Chapter 14

Bloodborne
Pathogens

Section 1 Presentation
Section 2 Narrative

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 Bloodborne Pathogens
• 29 CFR 1910.1030
• PURPOSE:
–limits exposure to blood
and other potentially
infectious materials

2
 Bloodborne Pathogens

• Microorganisms found in
infected blood
• Common bloodborne pathogens
–Hepatitis B Virus
–Human Immunodeficiency Virus
–Hepatitis C Virus
–Syphilis
–Malaria

3
 Hepatitis Viruses
• Hepatitis means inflammation
of the liver
• Four Types of Viral Hepatitis
– Hepatitis A
• Spread by Fecal Contamination
– Hepatitis B
• Spread by blood and bodily fluids

4
 Hepatitis Viruses
• Four Types of Viral Hepatitis
– Hepatitis C
• Spread by blood transfusion
– Hepatitis E
• Spread by Fecal/Oral
• Uncertain if present in the US

5
 Hepatitis B

• CDC estimates 300,000 people

infected annually
• Virus attacks and replicates in
liver cells
• May produce Acute or Chronic
Hepatitis
• Symptoms may not be noticeable
for 1-3 months after exposure

The CDC is the United States Center for Disease Control.

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 Acute Hepatitis

• Acute
–Antibodies destroy liver cells to
eliminate virus
–Flu like symptoms
–Jaundice
–Extreme Fatigue
–Several weeks to months of
work loss

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 Chronic Hepatitis

• The body is not able to clear

the virus from the liver cells
• Cirrhosis of the liver
• Liver cancer
• 10% of all deaths due to
cirrhosis attributed to an HBV
infection

8
 HBV Modes of
Transmission
• Injection
– most effective transmission mode
• Absorption through eyes or mouth
• Entry through skin breaks
• Sexual and Perinatal
• Blood is the most likely vehicle for
transmission but virus is also
found in saliva

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 Hepatitis Virus

• Virus can survive for at least one

week dried at room temperature
• Resistant to low level germicides
• Diluted solution of sodium
hypoclorite
–(1:10- 1:100) effective

10
 Vaccine

• Vaccine Licensed in 1982

• Given in three doses over six
months
• Protection last for at least nine
years
• Effective in 85% to 97% of
healthy adults

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 Human
Immunodeficiency Virus
• 1981 the first case is reported in
the US
• 1985 all 50 states have reported
Aids cases
• Over 400,000 confirmed cases of
AIDS in the US by 1995
• Estimated 1.5 million US citizens
infected with HIV

12
 HIV Biology

• Human Retrovirus
–Genetic material is RNA instead
of DNA
• Must reproduce in a host cell
–macrophages and lymphocytes
• Reproduction kills host cells
vital to the immune system

13
 HIV Transmission

• Parenteral or membrane
contact with infected blood
• Use of contaminated needles
• Sexual intercourse with
infected person
• Transplants of infected organs
or materials

14
 HIV and AIDS

• Most persons infected with HIV

will develop AIDS
• AIDS results in an immune
system unable to defend
against infection
• Pneumocystis Pneumonia most
common cause of death in
AIDS patients

15
Bloodborne
Pathogens
Case Study

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 1910.1030 Scope
• All employees "reasonably
anticipated"
anticipated to face
contact with blood and
other potentially infectious
materials.
–"Good Samaritan"
Samaritan acts
not considered

Be careful in taking advantage of the “Good Samaritan” provision in the standard. Just because
someone is not listed as a first responder does not necessarily mean they are a good Samaritan
when they act. Someone who is first aid trained, and his or her coworkers know it, may feel that
some action is expected of him or her when someone is injured. If that is the case then this
person is “reasonably anticipated” to face contact with potential infectious materials.

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 Infectious Materials
• Blood
• Semen
• Vaginal Secretions
• Cerebrospinal Fluid
• Synovial Fluid
• Pleural Fluid
• Pericardial fluid
• Peritoneal fluid

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 Infectious Material (cont.)

• Amniotic fluid
• Saliva in Dental Procedures
• Body Contaminated with
Blood
• Where Difficult to
Differentiate Between Body
Fluids

19
 Infectious Material (cot)

• Unfixed Tissue or Organ

• HIV Containing Cell or
Tissue Cultures
• HBV Containing
Cell or Tissue
Cultures

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 Exposure Control Plan

• Exposure Occurrence
–tasks & procedures
–job classifications
–without regard to PPE

Your exposure control plan must be site-specific. The tasks and procedures should be specific to
your employees and the tasks they perform. Your exposure control plan should list all job
classifications that are reasonably anticipated to be exposed. An employee is considered
“reasonably anticipated” even if he or she wears PPE for protection from the hazard.

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 Exposure Control Plan
(cont..)
• Location and
Accessibility of Program
• The Exposure Control
Plan is updated annually

The Exposure Control Plan must be assessable to all “reasonably anticipated” persons.

22
 Post Exposure
Procedures

Your Exposure Control Plan must include post exposure procedures. These procedures should
clearly outline, step-by-step, exactly how to handle an exposure.

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 Compliance Methods

• Universal Precautions
–treat body
fluids/materials as if
infectious

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 Compliance (cont..)

• Engineering Controls
• Work Practice Controls
• Handwashing

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 Compliance (cont..)

• Acceptable Disinfectants
–EPA Registered Tuberculocidal
Disinfectant
–A Solution of 5.25 percent
sodium hypochlorite
(household bleach) diluted
between 1:10 and 1:100 with
water

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 Compliance (cont..)

• Procedures to Minimize
Needlesticks
• Minimize Splashing and
Spraying of Body Fluids
• Appropriate Packaging
of Specimens

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 Compliance (cont..)

• Appropriate PPE
• Hepatitis B Vaccination
• Post-Exposure
Evaluation and Follow-up

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 Labeling

• Biohazard Symbol
–containers of waste
• Red Bags or Containers
Instead of Labeling

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BIOHAZARD

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 Labeling

• Signs to Identify Restricted

Areas
–in HIV & HBV Research
Laboratories and
Production Facilities

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 Labeling Exceptions

• Facility Wide Use of

Universal Precautions
• Blood Tested and Found
Free of HIV or HBV
• Decontaminated Regulated
Waste

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 Training

• Bloodborne Pathogens
training will occur annually
• Training will occur if there
is a change in exposure
• Incidents occur suggesting
the need for refresher
training

33
 Required PPE

• PPE
–Selection –Decon
–Types –Handling
–Use –Disposal
–Location
–Removal

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 Recordkeeping

• Access to Medical Records

–Kept for Duration of
Employment + 30 Years
•Confidential

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 Medical Records
Include
• Name
• Social Security Number
• HBV Vaccination Status
• Results of any Exams
• Medical Testing & Follow-
up

36
 Medical Records
Include
• Healthcare Professional's
Written Opinion
• Information Provided to
Healthcare Professional

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 Chapter 9 Bloodborne Pathogens
TABLE OF CONTENTS

TOPIC PAGE

Introduction and General Requirements ........................................................................ 1

Information and Training ................................................................................................ 4

RecordKeeping .............................................................................................................. 4

Health Effects ................................................................................................................ 4

Hepatitis Viruses ............................................................................................................ 5

Human Immunodeficiency Virus .................................................................................... 7

Needlesticks .................................................................................................................. 8

Decontamination ............................................................................................................ 9

Reporting Exposure Incidents ...................................................................................... 10

Confidentiality .............................................................................................................. 11

Vaccination .................................................................................................................. 11

PPE ............................................................................................................................. 12

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 BLOODBORNE PATHOGENS
PURPOSE
Limits occupational exposure to blood and other potentially infectious materials since
any exposure could result in transmission of bloodborne pathogens which could lead to
disease or death.

SCOPE
Covers all employees who could be "reasonably anticipated" as the result of performing
their job duties to face contact with blood and other potentially infectious materials.
OSHA has not attempted to list all occupations where exposures could occur. "Good
Samaritan" acts such as assisting a co-worker with a nosebleed would not be
considered occupational exposure.

Infectious materials include semen, vaginal secretions, cerebrospinal fluid, synovial

fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any body fluid visibly contaminated with blood and all body fluids in
situations where it is difficult or impossible to differentiate between body fluids. They
also include any unfixed tissue or organ other than intact skin from a human (living or
dead) and human immunodeficiency virus (HIV)- containing cell or tissue cultures,
organ cultures and HIV or hepatitis B (HBV)-containing culture medium or other
solutions as well as blood, organs or other tissues from experimental animals infected
with HIV or HBV.

EXPOSURE CONTROL PLAN

Requires employers to identify, in writing, tasks and procedures as well as job
classifications where occupational exposure to blood occurs--without regard to personal
protective clothing and equipment. It must also set forth the schedule for implementing
other provisions of the standard and specify the procedure for evaluating circumstances
surrounding exposure incidents. The plan must be accessible to employees and
available to OSHA. Employers must review and update it at least annually--more often if
necessary to accommodate workplace changes.

METHODS OF COMPLIANCE
Mandates universal precautions, (treating body fluids/materials as if infectious)
emphasizing engineering and work practice controls. The standard stresses
handwashing and requires employers to provide facilities and ensure that employees
use them following exposure to blood. It sets forth procedures to minimize needlesticks,
minimize splashing and spraying of blood, ensure appropriate packaging of specimens
and regulated wastes and decontaminate equipment or label it as contaminated before
shipping to servicing facilities.

Employers must provide, at no cost, and require employees to use appropriate personal
protective equipment such as gloves, gowns, masks, mouthpieces and resuscitation
bags and must clean, repair and replace these when necessary. Gloves are not
necessarily required for routine phlebotomies in volunteer blood donation centers but

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must be made available to employees who want them.

The standard requires a written schedule for cleaning, identifying the method of
decontamination to be used in addition to cleaning following contact with blood or other
potentially infectious materials. lt specifies methods for disposing of contaminated
sharps and sets forth standards for containers for these items and other regulated
waste. Further, the standard includes provisions for handling contaminated laundry to
minimize exposures.

HEPATITIS B VACCINATION
Requires vaccinations to be made available to all employees who have occupational
exposure to blood within 10 working days of assignment, at no cost, at a reasonable
time and place, under the supervision of licensed physician/licensed healthcare
professional and according to the latest recommendations of the U.S. Public Health
Service (USPHS). Prescreening may not be required as a condition of receiving the
vaccine. Employees must sign a declination form if they choose not to be vaccinated,
but may later opt to receive the vaccine at no cost to the employee. Should booster
doses later be recommended by the USPHS, employees must be offered them.

POST-EXPOSURE EVALUATION AND FOLLOW-UP

Specifies procedures to be made available to all employees who have had an exposure
incident plus any laboratory tests must be conducted by an accredited laboratory at no
cost to the employee. Follow-up must include a confidential medical evaluation
documenting the circumstances of exposure, identifying and testing the source
individual if feasible, testing the exposed employee's blood if he/she consents, post-
exposure prophylaxis, counseling and evaluation of reported illnesses. Healthcare
professionals must be provided specified information to facilitate the evaluation and
their written opinion on the need for hepatitis B vaccination following the exposure.
Information such as the employee's ability to receive the hepatitis B vaccine must be
supplied to the employer. All diagnoses must remain confidential.

HAZARD COMMUNICATION:
Requires warning labels including the orange or orange-red biohazard symbol affixed to
containers of regulated waste, refrigerators and freezers and other containers which are
used to store or transport blood or other potentially infectious materials. Red bags or
containers may be used instead of labeling. When a facility uses universal precautions
in its handling of all specimens, labeling is not required within the facility. Likewise,
when all laundry is handled with universal precautions, the laundry need not be labelled.
Blood which has been tested and found free of HIV or HBV and released for clinical
use, and regulated waste which has been decontaminated, need not be labeled. Signs
must be used to identify restricted areas in HIV and HBV research laboratories and
production facilities.

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INFORMATION AND TRAINING
Mandates training within 90 days of effective date, initially upon assignment and
annually--employees who have received appropriate training within the past year need
only receive additional training in items not previously covered. Training must include
making accessible a copy of the regulatory text of the standard and explanation of its
contents, general discussion on bloodborne diseases and their transmission, exposure
control plan, engineering and work practice controls, personal protective equipment,
hepatitis B vaccine, response to emergencies involving blood, how to handle exposure
incidents, the post-exposure evaluation and follow-up program, signs/labels/color-
coding. There must be opportunity for questions and answers, and the trainer must be
knowledgeable in the subject matter. Laboratory and production facility workers must
receive additional specialized initial training.

RECORDKEEPING
Calls for medical records to be kept for each employee with occupational exposure for
the duration of employment plus 30 years, must be confidential and must include name
and social security number; hepatitis B vaccination status (including dates); results of
any examinations, medical testing and follow-up procedures; a copy of the healthcare
professional's written opinion; and a copy of information provided to the healthcare
professional. Training records must be maintained for three years and must include
dates, contents of the training program or a summary, trainer's name and qualifications,
names and job titles of all persons attending the sessions. Medical records must be
made available to the subject employee, anyone with written consent of the employee,
OSHA and NIOSH--they are not available to the employer. Disposal of records must be
in accord with OSHA's standard covering access to records.

DATES
Effective date: March 6 1992. Exposure control plan: May 5, 1992. Information and
training requirements and recordkeeping: June 4, 1992. And the following other
provisions take effect on July 6, 1992: engineering and work practice controls, personal
protective equipment, housekeeping, special provisions covering HIV and HBV research
laboratories and production facilities, hepatitis B vaccination and post-exposure
evaluation and follow-up and labels and signs.

HEALTH EFFECTS
Certain pathogenic microorganisms can be found in the blood of infected individuals.
For the purposes of this standard, OSHA is referring to these microorganisms as
"bloodborne pathogens" and to the diseases that they cause as "bloodborne diseases."

These bloodborne pathogens may be transmitted from the infected individual to other
individuals by blood or certain other body fluids, for example, when blood-contaminated
needles are shared by intravenous drug users. Because it is the exposure to blood or
other body fluids that carries the risk of infection, individuals whose occupational duties
place them at risk of exposure to blood or other potentially infectious materials are also
at risk of becoming infected with these bloodborne pathogens, developing disease and,

4
in some cases, dying. Infected individuals are also capable of transmitting the
pathogens to others.

A discussion of two of the most significant bloodborne pathogens, hepatitis B virus, and
human immunodeficiency virus, follows. This includes a discussion of each of the
viruses, the disease each causes, modes of transmission, and documented risk of
infection resulting from occupational exposure. In addition, a discussion of other
bloodborne diseases, hepatitis C, delta hepatitis, syphilis, and malaria, is included.

HEPATITIS VIRUSES
Hepatitis means "inflammation of the liver," and can be caused by a number of agents
or conditions including drugs, toxins, autoimmune disease, and infectious agents
including viruses. The most common causes of hepatitis are viruses. There are four
types of viral hepatitis which are important in the U.S. Hepatitis A, formerly called
"infectious" hepatitis, is spread by fecal contamination and is not generally considered to
be a significant risk to healthcare workers, although episodes of transmission to
healthcare workers in hospitals have been reported. Hepatitis B, formerly called "serum"
hepatitis, is a major risk to healthcare workers and is extensively discussed in this
document. Delta hepatitis may coinfect with hepatitis B or may infect persons already
infected with HBV and can increase the severity of acute and chronic liver disease in
these individuals. Nosocomial infection with this virus has been reported.

Non-A, non-B hepatitis is caused by viral agents other than hepatitis A and hepatitis B.
Two that have been identified are hepatitis E, previously known as enterically
transmitted (ET) non-A, non-B hepatitis and hepatitis C, previously known as
parenterally transmitted (PT) non-A, non-B hepatitis. Hepatitis E transmitted by the
fecal-oral route and has occurred both in epidemic and sporadic forms in parts of Asia,
North and West Africa and Mexico. It is not known whether the virus is present in the
United States or Western Europe. Parenterally transmitted non-A, non-B hepatitis is
caused by at least one bloodborne virus, designated hepatitis C virus (HCV). This virus
is efficiently transmitted by blood transfusion and by needle sharing among IV drug
users (Exs. 6-430; 6-449; 6-286G) As there are reports of occasional transmission of
HCV to healthcare workers, this virus is discussed further in this document.

HEPATITIS B
Hepatitis B virus (HBV) infection is the major infectious bloodborne occupational hazard
to healthcare workers. The Hepatitis Branch of the Centers for Disease Control (CDC)
estimates that there are approximately 8,700 infections in healthcare workers with
occupational exposure to blood and other potentially infectious materials in the United
States each year. These infections cause over 2,100 cases of clinical acute hepatitis,
400-440 hospitalizations and approximately 200 deaths each year in healthcare
workers. Death may result from both acute and chronic hepatitis. Infected healthcare
workers can spread the infection to family members or rarely, to their patients. The use
of hepatitis B vaccine, engineering and work practice controls, and personal protective
equipment will prevent almost all of these occupational hepatitis B infections. Efforts to

5
reduce blood exposure and minimize puncture injuries in the workplace setting will
reduce the risk of transmission of all bloodborne hepatitis viruses.

HBV: Disease Outcomes

Infection with the hepatitis B virus in a susceptible person can produce two types of
outcomes: self-limited acute hepatitis B and chronic HBV infection. Similarly, the human
body can mount two types of response to HBV infection. The most frequent response
seen in healthy adults is development of self-limited acute hepatitis and the production
of an antibody against HBsAg, called anti-HBs. The production of this antibody
coincides with the destruction of liver cells containing the virus, elimination of the virus
from the body, and signifies lifetime immunity against reinfection. Persons having this
response also develop an antibody against the core protein, called anti-HBc, and
usually maintain both anti-HBc and anti-HBs in their blood for life.

The second type of response - development of chronic HBV infection - has more severe
long term consequences. About 6% to 10% of newly-infected adults cannot clear the
virus from their liver cells and become chronic HBV carriers. These individuals continue
to produce HBsAg for many years, usually for life. They do not develop anti-HBs, but do
produce anti-HBc antibody. HBV carriers are at high risk of developing chronic
persistent hepatitis, chronic active hepatitis, cirrhosis of the liver, and primary liver
cancer. About 25% of carriers develop chronic persistent hepatitis, a relatively mild,
non-progressive form of chronic liver disease, and 25% develop chronic active hepatitis.
The latter is a progressive, debilitating disease that often leads to cirrhosis of the liver
after 5-10 years.

Workplace: HBV is spread via several routes: parenteral (by direct inoculation through
the skin), mucous membranes (blood contamination of the eye or mouth), sexual, and
perinatal (from infected mother to newborn infant). The most efficient mode of
transmission is direct inoculation of infectious blood, such as might occur during blood
transfusion, needle sharing by IV drug users, or needlestick or other sharp instrument
injury in health care workers. One milliliter of HBsAg positive blood may contain 100
million infectious doses of virus; thus, exposure to extremely small inocula of HBV-
positive blood may transmit infection. In different studies, 7% to 30% of susceptible
healthcare workers sustaining needlestick puncture injuries from HBsAg positive
patients became infected if they did not receive post-exposure prophylaxis. Since 1972,
all units of blood collected for transfusion in the U.S. have been screened for HBsAg,
greatly decreasing the incidence of transfusion related HBV infection.

Blood and blood-derived body fluids (serous exudates and fluids from internal body
cavities) contain the highest quantities of virus and are the most likely vehicles for HBV
transmission. Certain other body fluids such as saliva and semen contain infectious
virus but at 1000-fold lower concentration. Other body fluids such as urine or feces
contain only small quantities of virus unless they are visibly contaminated with blood.

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Hepatitis B Vaccine
In 1982 a safe, immunogenic and effective hepatitis B vaccine derived from human
plasma was licensed in the U.S. and was recommended for use in healthcare workers
with blood or needle exposure in the workplace. A second vaccine, produced in yeast
by recombinant technology was first licensed in 1987. Since the introduction of these
vaccines, OSHA estimates a minimum of 2,568,974 persons in the United States have
been vaccinated.

NON-A, NON-B HEPATITIS

Non-A, non-B hepatitis in the United States is caused by more than one viral agent.
Studies have shown that parenterally transmitted (PT) non-A, non-B hepatitis accounts
for 20-40% of acute viral hepatitis in the U.S. and has epidemiologic characteristics
similar to those of hepatitis B. Recently, a virus designated as Hepatitis C virus (HCV)
was cloned and has been shown to account for a large proportion of parenterally
transmitted non-A, non-B hepatitis in this country. An immunoassay that detects
antibody to HCV has been developed and was licensed in May 1990 for use in
screening blood donors. Because the test is so new, there is not enough data to define
how important this pathogen is in the occupational setting. Further research will help in
clearly defining the importance of bloodborne transmission of this virus in the workplace.
The principal mode of transmission in the United States is bloodborne; therefore,
persons at greatest risk for infection include IV drug users, dialysis patients and
transfusion recipients. Over 90% of all post-transfusion hepatitis is due to the non-A,
non-B virus(es).

HUMAN IMMUNODEFICIENCY VIRUS

In June of 1981, the first cases were reported in the United States of what was to
become known as Acquired Immunodeficiency Syndrome (AIDS) (Ex. 6-382).
Investigators described an unusual illness characterized by Pneumocystis carinii
pneumonia (PCP) and Kaposi's sarcoma (KS) that developed in young, homosexual
men without a known underlying disease or cause for immunosuppression.

By early 1982, 159 AIDS cases had been identified in 15 states, the District of Columbia
and 2 foreign countries. All but one of them were men and over 92% of them were
homosexual or bisexual. By the end of 1982, cases of AIDS were reported among
children, intravenous (IV) drug users, blood transfusion recipients, hemophilia patients
treated with clotting factor concentrates, and Haitians. In 1983 the disease was also
documented among female sexual partners of male IV drug users in the U.S. and
among Africans. By the end of 1985, all 50 states, the District of Columbia and three
U.S. territories had reported AIDS cases.

During 1983 and 1984, French and American scientists independently isolated a human
virus associated with AIDS. Dr. Luc Montagnier and co-workers, of the Institute Pasteur
in Paris, called it lymphadenopathy associated virus (LAV). Dr. Robert Gallo and co-
workers at the National Cancer Institute identified this virus as human T-cell
lymphotropic virus type III. Eventually human immunodeficiency virus type 1 (HIV-1)

7
became the universally accepted term for the virus.

The increasing number of individuals with AIDS, the large number of unidentified HIV
infections, and the reports of occupational infection all indicate that exposed workers
are at risk for occupationally acquired HIV infection.

NEEDLESTICKS
On April 12, 2001 OSHA announced changes in its bloodborne pathogens standard
intended to reduce needlesticks among healthcare workers and others who handle
medical sharps.

The revisions clarify the need for employers to select safer needle devices as
they become available and to involve employees in identifying and choosing the
devices. The updated standard also requires employers to maintain a log of injuries
from contaminated sharps. Specifically, the revised OSHA bloodborne pathogens
standard obligates employers to consider safer needle devices when they conduct their
annual review of their exposure control plan. Safer sharps are considered appropriate
engineering controls, the best strategy for worker protection.

Involving frontline employees in selecting safer devices will help ensure that workers
who are using the equipment have the opportunity for input into purchasing decisions.
The new needlestick log will help both employees and employers track all needlesticks
to help identify problem areas or operations. The updated standard also includes
provisions designed to maintain the privacy of employees who have experienced
needlesticks.

NEW PROVISIONS
A needlestick or a cut from a contaminated scalpel can lead to infection from hepatitis B
virus (HBV) or human immunodeficiency virus (HIV) which causes AIDS. Although few
cases of AIDS have been documented as due to occupational exposure, approximately
8,700 health care workers each year contract hepatitis B. About 200 will die as a result.
The OSHA standard covering bloodborne pathogens specifies measures to reduce
these risks of infection.

Prompt Disposal
The best way to prevent cuts and sticks is to minimize contact with sharps. That means
disposing of them immediately after use. Puncture resistant containers must be
available nearby to hold contaminated sharps--either for disposal or, for reusable
sharps, later decontamination for re-use. When reprocessing contaminated reusable
sharps, employees must not reach by hand into the holding container. Contaminated
sharps must never be sheared or broken. Recapping, bending or removing needles is
permissible only if there is no feasible alternative or if required for a specific medical
procedure such as blood gas analysis. If recapping, bending or removal is necessary,
workers must use either a mechanical device or a one-handed technique. If recapping is

8
essential--for example, between multiple injections for the same patient--employees
must avoid using both hands to recap. Employees might recap with a one-handed
"scoop" technique, using the needle itself to pick up the cap, pushing cap and sharp
together against a hard surface to ensure a tight fit. Or they might hold the cap with
tongs or forceps to place it on the needle.

Sharps Containers
Containers for used sharps must be puncture resistant. The sides and the bottom must
be leakproof. They must be labeled or color coded red to ensure that everyone knows
the contents are hazardous. Containers for disposable sharps must have a lid, and they
must be maintained upright to keep liquids and the sharps inside.

Employees must never reach by hand into containers of contaminated sharps.

Containers for reusable sharps could be equipped with wire basket liners for easy
removal during reprocessing, or employees could use tongs or forceps to withdraw the
contents. Reusable sharps disposal containers may not be opened, emptied, or cleaned
manually.

Containers need to be located as near to as feasible the area of use. In some cases,
they may be placed on carts to prevent access to mentally disturbed or pediatric
patients. Containers should also be available wherever sharps may be found, such as in
laundries. The containers must be replaced routinely and not be overfilled, which can
increase the risk of needlesticks or cuts.

Handling Containers
When employees are ready to discard containers, they should first close the lids. If
there is a chance of leakage from the primary container, the employees should use a
secondary container that is closable, labeled or color coded and leak resistant.

Careful handling of sharps can prevent injury and reduce the risk of infection. By
following these work practices, employees can decrease their chances of contracting
bloodborne illness.

Decontamination
Every employer whose employees are exposed to blood or other potentially infectious
materials must develop a written schedule for cleaning each area where exposures
occur. The methods of decontaminating different surfaces must be specified,
determined by the type of surface to be cleaned, the soil present and the tasks or
procedures that occur in that area.

Regulated Waste
In addition to effective decontamination of work areas, proper handling of regulated
waste is essential to prevent unnecessary exposure to blood and other potentially
infectious materials. Regulated waste must be handled with great care--i.e., liquid or
semi-liquid blood and other potentially infectious materials, items caked with these

9
materials, items that would release blood or other potentially infected materials if
compressed, pathological or microbiological wastes containing them and contaminated
sharps.

Containers used to store regulated waste must be closable and suitable to contain the
contents and prevent leakage of fluids. Containers designed for sharps also must be
puncture resistant. They must be labeled or color-coded to ensure that employees are
aware of the potential hazards. Such containers must be closed before removal to
prevent the contents from spilling. If the outside of a container becomes contaminated,it
must be placed within a second suitable container. Regulated waste must be disposed
of in accordance with applicable state and local laws.

Laundry
Laundry workers must wear gloves and handle contaminated laundry as little as
possible, with a minimum of agitation. Contaminated laundry should be bagged or
placed in containers at the location where it is used, but not sorted or rinsed there.
Laundry must be transported within the establishment or to outside laundries in labeled
or red color-coded bags. If the facility uses Universal Precautions for handling all soiled
laundry, then alternate labeling or color coding that can be recognized by the
employees may be used. If laundry is wet and it might soak through laundry bags, then
workers must use bags that prevent leakage to transport it.

REPORTING EXPOSURE INCIDENTS

OSHA's new bloodborne pathogens standard includes provisions for medical follow-up
for workers who have an exposure incident. The most obvious exposure incident is a
needlestick. But any specific eye, mouth, other mucous membrane, non-intact skin or
parenteral contact with blood or other potentially infectious materials is considered an
exposure incident and should be reported to the employer.

MEDICAL EVALUATION AND FOLLOW-UP

Employers must provide free medical evaluation and treatment to employees who
experience an exposure incident. They are to refer exposed employees to a licensed
health care provider who will counsel the individual about what happened and how to
prevent further spread of any potential infection. He or she will prescribe appropriate
treatment in line with current U.S. Public Health Service recommendations. The
licensed health care provider also will evaluate any reported illness to determine if the
symptoms may be related to HIV or HBV development.

The first step is to test the blood of the exposed employee. Any employee who wants to
participate in the medical evaluation program must agree to have blood drawn.
However, the employee has the option to give the blood sample but refuse permission
for HIV testing at that time. The employer must maintain the employee's blood sample
for 90 days in case the employee changes his or her mind about testing--should
symptoms develop that might relate to HIV or HBV infection.

10
The health care provider will counsel the employee based on the test results. If the
source individual was HBV positive or in a high risk category, the exposed employee
may be given hepatitis B immune globulin and vaccination, as necessary. If there is no
information on the source individual or the test is negative, and the employee has not
been vaccinated or does not have immunity based on his or her test, he or she may
receive the vaccine. Further, the health care provider will discuss any other findings
from the tests.

The standard requires that the employer make the hepatitis B vaccine available, at no
cost to the employee, to all employees who have occupational exposure to blood and
other potentially infectious materials. This requirement is in addition to post-
exposuretesting and treatment responsibilities.

WRITTEN OPINION
In addition to counseling the employee, the health care provider will provide a written
report to the employer. This report simply identifies whether hepatitis B vaccination was
recommended for the exposed employee and whether or not the employee received
vaccination. The health care provider also must note that the employee has been
informed of the results of the evaluation and told of any medical conditions resulting
from exposure to blood which require further evaluation or treatment. Any added
findings must be kept confidential.

CONFIDENTIALITY
Medical records must remain confidential. They are not available to the employer. The
employee must give specific written consent for anyone to see the records. Records
must be maintained for the duration of employment plus 30 years in accordance with
OSHA's standard on access to employee exposure and medical records.

WHO NEEDS VACCINATION

The OSHA standard covering bloodborne pathogens requires employers to offer the
three-injection vaccination series free to all employees who are exposed to blood or
other potentially infectious materials as part of their job duties. This includes health care
workers, emergency responders, morticians, first-aid personnel, law enforcement
officers, correctional facilities staff, launderers, as well as others.

The vaccination must be offered within 10 days of initial assignment to a job where
exposure to blood or other potentially infectious materials can be "reasonably
anticipated."

DECLINING VACCINATION
Workers who decide to decline vaccination must complete a declination form.
Employers must keep these forms on file so that they know the vaccination status of
everyone who is exposed to blood. At any time after a worker initially declines to receive
the vaccine, he or she may opt to take it.

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AN EXPOSED WORKER THAT HAS NOT YET BEEN VACCINATED
If a worker experiences an exposure incident, such as a needlestick or a blood splash in
the eye, he or she must receive confidential medical evaluation from a licensed health
care professional with appropriate follow-up. To the extent possible by law, the
employer is to determine the source individual for HBV as well as human
immunodeficiency virus (HIV) infectivity. The worker's blood will also be screened if he
or she agrees.

The healthcare professional is to follow the guidelines of the U.S. Public Health Service
in providing treatment. This would include hepatitis B vaccination. The health care
professional must give a written opinion on whether or not vaccination is recommended
and whether the employee received it. Only this information is reported to the employer.
Employee medical records must remain confidential. HIV or HBV status must NOT be
reported to the employer.

PERSONAL PROTECTIVE EQUIPMENT

Wearing gloves, gowns, masks, and eye protection can significantly reduce health risks
for workers exposed to blood and other potentially infectious materials. The OSHA
standard covering bloodborne disease requires employers to provide appropriate
personal protective equipment (PPE) and clothing free of charge to employees.

Selecting PPE
Personal protective clothing and equipment must be suitable. This means the level of
protection must fit the expected exposure.

PPE may include gloves, gowns, laboratory coats, face shields or masks, eye
protection, pocket masks and other protective gear. The gear must be readily
accessible to employees and available in appropriate sizes.

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