Appendix M - BLOOD BORNE PATHOGENS CONTROL PROGRAM POLICIES AND PROCEDURES

1. 1. General Information

This procedure is mandated for all employers and employees by the U.S. Department of Labor in Occupational Safety and Health Act (OSHA) 1910.1030 and by the Commonwealth of Virginia through Virginia Occupational Safety and Health (VOSH). This policy covers certain faculty, administrators, and all other employees of EMU who may be at risk for exposure to bloodborne viruses including the viruses that cause hepatitis and acquired immunodeficiency syndrome (AIDS).
This control program is designed to prevent the spread of hepatitis and AIDS to persons who may come into contact with blood, body fluids and human tissue as a part of their work at EMU. "Exposure incident," as defined by OSHA, means 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.
OSHA defines "other potentially infectious materials" as human semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult to differentiate between body fluids. All body fluids are considered contaminated until proven otherwise after it is determined that the source was not infected with hepatitis or AIDS. These fluids may then be disposed of in a normal manner.
There is a mandatory requirement that organizations provide employees with training, protective clothing, puncture-proof containers for contaminated needles and other wastes, and a vaccination against hepatitis B. All approved costs, including the vaccinations, will be paid by EMU.
The Human Resources and Health Services Center in cooperation will provide assistance and oversee the Bloodborne Pathogens Control Program.

1. 1. Risk Categories/Personnel at Risk

1. OSHA and the Centers for Disease Control recommend that you know your level of risk.
Category IYour job involves contact with people or human specimen. Exposure to blood, body fluids, or human tissue is possible. If in this category, it is strongly recommended that you get the hepatitis B vaccine.
(Offer Hepatitis B vaccine – charge departmental expense)
Category IIYou may be exposed occasionally or in emergency situations to blood, body fluids, or human tissue. In this category it is encouraged that you get the hepatitis B vaccine.
(Encourage Hepatitis B vaccine – employee cost)
Category IIIYour job does not involve exposure to blood, body fluids or human tissue.
Training during orientation, optional annual training.
If you are in Category I or II, you must follow universal precautions by using personal protective equipment and clothing.
2. The following categories of personnel at EMU have been identified as at risk for exposure:
Category I
1.Health Services Center personnel
2.Athletic trainer, student trainers and coaches
3.Nursing faculty who supervise students in clinical agencies or the department Demonstration Laboratory, and work-study students assisting in the Lab
4.Biology faculty who supervise students in labs involving finger pricks or venipuncture
5.Custodians
6.Early Learning Center employees
7.Residence life staff, i.e. residence directors
Category II
1.Physical Education faculty who teach CPR
2.Faculty who supervise students in social service agencies, i.e., Education and Social Work Departments
3.Early Learning Center work study/student workers
Category III
Any other faculty, employee or student who is exposed to blood, body fluids or human tissue as a result of duties or educational activities at EMU will be covered by these policies.

1. 1. Universal Precautions

All persons in the primary risk categories (Categories I & II) shall wear the appropriate personal protective equipment when in situations where they may be exposed. The personal protective equipment should not permit blood, body fluids or human tissue to pass through to the person's skin, clothing, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the personal protective equipment is used.
1. Gloves
Latex gloves will be available to or carried by all primary risk categories personnel on duty. They must be put on immediately when exposure appears imminent. Gloves must be changed after contact with each patient or when torn. Wash hands immediately after removing gloves. Do not wash or disinfect gloves for reuse. Once used, the gloves must be destroyed; if there are traces of blood, treat as "contaminated" material.
2. Face Protection
Face mask or goggles will be worn when the face is very close to the wound or opening and when spraying or splatter of blood or body fluids is possible. A suitable protective mask over the nose and mouth area will suffice.
3. Body Protection
A water-resistant lab coat or plastic apron will be worn when it is anticipated there may be splashing of blood or body fluids. The protective device will be removed as soon as the procedure is completed.

1. 1. Work Practice Controls

The following work area restrictions will apply when blood, body fluids or human tissue is present or likely to be introduced.
1. No food or drink will be consumed or stored. Persons will not apply lip balm or cosmetics nor will contact lenses be handled. There will be no smoking.
2. Hand washing facilities will be available. When not available, antiseptic towelettes or dry hand wash will be provided.
3. Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or broken. Sharps will be handled with care to prevent accidental cuts or punctures. Discard immediately in a puncture resistant container.
4. Broken glassware which may be contaminated will not be picked up directly with the hands. It will be cleaned up with a broom and dust pan.
5. Specimens of blood or other potentially infectious materials will be placed in containers preventing leakage and labeled "biohazard" material.
6. Contaminated work areas will be decontaminated with appropriate disinfectant by only the personnel who have been trained and authorized to work with infectious materials.
7. Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited. Should mouth-to-mouth resuscitation be required the proper protective equipment will be used.
8. All bins, pails, cans or similar receptacles will be inspected regularly by the supervisor and decontaminated as soon as feasible.

1. 1. Information and Training

All employees in the primary risk categories (Categories I & II) will receive training in protecting themselves from exposure to blood, body fluids and other infectious materials. The training will be coordinated by the Health Services Coordinator. Employee records will be maintained by the Human Resources in coordination with the Health Services Center. The training will include:
1.Explanation of OSHA regulations.
2.Information about hepatitis and AIDS viruses.
3.Explanation about the transmission of bloodborne diseases.
4.Explanation of the exposure control plan.
5.Explanation of the universal precautions/personal protective equipment/how to minimize exposure risk.
6.Information on the hepatitis B vaccine.
7.Information on the appropriate persons to contact in case of emergency exposure incident along with the procedures to follow including method of reporting.
8.Explanation on the post-exposure evaluation and follow-up that the employer is to follow.
9.Explanation of signs and labels for disposal of contaminated materials.

1. 1. Vaccinations

All persons identified in Categories I under "Risk Categories/Personnel at Risk" will be offered the Hepatitis B vaccine within 10 working days after they have been assigned work. Medical records concerning the inoculations will be the responsibility of the Health Services Center and will be kept confidential. The person in the above category has four options and these files will be kept in the Human Resources Office. The options are:
1 - to take the vaccination;
2 - to show they have previously received the vaccination;
3 - to take an antibody testing to show they have sufficient immunity;
4 - to decline the vaccination and sign a waiver.
Persons who decline may decide at a later time to undergo the vaccination at no cost to themselves.

1. 1. Post-Exposure Evaluation and Follow-Up

All employees who experience an exposure incident will be offered a post-exposure evaluation and Hepatitis B Vaccine. Immediately contact the supervisor to determine if the exposure incident is related to bloodborne pathogen standard. The exposed employee or student will be referred to the Health Services Center for medical assessment, treatment and the appropriate follow-up. Related paperwork must be completed within 24 hours of the incident and sent to the Human Resources.
If possible, the source individual's blood will be tested as soon as feasible in order to determine HBV and HIV infectivity. EMU will pay for the tests and the test results will be kept confidential in the Health Services Center.
The exposed person will have the opportunity to have his/her blood tested for HIV serological status. The blood sample may be retained for 90 days for testing. This person will be given counseling by the Director of Health Services or contracting physician concerning the necessary precautions to practice during the period after the exposure incident. This will include potential illnesses and personal hygiene.

1. 1. Decontamination

Containers marked as "biohazard" or color coded in red will be used to store contaminated materials. After the materials/equipment are decontaminated they can be treated like any other soiled item.
Clothing and rubber items will be placed in a fluid-proof plastic bag for several days until the blood or body fluid is completely dry. (HBV can survive for at least one week in dried blood). Then the items will be washed or disposed of as trash. Glass and metal will be decontaminated in an autoclave.

1. 1. Medical Record Keeping

An accurate confidential medical record will be maintained for each employee with an exposure incident. The records will be maintained for the duration of employment plus 30 years. Employee medical records will be maintained in Health Services Center. Student employee records will be maintained in the Health Services Center.

1. 1. Responsibility

For the application and enforcement of this mandated policy each vice president and department head is responsible for the areas under their direction. The Human Resources and Health Services Center will facilitate compliance.