Bloodborne Pathogens Program
Please contact us if you have any questions regarding biomedical waste management at Bates College.
Purpose and Scope
The Bloodborne Pathogens Control Program is designed to minimize personal exposure to bloodborne pathogens. These guidelines describe precautions that must be taken by Bates College personnel whose work involves potential contact with human blood and potentially infectious materials, and defines the responsibility of Bates College personnel.
Implementation of the Bloodborne Pathogens Program is mandated by OSHA’s Bloodborne Pathogens Standard in 29 CFR 1920.1030. This standard was revised on January 18, 2001 to incorporate changes required by the Needlestick Safety and Prevention Act. This regulation applies to all personnel like to have occupational exposures to human blood and other potentially affected materials.
AIDS: Acquired Immune Deficiency Syndrome. The disease that results when the HIV virus attacks the human immune system.
Blood: Human blood, human blood components, and products made from human blood.
Bloodborne Pathogens: pathogenic microorganisms that are present in human blood and cause disease in humans. These pathogens include, but are not limited to:
- Human Immunodeficiency Virus (HIV), which causes Acquired Immune Deficiency Syndrome (AIDS)
- Hepatitis B Virus (HBV), which causes Hepatitis B, a liver disease
- Hepatitis C Virus (HCV), which causes Hepatitis C, a liver disease
- Human T-Lymphotrophic Virus Type 1
- Viral Hemorrhagic Fever
Clinical Laboratory: workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.
Contaminated Sharps: any blood contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, and exposed ends of wires.
Engineering Controls: equipment or devices that isolate or remove the bloodborne pathogen hazards from the workplace. Examples include sharps disposal containers, self-sheathing needles, equipment slash guards, biosafety cabinets, etc.
Exposure Incident: specific incident in which blood or other potentially infectious material contacts the employee in one of the following ways:
- Other mucous membrane
- Non-intact skin surface
- Puncture/stick/cut with sharp contaminated object
HBV: Hepatitis B Virus, a bloodborne pathogen that may cause inflammation of the liver.
HIV: Human Immunodeficiency Virus, the bloodborne pathogen that attacks the immune system and ultimately causes AIDS.
Occupational Exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials, that may result from the performance of an employee’s duties.
Potentially Infectious Materials (PIMS): materials that can carry bloodborne pathogens. They include:
- human blood and blood products
- vaginal secretions
- spinal fluid
- amniotic fluid
- other internal human body fluids from joints, chest cavity, heart sac, or abdomen
- saliva during dental procedures (special case due to liklehood of blood being present)
- breast milk (only by ingestion – known to transmit HIV)
- human or primate cell lines or strains that have not been documented to be free of bloodborne pathogens by testing
- unfixed human tissues or organs (living or dead)
- blood or tissues from animals experimentally infected with bloodborne pathogens
- cultures or other solutions containing specific bloodborne pathogens, such as HIV, HBV, or HCV
- equipment contaminated with human blood or other PIMs
- any bodily fluid that is visibly contaminated with blood, or that is difficult or impossible to distinguish
Potentially infectious materials DO NOT include the following, unless the material is visibly contaminated with blood or is difficult or impossible to distinguish:
- saliva (except during dental procedures)
- nose fluids, and
- intact human skin (living or dead source).
Regulate Medical Waste: a waste stream which is regulated and must be disposed of through EHS, even if it has been autoclaved or treated with another form of decontamination. The details of the waste stream are:
- Cultures and stock of microorganisms and biologicals. Discarded cultures, stocks, specimens, vaccines and associated items likely to contain organisms likely to be pathogenic to healthy humans.
- Blood and blood products. Wastes consisting of human blood, human blood products and items contaminated by human blood.
- Human tissues and other anatomical wastes. All human anatomical wastes and all wastes that are human tissues, organs, body parts, or body fluids.
- Sharps. It is protocol to include all sharps in the regulated medical waste stream. That is, ALL hollow-bore needles, pipettes and glassware from biological labs or medical settings.
- Some animal carcasses, body parts, bedding, and related wastes if the animal has been intentionally infected with pathogenic organisms and are likely to be contaminate.
Regulated Medical Waste EXEMPTIONS: the following waste streams are not subject to the requirements of regulated medical waste regulations when dispersed among other solid wastes and not accumulated separately:
- Used products for personal hygiene, such as diapers, facial tissues and sanitary napkins.
- Material, not including sharps, containing small amounts of blood or body fluids, but containing no free flowing or unabsorbed liquid (Band-Aids)
Universal Precautions: approach to infection control, where ALL body fluids and individuals are treated as known positives for HIV, HBV, and other bloodborne pathogens.
Work Practice Controls: procedures that reduce the likelihood of exposure through the manner in which tasks are performed.
Each department that has employees at risk of occupational exposure to bloodborne pathogens has the following responsibilities and functions.
- Circulating Exposure Control guidelines to employees.
- Funding and providing PPE, as needed.
- Notifying EHS before establishing research involving human pathogenic agents
- Ensuring that new employees do not engage in activities with potential exposure until they have had introductory training.
- Encouraging full participation of all at risk employees, to include:
- Allowing attendance at training sessions during normal work hours
- Requiring at risk employees to review Exposure Control Guidelines
- Requiring employees to follow safe work practices
The following departments have been identified by EHS as having at risk employees:
- Campus Safety
- EMS (Bates)
- Facility Services
The above list is not exhaustive.
Each department with at risk employees should appoint a coordinator, who will be responsible for ensuring that the Exposure Control guidelines are complete and accessible. Accessibility means that all at risk employees should be informed of the location of the guidelines and should be encouraged to read its content.
Supervisors / Managers
Bates College employees who supervise at risk employees should act as coordinators in departments where no one has been assigned that role. Furthermore, supervisors / managers should:
- Ensure that newly hired at risk employees receive introductory training
- Must allow employees to receive vaccinations during normal work hours
- Must secure PPE, such as gloves, for employees
- Must be familiar with reporting guidelines in the event of an exposure
At Risk Employees
Every employee that can reasonably anticipate exposure to blood or other potentially infectious materials during their normal job duties has certain responsibilities. They include:
- Attending training sessions
- Complying with these guidelines
- Adhering to Universal Precautions
- Reporting exposure incidents to Supervisors and EHS
EHS is responsible for coordinating the following program elements:
- Identification of at-risk employees
- Conducting introductory training classes and annual refresher classes
- Maintaining training records
- Providing post-exposure follow-up
- Creating, distributing, and revising college wide Exposure Control guidelines
- Operating a regulated waste disposal program
- Oversight of departmental compliance
- Assume that ALL blood is positive for HIV, HBV, and HCV
- Assume that ALL other human fluids/tissues are also positive
- When it’s difficult to differentiate, treat ALL fluids as potentially infectious
- Assume that ALL individuals are carrying these disease organisms
- Avoid skin contact with blood and other potentially infectious materials
- Avoid eye, nose, and mouth contact with blood and other potentially infectious materials
- Avoid punctures/sticks with contaminated sharp objects
Engineering controls are devices and tools that prevent exposure to health hazards. These sorts of safety controls shall be used, in conjunction with Work Practice Controls, to eliminate or minimize employee exposure.
These controls are extremely important, as they are the best methods of preventing exposure.
These devices/equipment must be inspected and maintained on a regular basis by the Implementation Coordinator or designee. Worn parts and equipment must be replaced as soon as indicated through the inspection process.
Here are some common engineering controls used to protect employees from bloodborne pathogens:
- Handwashing Facilities: there must be a facility to supply adequate running water, soap, and single-use towels or hot-air drying machines.
- Alternate Handwashing Devices: when running water handwashing facilities are not feasible, an appropriate antiseptic hand cleanser with clean cloth/paper towels OR antiseptic towelettes shall be provided.
- Needle Safety Devices: departments using sharps should make reasonable attempts to implement the use of safety devices for needles. Examples are:
- Needle-less connectors
- Protected needle IV connectors
- Needles that retract
- Hinged or sliding shields
- Protective encasements
- Self-blunting needles
- Retractable lancets
- Sharps Containers: proper containers for storage of contaminated sharps must be provided and these containers must be:
- Puncture resistent
- Labeled or color-coded
- Splash Guards: lab equipment that can potentially vaporize or splash blood should be equipped with a splashguard or similar protective device.
- Resuscitation Masks: must be made available to all First Responders. These devices prevent fluid exchange during the administration of CPR.
- Biosafety Cabinets: used in biological labs when the possibility of exposure to airborne pathogens is present.
Work Practice Controls
Work practice controls are procedures that employees need to follow in order to keep themselves safe. These required procedures are to be followed by all “at risk” employees and must be enforced by all departments.
It is extremely important that all at-risk employees follow strict hand/skin washing procedures at the following times:
- After removing gloves or other PPE
- Following contact with blood and other potentially infectious fluid
Hands and other skin areas must be washed with soap and water OR antiseptic cleanser (in the absence of water). Mucous membranes must be flushed with copious amounts of water for a minimum of 15 minutes.
When an antiseptic cleanser or towelette is used, washing with soap and water as soon as possible.
Whenever a needle or other sharp device is exposed, injuries can occur. Needlestick injuries have been related to certain work practices such as:
- transferring a bodily fluid between containers, and
- failing to properly dispose of used needles in puncture-resistant sharps containers.
If recapping cannot be avoided, it should be accomplished through the use of a mechanical device. Also, puncture resistant gloves may be worn if able to do so.
All procedures involving blood or other potentially infectious materials must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets.
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are strictly prohibited in work areas where there is a reasonable likelihood of occupational exposure.
- Food and drink shall not be kept where blood or other potentially infectious material is prohibited.
- Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
The following procedures must be followed when having potentially contaminated equipment serviced:
- Look for evidence of contamination.
- Decontaminate if necessary and feasible.
- If NOT feasible, label equipment with a BIOHAZARD label.
- Include on the label which parts are contaminated.
- Convey information to affected employees and servicing representative prior to shipping, so that precautions can be taken.
Personal Protective Equipment (PPE)
Where occupational exposure remains after the implementation of Engineering and Work Practice Controls, PPE must be used. Departments shall provide, at no cost to the employee, the appropriate PPE, including but not limited to:
- Lab Coats
- Face Shields
- Eye Protection
- Resuscitation Bags
- Pocket Masks
- Mechanical Respiratory Devices
PPE is considered appropriate if it is needed for, and is capable of, preventing blood or other fluids from passing through to the employee’s clothing, skin, or mucous membranes. Departments should complete a formal PPE Hazard Assessment to determine and document what PPE must be provided and used for hazard exposures.
Departments must ensure proper use, accessibility, cleaning, disposal, repair and replacement of PPE.
Employees must remove PPE before leaving the work area or whenever the PPE has become saturated with blood or other potentially infectious materials. Used PPE must be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
Gloves must be worn when it can be reasonably anticipated that the employee may have hand contact with:
- other potentially infectious materials
- mucous membranes
- non-intact skin, and
- when handling contaminated equipment or surfaces.
Disposal of gloves:
- Disposable gloves should be discarded when they become torn, punctured, or contaminated,
- Utility gloves that can be decontaminated should be discarded when cracked, peeling, torn, punctured, or deteriorating.
Face and Eye Protection
Masks, goggles, glasses, and face shields are to be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, and mouth contamination can be reasonably anticipated.
Gowns, aprons, lab coats, clinic jackets, and other protective body clothing are to be worn in occupational exposure situations when appropriate. The type and characteristics of the PPE will depend upon the task and degree of exposure anticipated.
All worksites shall be maintained in clean and sanitary conditions at all times. To meet the OSHA regulatory requirements, each work area covered by these guidelines must establish a written cleaning schedule.
Decontamination/Cleaning of surfaces and equipment must be performed at the following times:
- At the frequency determined in the written schedule
- Following a contamination incident
- Following routine procedures that may cause contamination
- At the end of work shifts, if contamination may have occurred since last cleaning
The following surfaces that are likely to need decontamination:
- Lab equipment
- Bench/Counter tops
- Receptacles intended for reuse, that may store bloody material
- Environmental Surfaces: large areas, such as entire lab rooms, etc.
Other housekeeping procedures include:
- Protective coverings must be removed and replaced as soon as feasible when they become obviously contaminated or at the end of the workshift if they may have become contaminated during that shift. Coverings include plastic wrap, aluminum foil, and imperviously-backed absorbent paper.
- Broken glass must not be picked up directly with the hands. It shall be cleaned up mechanically. Use a brush and dust pan, tongs, or forceps.
- Employees must never reach their hands into containers of contaminated sharps.
- Contaminated laundry must be handled as little as possible.
- Employees that have contact with contaminated laundry must wear protective gloves and other appropriate PPE.
- Employees are not to take contaminated laundry home for laundering. The department must arrange to have an approved laundry service collect and clean these items or provide access to laundering equipment in the work area.
- Contaminated laundry must be bagged or contained at the location where it was used and must not be sorted or rinsed in the location of use.
- Proper containers are:
- labeled with the Biohazard symbol, or color-coded fluorescent orange or orange-red
- capable of preventing soak-through, if laundry is wet and presents reasonable likelihood of leakage to the exterior of the container
- Contaminated laundry must be transported in proper containers, as described above.
- Laundry personnel must use Universal Precautions when handling ALL laundry.
Labels and Signs
A proper label is:
- A sticker, placard, or label that contains:
- The word BIOHAZARD
- The biohazard symbol
- Anything color-coded
- Fluorescent orange
What should be labeled?
- Containers of regulated waste
- Refrigerators/Freezers containing blood or other potentially infectious materials
- Containers used to store or transport above mentioned fluids
- Equipment that cannot be decontaminated (location of contamination must be written on label
Incidents / Accidents
If you find a needle: