ENVIRONMENTAL HEALTH AND SAFETY STANDARD


SUBJECT: Blood Borne Pathogens Exposure Control Program
ORIGINAL: August 30, 1993
LAST UPDATED: October 12, 2009


Table of Contents


References

  1. 29 CFR 1910.1030, OSHA Bloodborne Pathogens Standard
  2. COMM 32.50, Bloodborne Pathogens Standard

Scope

This Bloodborne Pathogens Exposure Control Standard applies to all University of Wisconsin - La Crosse employees whose position duties may reasonably be anticipated to result in occupational exposure to blood or other potentially infectious materials. (Other potentially infectious materials and other phrases and words are defined on page 2, under Key Definitions.) The personnel affected by the Standard are identified in Section I on Exposure Determination. The purpose of the UW-L plan is to provide information which will assist personnel in minimizing or eliminating their potential exposure to human immunodeficiency virus (HIV), hepatitis B (HBV), and other bloodborne pathogens. The secondary purpose is to comply with Occupational Safety and Health Administration (OSHA) regulations as enforced by the Wisconsin Department of Industry, Labor and Human Relations (DILHR).


Introduction

Employees in certain occupations face an increased health risk as a result of potential exposure to blood and other infectious materials which may contain bloodborne pathogens. Such pathogens include hepatitis B virus (HBV), which may cause a serious liver disease, and human immunodeficiency virus (HIV), which causes Acquired Immunodeficiency Syndrome (AIDS). These health risks can be minimized by using a combination of universal precautions, engineering and work practice controls, personal protective equipment, scrupulous housekeeping, training, appropriate vaccination, and medical evaluation and treatment following any actual exposure incidents.


Costs

All costs associated with program implementation will be funded by the University of Wisconsin. As follows, expenses or charges at the University of Wisconsin - La Crosse will be funded through centralized university funds or decentralized department funds.

Centralized costs

  1. Post-exposure and follow-up evaluations conducted by private or contract healthcare professional.
  2. Regulated waste disposal.

De-Centralized costs

  1. Personal protective equipment (PPE) and spill response kits.
  2. Appropriately color-coded or labeled waste receptacles.
  3. Any engineering controls necessary to implement the program.
  4. Biohazard warning labels and signs.
  5. Hepatitis B vaccination series and future booster vaccinations provided by the Health Center.

Implementation and Compliance Responsibilities

Every University of Wisconsin - La Crosse employee has personal responsibility for compliance and implementation of this written Bloodborne Pathogens Program. Generic responsibilities of identified organizations or personnel are as described below; refer to the written Program for a detailed description of responsibilities.

Appendix A contains a schedule for specific organization and individual implementation and compliance assignments.

Chancellor is:

Ultimately responsible for the UW-L compliance and implementation of the Bloodborne Pathogen Exposure Control Standard.

Environmental Health and Safety shall:

  1. Administrate implementation of the Bloodborne Pathogens Program.
  2. Conduct or arrange for training of personnel with occupational exposure.
  3. Conduct unannounced periodic inspections to evaluate program compliance.
  4. Coordinate biohazard waste disposal.
  5. Assist supervisors and others with determining the correct type of PPE.
  6. Annually review the written program and update as needed.
  7. Investigate and recommend methods to correct events where PPE is not used because it would have prevented the delivery of health care or would have posed an increased risk to any individual.

Health Center shall:

  1. Provide consultative medical services related to implementation of the Bloodborne Pathogens Program.
  2. Provide hepatitis B vaccinations, as requested.
  3. Coordinate vaccination recordkeeping and scheduling requirements with Human Resources, supervisor and employee.

Human Resources shall:

  1. Complete OSHA recordkeeping requirements and maintain employee medical records related to the
  2. Maintain training and exposure determination records.
  3. Work with employee to coordinate scheduling of post-exposure evaluations and follow-ups with private or contract healthcare professionals.

Supervisors and Directors shall:

  1. Ensure that safe work practices, controls and PPE are being correctly utilized.
  2. Ensure availability of adequate PPE supplies.
  3. Develop specific written guidelines, if not already provided in Section III (Engineering and Work Practice Controls), to address unique hazards associated with their laboratory procedures or equipment.
  4. Familiarize their employees with the contents of Appendix C or C2.
  5. Arrange to conduct an exposure incident investigation, with the Environmental Health and Safety Office, to develop and recommend methods to prevent recurrence of similar incidents.
  6. Document annually consideration and implementation of appropriate commercially available and effective medical devices designed to eliminate or minimize occupational exposure.

All Employees shall:

  1. Familiarize themselves with the contents of Appendix C or C2 and their responsibilities listed therein.
  2. Immediately report an exposure incident to their Supervisor and Human Resources. If the Human Resources is not available, contact Protective Services.

Employees with occupational exposure shall:

  1. Question their immediate supervisor regarding any point of the program they do not understand.
  2. Use PPE as directed in training, written area procedures and by their supervisor.
  3. Use engineering and administrative controls to minimize or eliminate exposure.
  4. Maintain facilities which use blood or other potentially infectious materials in a clean and sanitary condition.
  5. Coordinate with supervisor and Health center the scheduling of Hepatitis B vaccinations.

Custodial Staff shall:

  1. Perform housekeeping responsibilities in common area's and support cleaning activities in other area's.

Course Instructors, Coaches, etc. shall:

  1. Minimize or eliminate the use of human blood and other potentially infectious materials in all curricula.
  2. Observe and familiarize their students, team members and similar individuals with requirements specified in the policy on students in Section XV.

Purchasing shall:

Ensure that compliance with the OSHA Standards is included as a contract requirement whenever contract service or contract labor is procured.

University Police shall:

  1. Coordinate emergency response activities.

Key Definitions

Appropriately labeled or Color-coded means the following: "Label" refers to the universal biohazard symbol, printed in fluorescent orange or orange-red color, with the word "Biohazard" printed in contrasting color. "Color-coded" refers to bags or containers that are red.

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) and human immunodeficiency virus (HIV).

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

Contaminated laundry means laundry which has been soiled with blood or other potentially infectious materials.

Contaminated sharps means any contaminated object that can penetrate the skin including, but not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of deutal 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, self-sheathing needles, safer medical devices, such as sharps with engineered sharps, injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the work-place.

Exposure incident 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.

Hand washing facilities means a facility providing an adequate supply of running potable water, soap and single use towel or hot air drying machines.

HBV means hepatitis B virus.

HIV means human immunodeficiency virus.

Needleless Systems means a device that does not use needles for: (1) The collection of bodily fluids or withdrawal of body after initial venous or arterial access is established; (2) The administration of medication or fluids; or (3) And other procedure involving the potential for occupational expose to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

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.

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 body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; and (2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solution; and blood, organs, or other tissue from experimental animals infected with HIV or HBV. 

Parenteral means piercing mucous membranes or the skin barrier through such events as needle-sticks, human bites, cuts and abrasions.

Personal protective equipment (PPE) is 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 personal protective equipment.

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 are capable of releasing these materials during handling; contaminated sharps, pathological and microbiological wastes containing blood or other potentially infectious materials.

Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.

Source individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic 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. The approach treats all human blood and certain human body fluids as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

Work practice controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed. (e.g. prohibiting recapping of needles by a two-handed technique.)


I. EXPOSURE DETERMINATION

All University of Wisconsin - La Crosse employees in the following job classifications have occupational exposure.

  1. Physicians
  2. Health Center Nurses
  3. Laboratory Technicians in Health Center
  4. Medical Technology staff
  5. Campus Police and Security Officers
  6. Sports Medicine Specialists
  7. Athletic Department first aid providers and lifeguards
  8. Environmental Health and Safety staff
  9. Electricians and personnel that are safety back-ups for personnel that work on energized electrical systems.
  10. Custodial Staff in campus buildings.

Some University of Wisconsin - La Crosse employees in the following job classifications have occupational exposure. Specific exposure tasks are identified after the job classifications.

  1. Coaches and Trainers from the Athletic Department who are involved with providing first aid treatment and/or handling contaminated laundry.
  2. Researchers, Instructors, student employees or other personnel from any laboratory where human blood or other infectious materials are used or studied.
  3. Persons in any job title who are engaged in drawing human blood or obtaining samples of other potentially infectious materials.
  4. Any first-aid or cardio-pulmonary resuscitation (CPR) trained personnel who have been specifically authorized through a written job description to respond to emergencies that may involve blood or other potentially infectious materials.
  5. All personnel involved in handling or transporting regulated infectious waste.
  6. Laundry workers who handle contaminated laundry and any employee's who handle contaminated laundry.
  7. Personnel who work on effluent plumbing systems or other equipment which may be contaminated with blood or other potentially infectious materials.
  8. Child Care Center employees who are required by Wisconsin statute to provide first-aid services.

Personnel required to perform these activities as part of their assigned job duties have occupational exposure and are affected by the Standard.

Personnel that are included in this list are required to comply with all requirements of the Bloodborne Pathogen Exposure Control Standard.

Students are not affected by this Standard unless they are employed, and receive monetary payment, from the University of Wisconsin in one of the above listed job classifications or job class specific tasks. However, the University of Wisconsin - La Crosse will take action to minimize or eliminate students exposure to blood and other potentially infectious materials in courses and other campus sponsored activities.


II. UNIVERSAL PRECAUTIONS

All University of Wisconsin personnel with occupational exposure are to observe universal precautions.

Universal precautions apply to blood and other potentially infectious materials. Universal precautions do not apply to feces, nasal secretions, sputum, saliva, sweat, tears, urine, and vomitus, unless they contain visible blood. Under circumstances in which differentiation between body fluid types is difficult or impossible (such as certain emergency response situations), all body fluids should be considered potentially infectious.


III. ENGINEERING AND WORK PRACTICE CONTROLS

The following engineering and work practice controls shall be observed and implemented by all UW - La Crosse employees who have occupational exposure:

  1. Hand washing facilities shall be readily accessible. Where provision of such facilities is not feasible, antiseptic cleansers or towelettes shall be used, followed as soon as possible by hand washing.
  2. All employees shall wash their hands immediately or as soon as feasible after removal of gloves or other PPE.
  3. All employees are to wash their hands and any other skin with soap and water or to flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.
  4. Contaminated needles and sharps are not to be recapped or removed unless such action is required by a specific medical procedure. If recapping or needle removal is required, it must be done through the use of a mechanical device (e.g., a hemostat or needle holder) or by a one-handed technique.
  5. Immediately or as soon as possible after use, contaminated disposable sharps and needles are to be placed in leak-proof, puncture resistant designated sharps containers that are appropriately labeled or color coded. Sharps containers must be conveniently located and accessible to the areas where sharps are being used.
  6. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
  7. Food and drink shall not be kept in refrigerators, freezers, shelves cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.
  8. 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. All containers shall be appropriately labeled or color-coded.
  9. If outside contamination of the primary container occurs, the primary container shall be placed within an appropriately labeled or color-coded second container which prevents leakage during handling, processing, storage, transport, or shipping.
  10. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.
  11. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
  12. 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. If it is not feasible to decontaminate the equipment, a readily observable biohazard label shall be attached to the equipment stating which portions remain contaminated.
  13. Properly chosen, maintained and exhausted ventilation equipment shall be used during procedures which could cause aerosols of the infectious materials.
  14. UW - La Crosse personnel who organize blood drives must inform the organization conducting the blood drive, in writing, of their necessity to comply with Bloodborne Pathogen Standards specified in reference 1. Additional requirements are as follows: a) Rooms in which blood drives are conducted should have a tile floor or other impermeable flooring surface. b) The room in which a blood drive is conducted must be cleaned by personnel from the organization conducting the blood drive or custodial staff identified in Section I. c) The organization conducting the blood drive must remove and properly dispose of all potentially infectious waste materials they have generated. d) The organization conducting the blood drive must follow reasonable engineering and work practice controls to limit the likelihood of exposure.

Since the above engineering and work practice controls do not account for every conceivable method to minimize exposures, some Departments may need to develop specific written guidelines to address unique hazards associated with their laboratory procedures.


V. PERSONAL PROTECTIVE EQUIPMENT (PPE)

The University of Wisconsin - La Crosse will make PPE available, at no cost, to employees who have potential for occupational exposure to bloodborne pathogens.

In the context of exposure control, PPE refers to the following types of items:

  1. fluid resistant gloves;
  2. fluid resistant gown or apron;
  3. face shield or mask;
  4. eye protection;
  5. items of clothing that cover other parts of the body (e.g. shoe covers, caps, full body suits, etc.); and
  6. mouthpieces, resuscitation bags, pocket masks, and other ventilation devices.

There is no substitute for good judgment in deciding which items of PPE to wear in particular settings. At a minimum, protective gloves should be worn in any situation where there is potential for exposure to bloodborne pathogens, including cleaning and removal of contaminated materials or laundry.

Additional items of PPE should be added based upon good judgment and according to the type of job or task being performed. Personnel should utilize the PPE specified by their supervisor and as advised in bloodborne pathogens training. Course Instructors shall inform students of PPE requirements prior to any use of blood or other potentially infectious materials.

UW - La Crosse shall assume that appropriate PPE is used to prevent blood or other potentially infectious materials from contacting skin, eyes, mouth, other mucous membranes, or clothing. Where an employee under rare and extraordinary conditions exercises their professional judgment that the use of PPE would have prevented the delivery of health care or would have posed an increased risk to any individual, the event shall be reported to Human Resources. An investigation shall be conducted and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

All campus locations with personnel that have a chance of exposure to blood or other potentially infectious materials shall have a readily visible supply of gloves and other PPE available. Professional judgment of area personnel should be utilized to determine which items of PPE to wear in particular settings. Such locations shall also have emergency response kits readily available. The Health Center should have mouthpieces, resuscitation bags, pocket masks, or other ventilation devices available.

All emergency response kits shall include:

  1. fluid resistant gloves and gown or apron;
  2. masks that cover the oral cavity and nose;
  3. safety glasses with side shields; goggles or face shield; and
  4. additional PPE and other supplies available for cleaning, decontamination and disposal of the potentially infectious materials.

Personnel who are required and properly trained to provide ventilatory assistance should have some type of ventilatory or CPR mask in their emergency response kits.

Emergency response kits, PPE and other program implementation supplies are available for purchase through Campus Stores.

Disposal of PPE

Most items of PPE, especially gloves, will be designed to be single use items and shall be discarded after use and before leaving the work area. Disposable clothing is recommended for all areas that have minimal use of clothing. Refer to section VII for cleaning instructions for non-disposable clothing. If an item of PPE becomes excessively soiled during use, it shall be removed and disposed into a designated biohazard waste container or laundry bag. The user shall then wash their hands prior to putting on clean equipment.

PPE that is not designed for disposal (e.g. goggles, safety glasses) should be disinfected in a freshly prepared 10% household bleach in water solution, rinsed and allowed to air dry prior to re-use. PPE should not be cleaned with alcohol, autoclaved or exposed to other cleaning methods which may damage the equipment.


V. HOUSEKEEPING

All facilities which use blood and other potentially infectious materials are to be maintained in a clean and sanitary condition. All equipment and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

All personnel identified as having occupational exposure are responsible for housekeeping duties in their work area. Custodial Staff will perform housekeeping responsibilities in common area's and support cleaning activities in other area's.

Decontamination should, to the extent feasible, be conducted with disposable cleaning supplies. All disposable cleaning supplies and other contaminated items should be discarded in color-coded or labeled infectious waste receptacles. An adequate supply of waste receptacles should be placed in each area were infectious waste is normally generated. When proper waste receptacles are not available in the area, as in the case of medical emergencies, the waste should be retained by the generator in a secure location. The generator shall notify Environmental Health and Safety that the material needs to be disposed. Non-disposable cleaning supplies should be decontaminated after use.

Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated; 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. Appropriate disinfectant includes a freshly prepared 10% household bleach solution in water or other EPA registered disinfectants.

Cleaning of the Campus Health Center shall be performed in accordance with the routine custodial cleaning schedule. Since the building in which the Health Center is located is used by a variety of occupants, the schedule varies depending upon occupant and building requirements.

All bins, pails, cans, and similar receptacles intended for re-use, which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials, shall be periodically inspected and decontaminated. Such receptacles shall be cleaned and decontaminated immediately or as soon as feasible upon visible contamination.

Broken glassware shall not be picked up directly with the hands. It should be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps. Contaminated broken glassware should be placed in a biohazard sharps container. Other broken glassware should be placed in a puncture resistant container.

Employees are not to reach by hand into containers where contaminated sharps have been placed.


VI. REGULATED WASTE

All blood and other potentially infectious regulated waste materials are to be placed in durable leak-proof containers that are appropriately color-coded or labeled. As feasible, all containers should be autoclaved prior to disposal. Containers that will be autoclaved should have an indicator strip placed on the container prior to autoclaving. Autoclaved containers should be over-packed in sealable containers that are opaque to the inner containers. These containers can then be placed in any solid waste trash dumpster.

Containers that are not autoclaved prior to disposal should have no liquid or semi-liquid blood or OPIM. Contact Environmental Health and Safety to coordinate or receive instructions on the appropriate waste disposal methods.

The following discard and containment procedures applies to all locations and personnel that use single-use sharps, other sharps and broken glassware. The procedure also applies to all personnel that are needle dependant for insulin, allergy, or other shots, while on campus. Needle dependant personnel will be offered containers for proper handling of contaminated needles. The Health Center will supply empty containers and dispose of full containers.

  1. Contaminated sharps shall be discarded immediately or as soon as feasible in single use containers that are: a) closable, b) puncture resistant, c) leak-proof, d) appropriately labeled or color coded, and e) designed with an opening that will not allow easy access of any body part.
  2. During use, 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, b) maintained upright throughout use, c) maintained closed when not in use; and d) replaced routinely and not allowed to overfill.
  3. When moving containers of contaminated sharps from the area of use, the containers shall be: a) closed to prevent spillage or protrusion of contents during handling, storage, transport or shipping; b) if damaged, placed in a secondary container as specified in section A above, if leakage is possible.

The following discard and containment procedures applies to all locations and personnel that generate non-sharps regulated waste.

  1. Regulated wastes shall be discarded immediately or as soon as feasible in single use containers that are: a) closable, b) leak-proof, and c) appropriately labeled or color coded.
  2. During use, containers shall be: a) easily accessible to personnel and located as close as is feasible to the immediate area; b) maintained upright throughout use, c) maintained closed when not in use, and d) replaced routinely and not allowed to overfill.
  3. When moving containers from the area of use, the containers shall be: a) closed to prevent spillage or protrusion of contents during handling, storage, transport or shipping, b) if damaged, placed in a secondary container as specified in section A above, if leakage is possible.

Soiled sanitary napkins and other feminine hygiene products do not have to be treated as a regulated waste. However, the containers for these products shall be lined with a plastic or wax paper bag and the personnel handling the bags should wear suitable gloves.


VII. CONTAMINATED LAUNDRY

Contaminated laundry includes any garments, whether the employer's or employee's, or other laundry spotted with visible blood or other potentially infectious materials.

Contaminated laundry is to be handled as little as possible and with a minimum of agitation. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use. Contaminated laundry shall be placed and transported in appropriately labeled or color-coded bags or containers.

Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.

All contaminated laundry must be delivered to a departments designated laundromat in leak-proof bags or containers that are appropriately labeled or color-coded. Facilities that have minimal use of laundry services, not including the Campus Health Center and Health, Physical Education and Recreation Department, are recommended to use disposable clothing.


VIII. HEPATITIS B VACCINATION, POST-EXPOSURE EVALUATION AND FOLLOW-UP

UW - La Crosse, at no cost to the employee, shall make available hepatitis B vaccination to all employees who have occupational exposure. All vaccinations, post-exposure evaluations and follow-ups will be coordinated by the Human Resources Office. Hepatitis B vaccinations will be offered by the Health Center.

All medical evaluations and procedures, including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, will be performed by or under the supervision of a licensed physician or another licensed healthcare professional. All such actions will be provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place. All laboratory tests will be conducted by an accredited laboratory at no cost to the employee.

Hepatitis B Vaccination

The employee shall be offered an opportunity to receive hepatitis B vaccination at the conclusion of the initial bloodborne pathogen exposure avoidance training session. The employee must initially accept or decline the opportunity to accept the vaccination within 10 working days.

If an employee initially declines hepatitis B vaccination but at a later date while still covered under this standard decides to accept the vaccination, UW - La Crosse shall make the vaccination available at that time.

If subsequent recommendations from the U.S. Public Health Service indicate that a "booster" dose of the vaccine is required, such dose will be offered by UW - La Crosse, at no cost, to all employees who have occupational exposure.

Any employee who declines to receive the hepatitis B vaccination for any reason shall sign the appropriate statement of declination that appears on the Information/Authorization Form for Hepatitis Type B Immunization (Appendix B).


IX. POST-EXPOSURE EVALUATION AND FOLLOW-UP

Any employee with occupational exposure who has an exposure incident shall follow the procedures outlined in Appendix C.

Following a report of an exposure incident the University of Wisconsin - La Crosse shall, in coordination with any private or contract healthcare provider, immediately make available to the exposed employee a confidential medical evaluation and follow-up.


X. INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL

The University of Wisconsin - La Crosse Human Resources Office and the healthcare professional evaluating an employee after an exposure incident will coordinate data-sharing consistent with the Bloodborne Pathogens Standard and the Health Information Portability and Accountability Act (HIPAA).


XI. HEALTHCARE PROFESSIONAL'S WRITTEN OPINION

Within 15 days of the completion of the evaluation of an exposed employee, the UW - La Crosse Human Resources Office will assure the employee receives healthcare professional's written opinion containing the below listed information.

  1. In the case of evaluation of hepatitis B vaccination requirements, a statement regarding the need for vaccination and whether the employee has received such vaccination.
  2. In the case of post-exposure evaluation and follow-up, a statement limited to the following information: a) that the employee has been informed of the results of the evaluation, b) 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, c) all other findings or diagnoses shall remain confidential and shall not be included in the written report.

XII. RECORDKEEPING

The UW La Crosse Human Resources Office in coordination with the UW Office of Safety and Loss Prevention (worker's compensation function) shall maintain in the standard employee medical record an account of any occupational exposure. Such record will include the following:

  1. name and social security number of the employee;
  2. 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;
  3. a copy of all results of examinations, medical testing, and follow-up procedures relating to post-exposure evaluation and follow-up of an exposure incident;
  4. the employer's copy of the healthcare professional's written opinion; and
  5. a copy of the information provided to the healthcare professional as described above.

All employee medical records are confidential and are not to be disclosed or reported to any person within or outside of UW - La Crosse without the express written consent of the employee except as may be required by law. These records are to be retained by the University of Wisconsin for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.20.

Employee training records shall be maintained for at least three years from the date on which the training occurs. A copy of all training records should be forwarded to Environmental Health and Safety and Human Resources.


XIII. COMMUNICATION OF HAZARDS TO EMPLOYEES

Training

UW - La Crosse shall ensure that all employees with occupational exposure participate in a training program which will be provided during working hours and at no cost to the employee. Training shall be provided before the time of initial assignment to tasks where occupational exposure may take place and annually thereafter. Personnel will be informed in writing of annual training dates.

If there are modifications of tasks or procedures, or institution of new tasks or procedures that affect the employee's occupational exposure, UW - La Crosse shall provide additional training that addresses these newly created exposures.

The training program shall contain the following elements:

  1. an accessible copy of 29 CFR 1910.1030 and an explanation of its contents;
  2. a general explanation of the epidemiology and symptoms of bloodborne diseases;
  3. an explanation of the modes of transmission of bloodborne pathogens;
  4. an explanation of UW - La Crosse's exposure control standard and the means by which the employee can obtain a copy of the written standard;
  5. an explanation of how to recognize tasks and other activities that may involve exposure to blood and other potentially infectious materials;
  6. 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;
  7. information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;
  8. an explanation of the basis for selection of personnel protective equipment;
  9. information on hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
  10. information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;
  11. 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;
  12. information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident;
  13. an explanation of any signs, labels or color coding utilized; and
  14. an opportunity for interactive questions and answers with the person conducting the training session.

The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program, as it relates to the work-place that the training will address.

Labels and signs

Biohazard warning labels shall be affixed to containers of regulated waste, refrigerators, freezers and contaminated equipment containing blood or other potentially infectious materials, contaminated laundry; and other containers used to store, transport or ship blood or other potentially infectious materials. Red bags or red containers may be substituted for labels.

Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.


XIV. CONTRACT LABOR

It is UW - La Crosse's policy to have all independent contract service providers handle the compliance requirements for their employees. Purchasing shall ensure that compliance with the OSHA Bloodborne Pathogens Standard is included as a contract requirement whenever contract service or contract labor is procured. UW - La Crosse will work with contract employers to ensure compliance with the Standard.


XV. STUDENTS

Students who have a reasonably anticipated exposure to blood or other potentially infectious materials through their involvement with campus sponsored curricula, programs or activities, will be informed of these potential hazards. This policy does not refer to the student acting as a "good Samaritan". To the extent feasible, UW - Lacrosse will take actions to reduce student exposure to bloodborne pathogens.

The student is responsible for determining their acceptance or avoidance of the hazard and circumstances that can result from this decision. If the student determines that the hazard poses an unreasonable risk, the student may, after consultation and agreement with the instructor or other directly affected campus employee, decline to accept the risk without detrimental affect on their grade. However, additional justified assignments may be required to fulfill course-work requirements.

Course instructors, coaches, and other campus employee's who are involved with students that could have an exposure incident should take the following actions.

  1. Train students, to the level necessary, in the epidemiology and transmissivity of HBV and HIV, methods to reduce exposures, vaccination availability from Health Center, post exposure follow-up, waste handling procedures and appropriate use of PPE. Special emphasis should be placed on financial issues related to exposure prevention and prophylaxis.
  2. Present required information to the student in the first course session or meeting, and as necessary.
  3. Insure that students use PPE. All PPE, except for eye protection, will be provided to the student by UW - La Crosse. The minimum level of PPE for students will be gloves and eye protection.
  4. Take action to eliminate or reduce the use/volume of human blood and other potentially infectious materials. In addition, use less virulent organisms whenever possible.

To allow students to engage in hazardous activities without risk communication, proper training and ensuring the use of appropriate PPE, opens UW-L to liability under legal negligence theories.

Any student who has exposure to blood or other potentially infectious materials should be informed to follow the procedure described in Appendix C-1, Procedures for Students Following an Exposure Incident.

Students should be informed that they will not be directly charged for professional healthcare administered by Health Center staff. However, the student will be billed for any medical services provided by private healthcare professionals, which they seek on their own accord. Based upon the potential costs associated with treatment, students may desire to acquire private medical insurance coverage.

When evaluating students who have had an exposure incident the Health Center should make appropriate recommendations based upon their professional judgment and guidelines established by the Centers for Disease Control, for evaluation and post exposure follow-up.

Students who are not employees shall be prohibited from handling contaminated laundry and handling, treatment, or sewering of infectious waste, other than the handling required to immediately containerize an infectious waste generated by their laboratory or academic procedures. Students who are not employees shall be prohibited from the handling of contaminated laundry for University related purposes.


XVI. GOOD SAMARITANS AND VOLUNTEERS

Personnel who volunteer their services to the University should not ordinarily be requested or allowed to conduct any work that could reasonably be anticipated to result in exposure to human blood or other potentially infectious materials. If it is reasonably anticipated that the volunteer may have a potential for an exposure incident, the organization requesting the volunteer should ensure that the individual receives exposure control training, PPE is provided and other necessary actions are taken to minimize or eliminate an exposure incident. The campus organization which accepts the volunteer assistance is responsible for compliance with this policy.

Personnel who respond to incidents involving blood or other potentially infectious materials, that are not identified as having occupational exposure in Section I, Exposure Determination, are treated as "Good Samaritans". A "Good Samaritan" is defined as any individual not covered by this written program that responds to an unexpected emergency in an unofficial capacity.

Any "Good Samaritan" or volunteer who has exposure to blood or other potentially infectious materials should be informed to follow the procedure described in Appendix C-2, Procedures for Volunteers and Good Samaritans Following an Exposure Incident.

Good Samaritans and Volunteers medical costs associated with post exposure evaluation and follow-up will not be covered by this written Bloodborne Pathogens Program


APPROVAL

This written Bloodborne Pathogens Exposure Control Program and its Appendices are effective immediately. All personnel shall fulfill their responsibilities as designated within the written program and appendices.

Written Signature and Date on File in Environmental Health and Safety Office


APPENDICES

Appendix A Implementation and compliance responsibility and schedule.

Appendix B Hepatitis B vaccination procedures and information

Appendix C Procedures for employees and supervisors following an exposure incident.

Appendix C1 Procedures for students following an exposure incident.

Appendix C2 Procedures for good Samaritans and volunteers following an exposure incident.