection. PPE is to be used when there is any possibility of exposure to blood or other potentially infectious materials.
Although the EHS Coordinator has the overall responsibility in the implementation of the Bloodborne Pathogen Exposure Control Plan, several other departments share the responsibility in developing department specific control plans.
Individual departments and groups within a department will be responsible for developing in writing a department specific control plan. All control plans must meet the guidelines of the Occupational Safety and Health Administration (OSHA). Departments and groups within a department which have been identified as having employees with a potential for occupational exposure to bloodborne pathogens include, but are not limited to:
- Campus Safety
- Health Services
- Athletic Trainers
- Athletic Coaches
- Recreational Sports
- Physical Plant (Plumbers)
- Child Development Center
- Custodial Department (UNICCO)
- Food Service (Sodhexo)
Individual departments who choose not to write their own department Bloodborne Pathogen Exposure Central Plan must follow the Keene State College Bloodborne Exposure Plan that follows:
Employees incur risk each time they are exposed to blood or other potentially infectious materials. Any exposure incident may result in infection and subsequent illness. Considering the possibility of becoming infected from a single exposure incident, exposure incidents must be prevented whenever possible. The goal of the bloodborne pathogen standard is to reduce the significant risk of infection by:
- Eliminating or minimizing occupational exposure to blood and other potentially infectious material
- Providing the hepatitis B vaccine
- Providing post exposure medical evaluation and follow-up
- Identifying the tasks and procedures where occupational exposure may occur and the positions whose duties include those tasks and procedures is a critical element of exposure control. By identifying those job classifications with occupational exposure, identification can be made of those employees who are entitled to the protection afforded by the standard.
Exposure Control Plan
The key provision of the bloodborne pathogen standard is the written Exposure Control Plan. The Exposure Control Plan identifies individuals who will receive training, protective equipment, vaccinations, and other provisions of the standard. The written Exposure Control Plan is designed to eliminate or minimize employee exposure and:
- Provide a means in which employees are able to find out what provisions are in place in his or her workplace
- Provide a document for regulatory officials to evaluate Keene State College’s compliance status can be used for the employee training effort Based on the requirements established by the standard, the Keene State College Bloodborne Pathogen Exposure Control Plan has been developed and designed to eliminate or minimize employee occupational exposure to bloodborne pathogens during the performance of their duties, and to achieve regulatory compliance with the OSHA Bloodborne Pathogen Standard.
The Keene State College plan contains the following elements:
- Exposure determination
- Schedule and methods of implementation for:
- Universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping
- Hepatitis B vaccination and post-exposure evaluation and follow-up
- Communication of hazards to employees
- Record-keeping and procedure for the evaluation of circumstances surrounding exposure
The plan will be reviewed and updated annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The review of the Keene State College plan is the responsibility of the EHS Coordinator and the Keene State College EHS Committee. Individual departments will develop specific exposure control plans to complement the Keene State College plan and reflect specific activities and procedures under their responsibility. Plans will be submitted to the EHS Coordinator for review.
The plan(s) will be provided upon request for examination and copying to all Keene State College employees, employee representatives and regulatory authorities. The EHS Coordinator is the custodian of the document(s).
Arrangements to examine or copy the document(s) can be made by contacting the EHS Coordinator at x8 2879.
An initial review of employee positions at the college was conducted to determine which employees have occupational exposure to blood or other potentially infectious materials during the performance of their duties. The exposure determination review was conducted without regard to the use of personal protective equipment.
The following job classifications, task and procedures have been identified as having employees with occupational exposure include, but are not necessarily limited to:
All employees in the following job classification have occupational exposure:
- Campus Safety Police
- Health Services
- Athletic Trainers
- Child Development Center
Again, this listing is not limited to just these areas. Some employees in the following job classifications have occupational exposure: (A correct listing of affected employees shall be provided by employing departments to the Safety Compliance Officer.)
- Custodians (UNICCO)
- Laundry Workers
- Recreational Sports
- Athletic coaches
Tasks and procedures (on groups of closely related job tasks or procedures) for employees listed during which occupational exposures occur are:
- Respond to accidents, injury, crime or suicide scenes for clean-up of blood, body fluids, etc.
- Handling of clean-up materials contaminated with blood or body fluids. Improperly disposed needles, etc.
Methods of Compliance
Universal precautions will be observed by all Keene State College employees to prevent contact with blood and other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids will be considered potentially infectious. Employees should treat “commercially available” materials derived from human blood, bodily fluids or tissue as potentially infectious, unless it has been tested and proven negative for HIV or HBV.
Universal precautions are methods of preventing disease by preventing transfer of blood and potentially contaminated body fluids, e.g. semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, and saliva in dental procedures. The underlying concept of universal precautions is that all blood and certain body fluids are considered to be infectious for bloodborne pathogens. In most situations, an employee will treat all blood and certain body fluids as though they contained bloodborne pathogens and would accomplish this through a variety of measures including, but not necessarily limited to:
- Engineering controls
- Work practice controls
- Personal protective equipment
The only exception to the use of universal precautions is in rare instances, such as unexpected medical emergencies, where employees may not be able to put on gloves, don a gown, or tie on a face mask immediately. In those situations where leeway must be accorded the provider of health care or public safety services, the employees must not ignore the underlying concept of universal precautions nor should he or she decline to use any personal protective equipment if they feel such equipment will prevent the proper delivery of health care or public safety services or will create a greater hazard to their personal safety if they used such equipment.
The universal precaution exemption provided in the standard applies not to the general concept of universal precautions, but only to the use of the personal protective equipment under rare and relatively limited circumstances.
Engineering and Work Practice Controls
Engineering and work practice controls serve to reduce employees exposure in the workplace by either removing the hazard or isolating the worker from exposure. In fact, these control measures are viewed as the primary means of eliminating or minimizing employee exposure. These controls may include process or equipment redesign, e.g., self-sheathing needles, process or equipment enclosure, e.g., biosafety cabinets, and employee isolation. In general, engineering controls act on the source of the hazard and eliminate or reduce employee exposure without reliance on the employee to take selfprotective action. Once implemented, engineering controls protect the employee permanently, subject only, in some cases, to periodic replacement or preventative maintenance.
By comparison, work practice controls reduce the likelihood of exposure through alteration of the manner in which as task is performed. While work practice controls also act on the source of the hazard, the protection they provide is based upon the behavior of the employer and employee behavior rather than installation of a physical device such as a protective shield. The two control methodologies frequently work in tandem because it is often necessary to employee work practice controls to assure effective operation of engineering controls.
Primary reliance on engineering controls and work practices for controlling exposure is consistent with good industrial hygiene practice and with the OSHA traditional adherence to a hierarchy of controls. The hierarchy specifies that engineering controls and work practices are to be used in preference to personal protective equipment.
Engineering and work practice controls will be used by facilities and employees to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment will also be used. Department Heads over persons occupationally exposed shall establish and maintain engineering controls. Engineering controls will be examined and maintained or replaced on a regular schedule to ensure their effectiveness. The following engineering and work practice controls shall be in place at all Keene State College facilities that present potential bloodborne pathogen exposure issues.
Hand washing facilities are readily accessible in the workplace to employees that are reasonably anticipated to contact blood or other potentially infectious materials during the performance of their duties. In the event that handwashing facilities are not feasible, provisions will be provided for the placement of either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, employee have been instructed to wash their hands with soap and running water as soon as possible.
Employees are required to wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. And, most importantly, employees are required to wash their hands and any other skin 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 other potentially infectious materials.
Contaminated needles and other contaminated sharps will not be recapped or removed unless it can be demonstrated by the department that no alternative is feasible or that such action is required by a specific medical procedure. Under these circumstances, recapping or needle removal shall be accomplished through the use of a mechanical device or a one-handed technique.
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in an appropriate container until properly reprocessed. These containers shall be:
- Puncture resistant
- Appropriately labeled or color-coded
- Leak proof on the sides and bottoms
- Shall not be handled in a manner that requires employees to reach by hand into containers where these sharps have been placed.
Reprocessing generally refers to autoclaving techniques. Eating, smoking, drinking, applying cosmetics or lip balm, and handling contact lenses is prohibited in work areas where there is reasonable likelihood of occupational exposure. Food and drink will not be stored in refrigerators, freezers, shelves, cabinets, or on cabinet tops or bench tops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in a manner to minimize splashing, spraying, spattering, and generation of droplets of these substances.
Mouth pipetting/sectioning of blood or other potentially infectious materials is prohibited.
Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. The container for storage, transport, or shipping shall be labeled or appropriately color-coded and closed prior to being stored, transported or shipped. When universal precautions are utilized in the handling or specimens, the labeling/color-coding of specimens is not necessary, provided containers are recognizable as containing specimens. This exception only applies while such container is being handled by the person generating material. It must be appropriately labeled/color-coded prior to being given to any other individual.
If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping and is labeled or color-coded. If the specimen could puncture the primary container, the primary container shall be placed within a secondary container which is punctureresistant in addition to the above characteristics.
Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless it can be demonstrated that decontamination of such equipment or portions of such equipment is not feasible. An appropriate readily observable label will be attached to the equipment stating which portions remain contaminated. The department is responsible to ensure that this information is conveyed to all affected employees, the servicing representative, and/or the manufacturer as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken.
Personal Protective Equipment (PPE)
When there is occupational exposure, the department will provide at no cost to the employee, appropriate protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, or 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.
The department shall ensure that the employee uses appropriate personal protective equipment unless the department can demonstrate that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.
The department shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
The department will clean, launder, and dispose of personal protective equipment at no cost to the employee. The department will repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.
If a garment(s) is penetrated by blood or other potentially infectious materials, the garment will be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area. When personal protective equipment is removed it will be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.
Disposable, single use, gloves such as surgical or examination gloves, will 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 will not be washed or decontaminated for reuse. Utility gloves may be decontaminated for reuse 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.
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.
Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated. Surgical caps or hoods and/or shoe covers or boots will be worn in instances when gross contamination can reasonably be anticipated, i.e., autopsies, orthopedic surgery.
Departments shall ensure that the worksite is maintained in a clean and sanitary condition. The department will determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.
All equipment and environmental surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.
Protective coverings, i.e., plastic wrap, aluminum foil, or imperviously-backed absorbent paper, used to cover equipment and environmental surfaces, will 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 other potentially infectious materials will be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
Broken glassware which may be contaminated will not be picked up directly with the hands. The spill and/or debris will be cleaned up using mechanical means such as a brush and dust pan, tongs, or forceps and disposed of in a precautionary manor as in the case of sharps.
Reusable sharps that are contaminated with blood or other potentially infectious materials will not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
Contaminated sharps will be discarded immediately or as soon as feasible in containers that are:
- Puncture resistant
- Leak proof on sides and bottom
- Appropriately labeled or color-coded.
During use, containers for contaminated sharps shall be easily accessible to personnel and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found, i.e., laundries maintained upright throughout use replaced routinely and not be allowed to overfill.
When moving containers of contaminated sharps from the area of use, the containers will be closed immediately prior to removal or replacement to prevent spillage or protrusion of content during handling, storage, transport, or shipping placed in a secondary container if leakage is possible. The second container will be:
- Constructed to contain all content and prevent leakage during handling, storage, transport, or shipping
- Appropriately labeled or color-coded.
Reusable containers will not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury. Regulated waste will be placed in containers which are:
- Constructed to contain all content and prevent leakage during handling, storage, transport, or shipping
- Appropriately labeled or color-coded.
- Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
Disposal of all regulated waste will be in accordance with applicable regulations of the Occupational Safety and Health Administration. Contaminated laundry will be handled as little as possible with a minimum of agitation. Contaminated laundry will be bagged or containerized at the location where it was used and will not be sorted or rinsed in the location of use. Contaminated laundry will be placed and transported in bags or containers appropriately labeled or color-coded. When a department utilized universal precautions in the handling of all soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions.
Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through or leakage from the bag or container, the laundry will be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.
The department will provide employees who have contact with contaminated laundry with protective gloves and other appropriate personal protective equipment.
When a department ships contaminated laundry off-site to a second facility which does not utilize universal precautions in the handling of all laundry, the department generating the contaminated laundry will transport such laundry in bags or containers which are appropriately labeled or color-coded.
Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-Up
The department will make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and postexposure evaluation and follow-up to all employees who have had an exposure incident. The department will ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis are made available at no cost to the employee made available to the employee at a reasonable time and place performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional provided according to recommendations of the U. S. Pubic Health Service current at the time these evaluations and procedures take place.
All diagnostic laboratory tests will be conducted by an accredited laboratory at no cost to the employee. Cheshire Medical Center/ Keene Clinic Occupational Health Department will manage post-exposure evaluation and follow-up protocol due to occupational exposure to bloodborne pathogens. Cheshire Medical Center/ Keene Clinic Occupational Health Department will administer prophylactic hepatitis B vaccinations for all college employees.
Hepatitis B Vaccination
A hepatitis B vaccination will be made available after the employee has received the required training and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.
The department will not make participation in a prescreening program a prerequisite for receiving hepatitis B vaccination. If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the department will make available hepatitis B vaccination at that time.
The department will require employees who decline to accept hepatitis B vaccination offered by the department to sign a Declination statement. The original signed statement will be maintained in the employee’s permanent personnel file and copies will be provided to the employee, the employee’s department and Life Safety Services.
If a routine booster dose(s) of hepatitis B vaccine is recommended by the U. S. Public Health Services at a future date, such booster dose(s) will be available.
Post-Exposure Evaluation and Follow-Up
Following a report of an exposure incident the department will make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:
- Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred.
- Identification and documentation of the source individual, unless the primary care provider can establish that identification is not feasible or prohibited by state or local law:
- The source individual’s blood will be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, Cheshire Medical will establish that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, will be tested and the results documented.
- 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.
- Collection and testing of blood for HBV and HIV serological status.
- The exposed employee’s blood will be collected as soon as feasible and tested after consent is obtained
- If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample will be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing will be done as soon as feasible. post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service.
Information Provided to the Healthcare Professional
The primary care provider, designated by the college for worker’s compensation, shall provide past-exposure evaluation and counseling follow-up for college employees. The department will provide the healthcare professional evaluating an employee after an occupational exposure incident the following information:
- 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.
The current primary worker’s compensation care provider for the college is
Dartmouth Hitchcock Keene
Department of Occupational Health
590 Court Street
Keene, NH 03431
Healthcare Professionals Written Opinion
The college 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 healthcare professional’s written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination. The healthcare professional’s written opinion for post-exposure evaluation and follow-up shall be limited to the following information:
- That the employee has been informed of the results of the evaluation
- That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written report.
Human Resources, in cooperation with the designated Workers’ Compensation medical provider, will establish and maintain an accurate record for each employee with occupational exposure, in accordance with 29 CFR 1910.20. The record shall include:
- The name and social security number of the employee
- A copy of the employee’s hepatitis B vaccination status including the dates of all the Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination
- A copy of all results of examinations, medical testing, and follow-up procedures required
- The copy of the healthcare professional’s written opinion as required
- A copy of information provided to the healthcare professional as required.
Human Resources will ensure that employee medical records required are kept confidential and are not disclosed or reported without the employee’s express written consent to any person within or outside the workplace except as required by the standard or as may be required by law. Human Resources will maintain the records required for at least the duration of employment plus thirty years in accordance with 29 CFR 1910.20.
Communication of Hazards To Employees
Efforts directed at communicating hazards of bloodborne pathogens to college employees through the use of labels, signs, and information and training are intended to provide employees with adequate warning to eliminate or minimize their exposure. Labels and signs may be obtained through Life Safety Services.
Information and Training
All college employees with occupational exposure to blood or other potentially infectious materials will participate in a bloodborne pathogen information and training program which is provided at no cost to the employee and conducted during their normal working hours.
Training must be coordinated through the college Safety Compliance Officer. Copies of records of required training and retraining shall be provided to Life Safety Services.
Training will be provided at the time of initial assignment to tasks where occupational exposure may take place or within 90 days after the effective date of the standard, i.e., June 4, 1992; and at least annually thereafter. Employees who have received training on bloodborne pathogens in the year preceding the effective date of the standard, i.e., March 6, 1992, only need further training with respect to the provisions of the standard which were not included in previous training.
Annual training will be provided for ally employees with occupational exposure within one year of their previous training. Employees will receive additional training when changes or modifications of tasks or procedures occur or when new tasks or procedures affect the employee’s occupational exposure. The additional training will be limited in scope by only addressing the new exposure created.
Material will be used that is appropriate in content and vocabulary to educational level, literacy, and language of employees undergoing the training program.
The training program will contain the following elements:
- An accessible copy of the regulatory text of the bloodborne pathogen standard and an explanation of its contents
- A general explanation of the epidemiology and symptoms of bloodborne diseases
- An explanation of the modes of transmission of bloodborne pathogens
- An explanation of Keene State College’s Exposure Control Plan and the means by which the employee can obtain a copy of the written plan
- An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials
- An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment
- Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment (PPE)
- An explanation of the basis for selection of personal protective equipment
- Information on the hepatitis B vaccine, including information on its efficiency, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge to the employee
- Information on appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
- 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 of the post-exposure evaluation and follow-up that the department 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
- An opportunity for interactive questions and answers with the person conducting the training session
- Training will be conducted by individuals knowledgeable in the subject matter covered in the training program as it relates to the specific workplace being addressed.
Training records will include the following information:
- The dates of the training sessions
- The contents or a summary of the training sessions
- The names and qualifications of persons conducting the training
- The names, social security number, and job titles of all persons attending the training sessions
All training records relative to the bloodborne pathogen standard will be maintained for a minimum of three years from the date on which the training occurred. The Safety Compliance Officer will act as custodian of all bloodborne pathogen standard training records. All training records required by this standard will be provided upon request for examination and copying to all employees, employee representatives, the Director of the National Institute for Occupational Safety and Health (NIOSH), and the Assistant Secretary of the U.S. Department of Labor in accordance with 29 CFR 1910.20.
Keene State College must comply with the requirements involving transfer of records set forth in 29 CFR 1910.20(h). Should Keene State College cease to do business and there is no successor employer to receive or retain the records for the prescribed period, the College will notify the NIOSH Director at least three months prior to their disposal and transmit them to the NIOSH Director, if required by the Director to do so, within the three month period.
Warning labels will 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. Labels and signs may be obtained through Life Safety Services. These labels conform to the requirements of 29 CFR 1910.1030 (g) (1) (i) (B) and (C). Provision of labels does not include bags nor containers.
There are several exemptions to the labeling requirement:
- Containers of blood, blood components, or blood product that are labeled as to their contents and have been released for transfusion or other clinical use do not need to be labeled in accordance with the provisions outlined in this section
- Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment, or disposal do not need to be labeled in accordance with the provisions outlined in this section
- Regulated waste that has been decontaminated does not need to be labeled
- Red bags can be substituted for labels on bags or containers of regulated waste.
- Labels will be affixed as close as feasible to the container by string, wire adhesive, or other method.
- Contaminated equipment scheduled for maintenance or repair will be labeled in accordance with the provisions in this section and the label will also state which portions of the equipment remain contaminated.