BLOODBORNE PATHOGEN POLICY

July, 2004

TABLE OF CONTENTS

PREFACE

      The Bloodborne Pathogen Policy was developed by an ad-hoc committee composed of a cross section of University professionals, as a basic guideline to aid departments and individuals in their development of protective measures and practices.  The formulation of the plan was guided by the federal regulations which are available from the University Office of Environmental Health and Safety. As regulations change, periodic revisions of the plan are necessary. The 2004 edition reflects the latest regulations and guidelines.

      As an initial step, each department/area supervisor should determine whether any of their employees or students are potentially exposed to bloodborne pathogens as a function of their jobs or academic assignments.  Supervisors should document their assessments of the level of exposure associated with job classifications and student assignments within their jurisdiction.  Supervisors shall be responsible for developing an exposure control plan (using the model presented in these guidelines) if any employees or students within their jurisdiction are at risk for exposure to bloodborne pathogens.

      The Office of Environmental Health and Safety will serve as the contact to assist individuals or departments with exposure determination as well as development and implementation of the Administrative Units' Exposure Control Plans.

POLICY STATEMENT

      The University of Alabama endeavors to maintain a safe and healthy working environment for its faculty, staff, and students.  In support of this goal, the University is committed to developing and implementing health and safety programs for the benefit of its employees and students.

      In accordance with this commitment the University established the Ad-Hoc Bloodborne Pathogens Committee to formulate guidelines for University employees and students who work with, or who may be at risk, occupationally or academically for exposure to, bloodborne pathogens or other potentially infectious materials.  These guidelines will specify procedures to provide University employees and students with education and training about bloodborne pathogens and identify procedures and precautions that will reduce the likelihood of accidental exposure to these infectious substances.  The Office of Environmental Health and Safety will oversee the implementation of this policy.

I.  DEFINITIONS

For the purpose of this policy, the following definitions shall apply:

"Administrative Unit" means the units identified by the vice-presidents which are responsible for conducting annual risk appraisals and implementing the Bloodborne Pathogens Policy.

"Biological Cabinet" means a device enclosed except for necessary exhaust purposes on three sides and top and bottom, designed to draw air inward by means of mechanical ventilation, operated with insertion of only the hands and arms of the user, and in which virulent pathogens are used. Biological cabinets are classified as:

1.      Class I: A ventilated cabinet for personnel protection with an unrecirculated inward airflow away from the operator and high-efficiency particulate air (HEPA) filtered exhaust air for environmental protection.

2.      Class II: A ventilated cabinet for personnel, product, and environmental protection having an open front with inward airflow for personnel protection, HEPA filtered laminar airflow for product protection, and HEPA filtered exhaust air for environmental protection.

3.  Class III: A total enclosed, ventilated cabinet of gas-tight construction. Operations in the cabinet are conducted through attached protective gloves.

"Blood" means human blood, human blood components, and products made from human blood.

"Bloodborne Pathogens" means 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).

"Clinical Laboratory" means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

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

"Contaminated Laundry" means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

"Contaminated Sharps" means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, scissors, broken glass, broken capillary tubes and exposed ends of dental wires.

"Decontamination" means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

"Engineering Controls" means 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.

"Engineered Sharps Injury Protection" means either:

1.      A physical attribute built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, which effectively reduces the risk of an exposure incident by a mechanism such as barrier creation, blunting, encapsulation, withdrawal or other effective mechanisms; or

2.      A physical attribute built into any other type of needle device, or into a non-needle sharp, which effectively reduces the risk of an exposure incident.

"Exposure Incident" means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee's duties.

"Handwashing Facilities" means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

"HBV" means hepatitis B virus.

"HCV" means hepatitis C virus.

"HIV" means human immunodeficiency virus.

"Licensed Healthcare Professional" is a person whose licensed scope of practice includes an activity which this section requires to be performed by a licensed healthcare professional.

"Needle" or "Needle Device" means a needle of any type, including, but not limited to, solid and hollow-bore needles.

"Needleless system" means a device that does not utilize needles for:

1.  The withdrawal of body fluids after initial venous or arterial access is established;

2.  The administration of medication or fluids; and

3.  Any other procedure involving the potential for an exposure incident.

"NIOSH" means the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, or designated representative.

"Occupational Exposure" means 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.

"One-Hand Technique" means procedure wherein the needle of a reusable syringe is capped in a sterile manner during use. The technique employed shall require the use of only the hand holding the syringe so that the free hand is not exposed to the uncapped needle.

"OPIM" means other potentially infectious materials.

"Other Potentially Infectious Materials" means:

1. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any 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.

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

3. Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV:

a.  Cell, tissue, or organ cultures from humans or experimental animals;

b.  Blood, organs, or other tissues from experimental animals; or

c.  Culture medium or other solutions.

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

"Personal Protective Equipment" is specialized clothing or equipment worn or used 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.

"Production Facility" means a facility engaged in industrial-scale, large-volume or high concentration production of HIV, HBV or HCV.

"Regulated Waste" means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi liquid state if compressed: items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling: contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

"Research Laboratory" means a laboratory producing or using research-laboratory-scale amounts of HIV, HBV or HCV. Research laboratories may produce high concentrations of HIV, HBV or HCV but not in the volume found in production facilities.

"Sharp" means 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.

"Sharps Injury" means any injury caused by a sharp, including, but not limited to, cuts, abrasions, or needlesticks.

"Sharps Injury Log" means a written or electronic record, which is a record of each exposure incident involving a sharp.

"Sterilize" means the use of a physical or chemical procedures to destroy all microbial life including highly resistance bacterial endospores.

"Student Academic Exposure" means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the student's participation in academic assignments.

"Source Individual" means 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" is 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 or HCV, and other bloodborne pathogens.

"Work Practice Controls" means controls that reduce the likelihood of exposure by defining the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique and use of patient-handling techniques).

II.  Exposure Control PLAN

A.  Step 1:  Identifying Students and Employees at Risk

1.      Between October-November each year, each of the vice-presidents of the university will be responsible for conducting a risk appraisal survey within their respective divisions to identify all employees and students who are at risk for occupational or student academic exposure to bloodborne pathogens.

a.   This survey will be conducted using a survey form (see Attachment A) that is developed and revised as appropriate.

b.   The vice-presidents will determine the most appropriate mechanism for disseminating the survey forms within their divisions.  The vice-presidents will identify individuals within each Administrative Unit who shall be coordinators responsible for implementing this policy.  The vice-presidents shall send a list of the names of these coordinators to the Office of Environmental Health and Safety.  The risk appraisal forms should be completed by individuals who are sufficiently familiar with the job functions and academic assignments within their Administrative Units that they can evaluate the potential for exposure to bloodborne pathogens.  Divisions are responsible for identifying academic courses in which students may be at risk for academic exposure.

c.   Upon request, a designated staff member from the University Office of Environmental Health and Safety will meet with the group of individuals charged with completing the surveys in order to provide guidance and assistance.

d.   The completed surveys will be returned to the Office of Environmental Health and Safety for review and comment.

B.  Step 2: Developing an Exposure Control Plan

      Written exposure control plans shall be developed by each Administrative Unit in which there are employees or students at risk for occupational or student academic exposure.  The plan should be individualized for each Administrative Unit.  The model plan available from the Office of Environmental Health and Safety (or in Attachment B of this policy) may be used as a guideline in developing each individual plan.

1.      An Exposure Control Plan must contain the following:

a.  A Risk Appraisal Survey (see Attachment A) which contains the following.

(1)  A list of all job classifications in which all employees and students in those job classifications have occupational or student academic exposure.

(2)   A list of job classifications in which some employees or students have occupational or student academic exposure.

(3)   A list of all tasks and procedures, or groups of closely related tasks and procedures, in which occupational or student academic exposure occurs and that are performed by employees or students in the job classifications listed in paragraph 1a(2) above.

(4)    This exposure determination shall be made without regard to the use of personal protective equipment.

(5)    An effective procedure for gathering the information required by the Sharps Injury Log.

(6)    An effective procedure for periodic determination of the frequency of use of the types and brands of sharps involved in the exposure incidents documented on the Sharps Injury Log; (NOTE: Frequency of use may be approximated by any reasonable and effective method.)

(7)     An effective procedure for identifying currently available engineering controls, and selecting such controls, where appropriate, for the procedures performed by employees in their respective work areas or departments;

(8)    An effective procedure for obtaining the active involvement of employees in reviewing and updating the exposure control plan with respect to the procedures performed by employees in their respective work areas or departments.

b.   Methods of compliance with the plan including schedules for implementing or periodically maintaining the compliance procedures;

c.  Methods of Hepatitis B vaccination;

d.  Method of communication of hazards to employees;

e.   Method of recordkeeping as required by the Policy;

f.   The procedure for the post exposure evaluation and follow-up after exposure incidents; and

g.  Methods for providing information and training.

2.      The Exposure Control Plans should be submitted for review to the Director of the Office of Environmental Health and Safety by February 1 following the October-November risk appraisal.

3.      The Plans should be reviewed annually (by February) by the supervisor in each Administrative Unit who is designated by the Vice-president as having responsibility for implementing this policy.  The review will occur at the time the risk appraisal survey is administered to determine the need for revision to reflect occupational or student academic exposure to new job positions or activities.

4. The Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary as follows:

a.     To reflect new or modified tasks and procedures which affect occupational exposure;

b.     If sharps are used in the employer's place of employment, to reflect progress in implementing the use of needleless systems and sharps with engineered sharps injury protection.

c.     To include new or revised employee positions with occupational exposure;

d.     To review and evaluate the exposure incidents which occurred since the previous update;

e.      To review and respond to information indicating that the Exposure Control Plan is deficient in any area.

5.      At any time when a student or employee assumes responsibilities that would place them at risk for exposure, all of the exposure control procedures in the Plan shall apply.

6.      A copy of the Exposure Control Plan shall be accessible in the work place to all employees and students at risk for occupational or student academic exposure.

C.  Step 3: Sharps Injury Log

The employer shall establish and maintain a Sharps Injury Log, which is a record of each exposure incident involving a sharp. The exposure incident shall be recorded on the log within 14 working days of the date the incident is reported to the employer. The information recorded shall include the following information, if known or reasonably available:

1.      Date and time of the exposure incident;

2.      Type and brand of sharp involved in the exposure incident;

3.      A description of the exposure incident which shall include:

a.     Job classification of the exposed employee;

b.     Department or work area where the exposure incident occurred;

c.     The procedure that the exposed employee was performing at the time of the incident;

d.     How the incident occurred;

e.      The body part involved in the exposure incident;

f.      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;

g.     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;

h.     The employee's opinion about whether any other engineering, administrative or work practice control could have prevented the injury.

III.  Methods of Compliance.

            The following methods of compliance should be incorporated in the Exposure Control Plans, as appropriate, in Administrative Units where students or employees are at risk for student academic or occupational exposure to bloodborne pathogens.  Universal precautions shall be observed to prevent contact with blood or potentially infectious materials (pim).  Unless differentiation between body fluid types is possible, all body fluid types shall be considered potentially infectious material.

A.  Engineering Controls

            Engineering controls shall be used whenever possible to eliminate or minimize exposure. They shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.

1.      Handwashing facilities shall be readily accessible to employees and students.

2.      Contaminated sharps shall be placed in appropriate containers immediately or as soon as possible after use.  The containers shall be:

a.  Puncture resistant;

b.   Labeled or color coded as described in section III E herein of this policy;

c.  Leak proof on the sides and bottom; and

d.  Constructed in such a manner so it is not necessary for a person to reach into the container to retrieve sharps.

3.      Specimens of blood or potentially infectious materials shall be placed in containers which prevent leakage during collection, handling, processing, storage, or transport.

a.  If Universal Precautions are utilized in the handling of all specimens additional labeling or color coding is not necessary if the containers are recognizable as containing specimens and do not leave the facility.

b.   If specimen containers leave the facility they must be labeled in accordance with the communication of hazards section of this policy.

c.  If the primary container begins leaking or outside contamination occurs it shall be placed within a secondary container which meets all of the construction and labeling requirements.

d.  Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and decontaminated as necessary.

B.  Required Work Practices (General)

1.      Employees or students shall wash their hands immediately after removal of gloves or other personal protective equipment, using an appropriate disinfectant soap.

2.      Administrative Units shall ensure that employees/students wash immediately following contact of body areas with blood or potentially infectious material, using an appropriate disinfectant soap.

3.      All personal protective equipment must be removed immediately upon leaving the work area or as soon as possible if overtly contaminated and placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

4.      Contaminated needles and sharps shall not be bent, recapped, sheared, broken or removed.

5.      If recapping or removal is required by a specific medical procedure, documentation of this necessity must be maintained.  Recapping or removal must be with the use of a mechanical device or a one-handed technique.

6.      Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses are prohibited in work areas where there is a possibility of occupational or student academic exposure.

7.      Food and drink shall not be consumed or stored in areas where blood or other potentially infectious materials are present.

8.      All procedures involving blood or other potentially infectious materials shall be performed in a manner that minimizes splashing, spraying, or generation of droplets.

9.      Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited.

10.  If conditions are such that handwashing facilities are not available, antiseptic hand cleaners are to be used.  Because this is an interim measure, employees/students are to wash hands at the first available opportunity.

C.  Engineering and Work Practice Controls (Specific Requirements).

1.      Needleless Systems shall be used for:

a.     Withdrawal of body fluids after initial venous or arterial access is established.

b.     Administration of medications or fluids; and

c.     Any other procedure involving the potential for an exposure incident for which a needleless system is available as an alternative to the use of needle devices.

2.      Needle Devices. If needleless systems are not used, needles with engineered sharps injury protection shall be used for:

a.     Withdrawal of body fluids;

b.     Accessing a vein or artery;

c.     Administration of medications or fluids; and

d.     Any other procedure involving the potential for an exposure incident for which a needle device with engineered sharps injury protection is available.

3.      Non-Needle Sharps. If sharps other than needle devices are used, these items shall include engineered sharps injury protection.

4.      EXCEPTIONS: The following exceptions apply to the engineering controls required by subsection III C. 

a.     Market Availability. The engineering control is not required if it is not available in the marketplace.

b.     Patient Safety. The engineering control is not required if a licensed healthcare professional directly involved in a patient's care determines, in the reasonable exercise of clinical judgment, that use of the engineering control will jeopardize the patient's safety or the success of a medical, dental or nursing procedure involving the patient. The determination shall be documented.

c.     Safety Performance. The engineering control is not required if the employer can demonstrate by means of objective product evaluation criteria that the engineering control is not more effective in preventing exposure incidents than the alternative used by the employer.

d.     Availability of Safety Performance Information. The engineering control is not required if the employer can demonstrate that reasonably specific and reliable information is not available on the safety performance of the engineering control for the employer's procedures, and that the employer is actively determining by means of objective product evaluation criteria whether use of the engineering control will reduce the risk of exposure incidents occurring in the employer's workplace.

D.  Personal Protective Equipment

      Where occupational exposure remains after institution of engineering and work practice controls, the employer shall provide, at no cost to the employee, appropriate personal 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.

1.      Each Administrative Unit shall provide personal protective equipment such as gloves, gowns, coats, face shields, masks, eye protection, resuscitation mouthpieces, or resuscitation bags.

2.      The personal protective equipment will be adequate only if it does not permit blood or potentially infectious materials to reach the employee's/student's work clothes, skin, eyes, mouth or other mucous membranes.

3.      The Administrative Unit shall ensure that the employee/student uses personal protective equipment whenever appropriate.

4.  Accessibility. The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees.

5.  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.

6.      Contaminated personal protective equipment shall be removed as soon as possible.

7.      All personal protective equipment shall be removed prior to leaving the work area.

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

9.      Gloves shall be worn when the employee/student may have hand contact with blood, potentially infectious material or contaminated items or surfaces.

10.  Gloves must be discarded as soon as their ability to function as a barrier is compromised.

11.  Disposable items such as gloves shall not be re-used.

12.  Masks, eye protection and/or face shields shall be worn whenever splashes, spray or droplets of blood or potentially infectious materials may be generated.

13.  Gowns, aprons and other protective body clothing shall be worn in exposure situations.

14.  Surgical caps or hoods and boots or shoe covers shall be worn when gross contamination is anticipated.

E.  Housekeeping

1.      Each Administrative Unit shall develop a written schedule for cleaning and methods of decontamination based upon type of surface, and the procedures being performed.

2.      All equipment and surfaces shall be cleaned and decontaminated as soon as possible after contact with blood or potentially infectious material.

3.      Protective coverings shall be removed and replaced as soon as possible after contamination.

4.      Receptacles with a possibility of contamination shall be inspected and decontaminated on a regularly scheduled basis and decontaminated as soon as possible upon visible contamination.

5.      Broken glassware shall be cleaned up using mechanical means.

6.      Specimens of blood or other potentially infectious materials shall be placed into a closable, leakproof container labeled or color-coded according to the University's Medical Waste Management Plan prior to being stored or transported.  If outside contamination of the primary container is likely, then a second leakproof container that is labeled or color-coded (as per the Medical Waste Management Plan) shall be placed over the first and closed to prevent leakage during handling, storage or transport.  If puncture of the primary container is likely, it shall be placed within a leakproof, puncture-resistant secondary container.

7.      Reusable items contaminated with blood or other potentially infectious materials shall be decontaminated prior to washing and/or reprocessing.

F.  Waste Disposal

      All infectious waste destined for disposal shall be placed in closable, leakproof containers or bags that are color-coded or labeled as described in the University of Alabama Medical Waste Management Plan.

1.      If outside contamination of the container or bag is likely to occur, then a second leakproof container or bag which is closable and labeled or color-coded (as per the Medical Waste Management Plan) will be placed over the outside of the first and closed to prevent leakage during handling, storage and transport.

2.      Immediately after use, sharps shall be disposed of in closable, puncture resistant, disposable containers which are leakproof on the sides and bottom and that are labeled or color-coded, per the Medical Waste Management Plan.

3.      These containers will be easily accessible to personnel and located in the immediate area of use.

4.      These containers will be replaced routinely and not allowed to overfill.  Employees must not have to insert hands into the container in order to dispose of a sharp.

5.      When moving containers of sharps from the area of use they must be closed immediately prior to removal or transport.

6.      Reusable containers may not be opened, emptied or cleaned manually or in any other manner which would pose the risk of percutaneous injury.

7.      Disposal of contaminated personal protective equipment will be provided at no cost to employees or students.

G.  Requirements for Handling Contaminated Sharps.

1. All procedures involving the use of sharps in connection with patient care, such as withdrawing body fluids, accessing a vein or artery, or administering vaccines, medications or fluids, shall be performed using effective patient-handling techniques and other methods designed to minimize the risk of a sharps injury.

2. Immediately or as soon as possible after use, contaminated sharps shall be placed in appropriate disposal containers.

3. At all time during the use of sharps, containers for contaminated sharps shall be:

a.     Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries);

b.     Maintained upright throughout use, where feasible; and

c.     Replaced as necessary to avoid overfilling.

H.  Sharps Containers for Contaminated Sharps.

1.      All sharps containers for contaminated sharps shall be:

a.     Rigid;

b.     Puncture resistant;

c.     Leakproof on the sides and bottom;

d.     Portable, if portability is necessary to ensure easy access by the user.

e.      Properly labeled in accordance with subsection M, 2-8.

2. If discarded sharps are not to be reused, the sharps container shall also be closeable and sealable so that when sealed, the container is leak resistant and incapable of being reopened without great difficulty.

I.  Cleaning and Decontamination of the Worksite.

1. General Requirements.

a.     Employers shall ensure that the worksite is maintained in a clean and sanitary condition.

b.     Employers shall determine and implement an appropriate written schedule for cleaning and decontamination of the worksite.

c.     The method of cleaning or decontamination used shall be effective and shall be appropriate for the: location within the facility; type of surface or equipment to be treated; type of soil or contamination present; and tasks or procedures being performed in the area.

d.     All equipment and environmental and work surfaces shall be cleaned and decontaminated after contact with blood or OPIM no later than at the end of the shift. Cleaning and decontamination of equipment and work surfaces is required more often as specified below.

2. Specific Requirements.

a.     Contaminated Work Surfaces. Contaminated work surfaces shall be cleaned and decontaminated immediately or as soon as feasible when: surfaces become overtly contaminated; there is a spill of blood or OPIM; procedures are completed; and at the end of the work shift if the surface may have become contaminated since the last cleaning.

b.     Receptacles. 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 decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.

c.     Protective Coverings. 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 workshift if they may have become contaminated during the shift.

J.  Laundry

1.      Contaminated laundry shall be bagged at the area of use and not sorted or rinsed.

2.      Contaminated laundry shall be placed and transported in containers labeled according to the hazards communication section unless the facility utilizes Universal Precautions (UP) in handling all soiled laundry.  Then alternative labeling is sufficient if all employees recognize the containers as requiring compliance with Universal Precautions.

3.      If the laundry is wet it shall be placed and transported in leak proof bags.

4.      Each Administrative Unit shall ensure that employees or students who contact contaminated laundry wear appropriate gloves and other appropriate personal protective equipment.

5.      Laundering of personal protective equipment is to be provided by the Administrative Unit at no cost to employees or students.

6.      If laundry is shipped offsite to a second facility which does not utilize Universal Precautions in its handling of all laundry, bags or containers with appropriate labeling and/or color-coding will be used to communicate the hazards associated with this material.

K  Hepatitis B Vaccination

      1.  Employees

a.  The University Medical Center (UMC) shall make available the hepatitis B vaccine and vaccination series to all employees who are at risk for occupational exposure.  University Medical Center will provide post exposure evaluation and follow up to all employees who have an exposure incident.

b.   These evaluations and procedures shall be:

(1)    Made available at no cost to the employee;

(2)    Made available at a reasonable time and place;

(3)    Performed under the supervision of a licensed physician;

(4)    Provided according to the recommendations of the US Public Health Service.

c.     Laboratory tests shall be conducted by an appropriate accrediting agency, approved by the UMC Chief Medical Officer, at no cost to the employee.

d.     The hepatitis B vaccination shall be made available to an employee who has occupational exposure, within 10 workdays of initial assignment.  Exceptions are:

(1)   The employee has previously received the complete hepatitis B vaccination series and submits acceptable proof thereof;

(2)     Antibody testing reveals the employee is immune;

(3)    The vaccine is contradicted for medical reasons; or

(4)   The employee signs a statement (Attachment D) declining the vaccination series.

(5)  The employee shall be employed for a period of less than six months.

e.      The University Medical Center shall not make participation in a pre-screening program a prerequisite for receiving the vaccination.

f.      Employees who accept the vaccination will receive information about the vaccine from the University Medical Center and sign a consent form (see Attachment C).  A copy of the consent form will be maintained in the University Medical Center files.

g.     Employees who decline the hepatitis B vaccination shall sign the prescribed statement shown in Attachment D.  This signed statement shall be placed in the departmental file.

h.     If an employee initially declines the vaccination but at a later time (while still covered by this policy) desires to accept it, it shall be made available after signing the appropriate consent form (Attachment C).

i.        Documentation of the employee's hepatitis B vaccination status (Attachment E) will be maintained in the University Medical Center.

2.  Students

a.     Students who are at risk for student academic exposure to bloodborne pathogens will be required to submit proof of immunity to Hepatitis B (either by vaccination or previous exposure) to their supervisor, or sign a statement (Attachment D) indicating that they understand their risks of exposure but have declined vaccination.  If a student is under the age of 19, parental signature on the declination form will be required.

b.     Documentation of the vaccination status for a student at risk for exposure (Attachment E) and, if applicable, the signed statement declining vaccination (Attachment D), may be placed in the student's Health Center records.  A copy of this documentation shall be provided to the student to be submitted to the faculty member responsible for the academic activity associated with a risk for exposure.

L.  Post-Exposure Evaluation and Follow-Up

      1.  Employees

Should an employee be exposed to a potentially infectious material (via needle stick, splash, etc.) post-exposure evaluations will be provided as described herein.

a.     Following a report of an exposure incident, the University Medical Center will provide a confidential medical evaluation and follow-up including:

(1)   Documentation of the route(s) of exposure, HBV and HIV antibody status of the source patient(s) (if known), and the circumstances under which the exposure occurred.

(2)   If the source patient can be determined and permission is obtained, collection and testing of the source patient's blood to determine the presence of HIV or HBV infection.

(3)   Collection of blood from the exposed employee as soon as possible after the exposure incident for determination of HIV/HBV status.  Actual antibody or antigen testing of the blood or serum sample may be done at that time or at a later date, if the employee so requests.  Samples will be preserved for at least 90 days, but not more than 120 days, unles