Bloodborne Pathogens Exposure Control Plan
Biosafety Officer: Ryan Bartlett, [email protected], (406) 994-6733
MSU Office of Research Compliance
Table of Contents
Certification and Approvals
- Safety and Risk Management and Office of Research Compliance
- Individual Personnel
- Exposure Control Plan
- Universal Precautions
- Safe Work Practices
- Engineering Controls
- Personal Protective Equipment (PPE)
- Sharps Policy
- Research Handling Human Blood, OPIM, Bloodborne Pathogens, or Human Derived Tissue Cultures
- Requirements that may exceed those for research laboratories not involved in the above activities include
- During business hours (between 8 AM and 6PM, Monday through Friday)
- After business hours (between 6 PM and 8 AM, and on weekends)
- Medical Evaluation and Follow up
Montana State University (MSU) is committed to providing a safe and healthful work environment for our employees and students. In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910. 1030, “Occupational Exposure to Bloodborne Pathogens.”
The ECP is a key document to assist MSU in implementing and ensuring compliance with the standard, thereby protecting our employees and students. This ECP includes:
- Implementation of various methods of exposure control, including:
- Universal precautions
- Engineering and work practice controls
- Personal protective equipment (PPE)
- Hepatitis B vaccinations and immune surveillance
- Determination of employee exposure
- Post-exposure evaluation and follow-up
- Communication of hazards to employees and training
- Procedures for evaluating circumstances surrounding exposure incidents
Safety and Risk Management (SRM) and the Office of Research Compliance (ORC) are responsible for implementation of the ECP through the Occupational Health Program (OHP) and Biosafety Office (BSO). SRM and ORC will oversee the implementation of the ECP, along with developing, in cooperation with administrators and departmental authorities, any additional policies and practices needed to support the implementation of the ECP. SRM and the ORC will maintain, review, and update the ECP annually, and whenever necessary to include a new or modified tasks and procedures. Training will be coordinated by SRM and ORC and will work with supervisors in the evaluation of employee exposure potential. SRM and ORC will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained.
Departments that have employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP. Departments must also identify personnel governed by the ECP, meet training requirements, ensure proper training and records are maintained.
Supervisors (managers, directors, supervisors, and principal investigators) are responsible for identifying personnel who may have exposure to human blood, bloodborne pathogens, or OPIM during the performance of their assigned duties.
In addition, supervisors are required to provide and maintain necessary personal protective equipment (PPE) in the necessary sizes, labels, and biohazardous waste containers as required by the standard.
Individuals who are determined to have occupational exposure to human blood or OPIM must comply with the procedures and requirements presented in this ECP. Individuals must share responsibility for acting in a safe manner and should consult with theirsupervisors regarding the safe handling and proper disposal of human blood or OPIMs. Individuals must complete initial required training and annual retraining thereafter, report job related bloodborne pathogen exposures to supervisors and OHP, and wear all necessary PPE.
Occupational exposure is defined as reasonably anticipated skin, eye, mucous membrane, or parenteral (non-ingested) contact with human blood or potentially infectious material (OPIM) that may result from the performance of an employee’s duties.
An exposure incident would involve contact with blood or other potentially infectious body fluid through:
- Percutaneous (needle stick, puncture or cut through the skin)
- Mucousmembrane (contact with eyes, mouth, nasal passage)
- Non-intactskin (contact through cuts, abrasions in the skin)
- Inhalation (inhaling aerosols)
Bloodborne pathogens are microorganisms found in human blood that can infect and cause disease when persons are exposed to blood that contain the microorganisms. While there are many bloodborne pathogens, the 3 specifically covered in this ECP are:
- Human Immunodeficiency Virus (HIV) – causes Acquired Immunodeficiency Syndrome (AIDS)
- Hepatitis B Virus (HBV)
- Hepatitis C Virus (HCV)
Materials that can contain bloodborne pathogens. OPIMsinclude:
- Human blood and blood products
- Semen or vaginal secretions
- Internal human body fluids, including cerebrospinalfluid, and fluids from joints,
chest cavity, heart sac or abdomen
- Breast milk (only if ingested)
- Unfixed human tissues or organs (both living and dead)
- Human cell lines not documented to be free of bloodborne pathogens
- Blood, tissues, or cell lines from animals experimentally infected with bloodborne
- Cultures or any liquid containing bloodborne pathogens (this includes culture media)
- Equipment contaminated with human blood or OPIMs
- Other body fluid(s) visibly contaminated with human blood
- Any body fluid that is difficult to differentiate from other fluids
The following are not considered to be OPIMs unless they are visibly contaminated
blood, or it is difficult or impossible to distinguish:
- Saliva (except during dentalprocedures)
- Nose fluids
- Intact human skin (from living or dead source)
The following is a list of all job classifications at MSU in which personnel have occupational exposure to human blood or OPIM:
- Personnel working with or conducting research on human blood, OPIMs, unfixed human tissues and organs, and/or cultures derived from human cells or tissues
- Personnel conducting research on HIV and/or Hepatitisviruses
- Emergency responders, police officers, and personnel administering first aid
- Personnel whose regular job duties include contact with or clean-up of blood spills or other potentially infectious material (e.g. select custodial staff, plumbers, laborers, student health, college of nursing, sports facilities and athletics, maintenance personnel, etc.)
Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training.
All employees can review this plan at any time during their work shifts.
Go to http://www.montana.edu/biosafety/exposurecontrolplan or contact SRM or ORC at 406-994-7870 or 406-994-6757 respectively. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.
SRM and ORC are responsible for reviewing and updating the ECP annually, or more frequently if necessary, to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with potential occupational exposure.
All employees will utilize universal precautions, which are an approach to prevent the occupational exposure to human blood or OPIM. According to the concept of universal precautions, all human blood, tissue, and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other bloodborne pathogens.
Safe work practices are designed to reduce the likelihood of occupational exposure, and include the following:
- No eating, drinking, or chewing tobacco or gum
- No applying cosmetics or handling contact lenses
- No storage of food for human consumption in refrigerators, freezers, cabinets, or any other area that may be contaminated with human blood or OPIM
- PPE requirements (gloves, lab coats, eye protection as warranted) in any circumstance
where there is the possibility of contact with human blood or OPIM
- Gloves must be changed after becoming torn or contaminated
- Hands must be washed after glove removal
Additionally, when working with human blood, OPIM, or when conducting research on HIV, HBV, HCV, or other human bloodborne pathogens, personnel must follow:
- Follow standard operating procedures(SOP) to minimize the generation of aerosols caused by splashing, splattering, and generating droplets.
- Use leak proof and non-breakable containers.
- Use caution when working with sharps such as needles, razor blades, scalpels, or broken glass.
- Properly dispose of sharps in appropriate sharps containers.
- Not recap, remove, sheer, or break needles; instead, drop directly into sharps containers.
- Ensure that unsterilized containers of blood or OPIM are labeled as a biohazard.
- Keep waste containers near the work area.
- Use a biosafety cabinet whenever possible to contain potentially dangerous aerosols.
- Decontaminate all equipment prior to servicing or shipping.
- Follow proper autoclaving and disposal procedures for biohazardous waste.
These engineering and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens:
- Sharps engineered for safer use (i.e. self-sheathing needles, needless systems etc.)
- Sharps containers
- Eyewash stations
- Biosafety cabinets
MSU identifies the need for changes in engineering controls and work practices through review of OSHA recommendations, employee interviews, risk assessment, and committee discussions. New procedures and products are evaluated regularly by literature review, supplier information, and risk assessment. Individual laboratories and departments are responsible for ensuring that these recommendations are implemented. SRM/ORC will provide sharps and broken glass containers to laboratories and departments upon request. To request sharps or broken glass containers, please fill out a sharps container request pickup form.
PPE is provided to employees at no cost to them by individual laboratories or departments. Training in the use of the appropriate PPE for specific tasks or procedures is provided by the supervisors. Supervisors may contact OHP or BSO for informational or appropriate PPE assistance.
The types of PPE available to employees if needed are as follows:
- Gloves (latex or nitrile)
- Eye protection (safety glasses or face shield)
- Protective clothing (lab coat, gown, apron)
- Respiratory protection
PPE is provided by individual laboratories or departments and may be obtained through the supervisors.
All employees using PPE must observe the following precautions:
- Wash hands immediately after removing gloves and other PPE.
- Before leaving the work area, remove contaminated PPE and dispose of properly.
- Discard disposable PPE in biohazard bags, and autoclave non-disposable PPE before placing in dedicated laundry bags.
- Wear appropriate (latex or nitrile) gloves when contact with blood or OPIM is possible, and when handling or touching contaminated materials.
- Immediately replace gloves if their ability to function as a barrier is compromised; wash hands before putting on new pair.
- Face shields, safety glasses, and certain respirators may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration
- Never reuse latex, nitrile, or other disposable gloves.
- Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to eye nose, or mouth
- Remove any contaminated garments (street clothes and/or PPE) immediately or as soon as feasible.
Facilities Services, Axillary Services, and Athletics must work together with supervisors and departments to ensure that the following conditions are met:
- Decontamination must be performed with disinfectants registered for destruction of HBV, HCV, and HIV.
- Equipment and surfaces must be clean and decontaminated after contact with blood or OPIM.
- Bins/pails (e.g. wash basins) need to be cleaned and decontaminated as soon as feasible after visible contamination.
- Spills of blood or OPIM should be cleaned up as soon as possible by personnel specifically trained for bloodborne pathogen spill response.
- Regulated waste needs to be placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling.
- Broken glassware must be picked up using mechanical means (e.g. tongs, dustpan and brush) and disposed of in an appropriate sharps container.
- Contaminated sharps are discarded as soon as possible into containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled or color coded. Sharps disposal containers are availablethrough supervisors and must be located where sharps are being used.
- Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.
- Do not reach into waste bins – biohazard waste bins should be closeable with leakproof bottom and sides and lined with a biohazard bag. Biohazardous waste bins should be emptied when ¾ full and disposed of per Montana State University procedures.
- Disposal of biohazardous waste:
Supervisors must instruct employees in the proper disposal and procedures when using biohazard bags.
Biohazard bags must be autoclaved and placed in black trash bags before they can be disposed of in the regular trash stream.
Waste containers must be in an upright position and replacedroutinely.
Containers with blood or OPIM must be closed after use prior to disposal or transfer to an autoclave.
Most of the body fluids directed into the sanitary system are not regulated under the OSHA Bloodborne Pathogens Standard. However, because diseases are associated with exposure to sewage, certain employees who are involved in drain plumbing activities will be provided equipment to prevent contact with this type of material.
- Flush piping with excess water prior to maintenance of drain piping if possible.
- Wear appropriate gloves before breaking into the drain system.
- If drain traps are removed, disassemble carefully and inspect contents for human blood or OPIM and sharps.
- Immediately place any sharp objects into sharps containers.
- Handle contaminated material, especially sharps, with tongs.
- In addition to the steps outlined for general drain repairs, employees should take additional protective measures when repairing drains in laboratories to prevent contact with drain contents.
- Confirm from laboratory personnel that any necessary decontamination has been performed prior to entry into the lab.
- Wear appropriate gloves, eye protection, and mask before starting repairs.
- If there is a likelihood that drain material will splash onto clothing, wear fluid-resistant coveralls.
- Wear disposable utility gloves for all sewage cleanup.
- If cleanup activities will cause splashing, wear eye protection and a disposable respiratory protection mask.
- Disinfect all reusable equipment prior to removal from the site.
- Wear waterproof boots especially if sewage depth exceeds an eighth of an inch.
- Wear waterproof coveralls if cleaning activities might produce splashing of personnel clothing or skin.
- Remove sewage materials from floors and other surfaces and dispose into a functioning sanitary drain.
- During cleanup, watch for visible human blood and sharps.
- Place sharps into sharps containers.
- Handle sharps with tongs.
- After removal of the majority of the sewage material, apply appropriate disinfectant.
- Hard surfaces should be wiped clean and left to dry after disinfection.
- Decontaminate porous surfaces with an appropriate disinfectant and allow to air dry. Application of bleach solutions to carpets, furnishings, etc., should be avoided.
Sharps must be handled and disposed of in approved sharps containers.
- Extreme caution must be used when working with sharp objects such as needles, scalpels, razor blades, or broken glass and properly dispose of sharps in appropriate sharps containers.
- Always properly dispose of sharps in designated sharps containers.
- Needles shall be disposed of in labeled sharps containers. Avoid recapping.
- Sharps containers are inspected and maintained or replaced by designated individuals as needed or whenever necessary to prevent overfilling.
- Needles should not be recapped, yet some applications may require re-capping. In those cases, the use of re-capping needles or mechanical re-capping devices are strongly recommended. If these alternatives are not feasible, then the one-handed scoop method for re-capping should be employed:
Place the cap on the counter top and “scoop” it up with the needle, keeping your free hand out of the way.
Needles and other sharps should be handled as little as possible. Handling sharps for transport, cleanup or disposal must be done using mechanical device (broom and dust pan, forceps).
- Breaking or shearing needles is prohibited.
- Controls should be used to prevent needle stick injuries, and include specially engineered sharps injury protection (e.g., luer-lock syringes, permanent needle and syringe combination, self-sheathing needles, or needle-less systems).
Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled or color coded. Sharps disposal containers are available through SRM and must be easily accessible and as close as feasible to the immediate area where sharps are used.
Broken glassware that may be contaminated is only picked up using mechanical means, such as a brush and dustpan.
The following contaminated articles will be laundered by individual departments:
- Lab coats and scrubs: place in clean biohazard bag and autoclave beforehand.
- Sports towels
- Personal clothing known or believed to be contaminated with bloodborne pathogens
- Towels provided in showering facilities
Laundering provided by departments needs to be performed in house or by a designated laundry service.
The following laundering requirements must be met:
- Handle contaminated laundry as little as possible, with minimal agitation.
- Autoclave in a biohazard bag to decontaminate; then place in laundry stream.
- Place wet contaminated laundry in leak-proof containers labeled as biohazardous before transport
- Wear the following PPE when handling and/or sorting contaminated laundry: gloves, eye protection
The following labeling methods are used at MSU:
- Biohazard label for all equipment used with or to store infectious material (sharps container, biohazardous trash, refrigerators, freezers, and centrifuges and any other equipment that has come in contact with potentially infectious materials).
Supervisors are responsible for ensuring that biohazard labels are affixed on orange or red bags, and are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify SRM or ORC if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.
Principal Investigators (PIs) and departments must provide additional appropriate administrative controls, protective equipment, information and training as appropriate for all employees engaged in:
- Culture, concentration or research of HIV, HBV, or HCV and/or other bloodborne pathogens.
- Work with human or animal cell lines potentially infected with bloodborne pathogens.
Note: Certain cell lines may be exempt from this requirement. PIs must consult with OHP/BSO to determine specific exemptions.
- Manipulation of human blood or OPIM.
- Manipulation of animal blood or tissue cultures experimentally infected with HIV, HBV, or HCV.
Requirements that may exceed those for research laboratories not involved in the above activities include:
- Closed, locked when not attended, laboratory doors and limited lab access
- Appropriately labeled laboratory access doors
Work Practices and Administration
- Site specific training must document that personnel have:
- Taken the online CITI Biosafety training
- Read the MSU Biosafety Manual
- All spills must be contained or cleaned up immediately
- All spills and accidents must be reported immediately to the supervisor and OSP/BSO
- All waste must be decontaminated appropriately
- Transportation of contaminated materials for decontamination must be performed in a primary and secondary leak proof container
- Site specific training must document that personnel have:
- Certified biosafety cabinets
- Centrifuge containment devices
- Autoclave or other effective decontaminating method for decontamination of waste
- HEPA filters for vacuum lines
- Leak proof and appropriately labeled containers for transporting contaminated materials
- Handwashing sink
- Eyewash station
- Safety needles/syringes will be used whenever possible
- Caution is to be used whenever performing procedures with sharps
- Needles should not be recapped, bent, or removed from syringe after use
- Sharps will be place in sharps container immediately after use
Personal Protective Equipment
- Lab coats, gowns, or other appropriate clothing are required when working with bloodborne pathogens.
- Gloves must be worn when manipulating potentially infected materials.
- Personal Protective Equipment must not be worn outside the work area.
The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the exposure determination section of this plan. Vaccination is encouraged unless: 1) documentation exists that the employee has previously received the series; 2) antibody testing reveals that the employee is immune; or 3) medical evaluation shows that vaccination is contraindicated.
Each employee must indicate whether they wish to be vaccinated or not by signing a Declaration of Vaccination Preference form. Employees who initially decline may receive the vaccination later at no cost. Documentation of vaccination or refusal of the vaccination is kept by Occ Health.
Vaccination, antibody testing, and medical evaluation information will be provided by the designated MSU Occupational Health Provider.
Individuals handling material with potential bloodborne pathogens have the responsibility to report any exposure to their supervisor and to OHP and BSO. Medical information will be held confidential and will not be released without permission of the employee.
Immediate Actions to be Taken After an Exposure Incident
- Stop all activity
- Rinse affected areas affected by splash with water for a minimum of 5 minutes
- Express area, encourage outward flow where skin integrity is compromised
- Cleanse all exposed skin with soap and water as soon as possible following an exposure incident
- Record the name and phone number of the source individual (if known, and location and time of incident)
- Notify your supervisor and SRM. All exposures must be reported to the supervisor and OHP/BSO
- The supervisor will work with SRM for reporting and follow up
- Seek medical attention immediately:
- Attention must be sought at: Bridger West - Occupational Health & Urgent Care 3406 Laramie Dr., Bozeman, MT
- Attention must be sought at: Bozeman Deaconess Hospital Emergency Room 915 Highland Blvd, Bozeman, MT
- Follow up must be performed with SRM at 994-7384
- Medical charges to be considered for Worker’s Compensation, will need to file a report of injury, which must be completed within 24 hours of injury/incident at: https://www.montana.edu/firstreport/SRM/firstReport.php
An immediate confidential medical evaluation will be conducted by the medical provider.
This procedure includes:
- Documentation of the route(s) of exposure and how it occurred.
- Identification of the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
- If permission is given, testing arrangements to have the source individual evaluated for HIV, HCV, and HBV infectivity; source individual’s test results are documented and communicated with the employee’s health care provider. If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed.
- Assurance that the exposed employee will be provided with the source individual’s test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality).
- Collection (upon consent) of exposed employee’s blood as soon as feasible after exposure incident, and testing of blood for HBV and HIV serological status.
- Preservation of the baseline blood sample for at least 90 days in the event that the employee does not give consent for HIV serological testing; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.
SRM and the ORC ensures that health care provider(s) responsible for employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA’s bloodborne pathogens standard.
SRM ensures that the health care provider evaluating an employee after an exposure incident receives the following:
- A description of the employee’s job duties relevant to the exposure incident
- Route(s) of exposure
- Circumstances of exposure
- If possible, results of the source individual’s blood test.
- Relevant employee medical records, including vaccination status
The evaluating health care provider will provide the employee with a copy of their written opinion within 15 days after completion of the evaluation.
SRM and the ORC will review the circumstances of all exposure incidents to determine:
- Engineering controls in use at the time
- Work practices followed
- A description of the device being used (including type and brand)
- Protective equipment or clothing that was use at the time of the exposure incident
- Location of the incident
- Procedure being performed when the incident occurred
- Potential preventative measures for minimizing future occurrences
- Employee’s training
All percutaneous injuries from contaminated sharps will be documented in a sharps injury log by SRM and ORC.
If revisions to this ECP are necessary SRM and ORC will ensure that appropriate changes are made. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.)
All employees who have occupational exposure to bloodborne pathogens receive initial and annual training conducted by SRM and ORC.
Several training techniques may be used, as approved by SRM and ORC, including:
- Instructor led
- Computer aided interactive training CITI training for research activities or BLR training for non-research activities
All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of the bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:
- A copy and explanation of the OSHA bloodborne pathogen standard
- An explanation of our ECP and how to obtain a copy
- An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
- An explanation of the use and limitations of engineering controls, work practices, and PPE
- An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
- An explanation of the basis for PPE selection
- Waste management and disposal
- Disinfection strategies
- Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge.
- Information on the appropriate actions to take and persons to contact in an emergency
involving blood or OPIM
- An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
- Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
- An explanation of the signs and labels and/or color coding required by the standard and used at this facility
- An opportunity for interactive questions and answers with the person conducting the training session
Training materials for MSU are available through SRM or ORC, upon request.
It is the supervisor’s responsibility to ensure that:
- Prior to assignment duties with occupational exposure:
- Initial training is completed
- Site-specific training is completed
- The Declaration of Vaccination Preference is filed with OHP/BSO
- Vaccination, if requested, has been initiated
- Employees are re-trained annually
- Site-specific training is documented and maintained with the employee files. Copies should be submitted to SRM.
Training records are completed for each employee upon completion of training. These
documents will be kept for at least three years at SRM, ORC or in an institutional
The training records include:
- The dates of the training sessions
- The contents or a summary of the training sessions
- The names and qualifications of persons conducting the training
- The names and job titles of all persons attending the training sessions.
Employee training records are provided upon request to the employee or the employee’s authorized representative within 15 working days. Such requests should be addressed to employee’s supervisor.
Medical records are maintained by Bridger West - Occupational Health & Urgent Care for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records.” All information is confidential. Information will not be disclosed without the employee’s written consent, except as required or permitted by law.
Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to the medical provider.
All percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:
- Date of injury
- Type and brand of the device involved (syringe, suture needle)
- Department or work area where the incident occurred
- Explanation of how the incident occurred
This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.