St. Olaf College

Bloodborne Pathogens

Exposure Control Manual

Section 1

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  • A. In December of 1991 OSHA published the Final Rule governing Occupational Exposure to Bloodborne Pathogens in 29 CFR Part 19lO.030 Subpart Z. This Final Rule, effective March 6, 1992, provides guidelines for healthcare facilities to reduce significant risk of infection of employees exposed to infected body fluids or tissue from infected persons or animals.

  • B. The targeted diseases specifically include human immunodeficiency virus (HIV) and hepatitis B virus (HBV), among other bloodborne diseases such as syphilis, malaria, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, creutzfelt-jakob, human T-lymphotrope virus Type 1 and viral hemorrhagic fever.

  • C. The Rule addresses definitions, work practices, procedures, equipment and policies related to employee training, information dissemination, preventative and post-incident medical interventions. The objective is to minimize risk of exposure or, if necessary, to effectively treat employees involved in an incident were there is a significant possibility of exposure.

  • D. The new Exposure Control Rule focuses on identifying employees at various degrees of risk to insure that they receive appropriate training, protective equipment, vaccination, and that existing Universal Precautions are employed to reduce risk of infection by bloodborne pathogens.

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  • A. The administration of St. Olaf College recognizes the potential danger to its health care and service staff which results from occupational exposure to bloodborne pathogens as addressed by OSHA's Occupational Exposure to Bloodborne Pathogens Final Rule. In the best interests of administration, employees and injured workers, the college intends to fully comply with the letter, spirit and intent of these rules. To this end, the following Exposure to Bloodborne Pathogens Control Plan (ECP) has been compiled.

  • B. This plan addresses the methods of compliance with 29 CFR 1910.1030 through the use of institutional policies and standards of practice. These specific policies and procedures are intended to strengthen the widely used Universal Precautions. It is the intent of this ECP to focus attention on reducing the risk of contracting a bloodborne pathogen while working at St. Olaf College.

  • C. Attention is given to the identification of the degrees or classifications of risk associated with different jobs. Each job is based on a series of tasks, some of which may present some individuals with exposures to blood borne pathogens. By carefully classifying and identifying tasks and potential exposures, we will be able to provide specific policies and training aimed at reducing the risk of infection among St. Olaf employees.

  • D. This plan is effective immediately, and will be under continual evaluation and review. All employees have a responsibility for identifying situations or conditions which have an impact on this plan and should be addressed by modifications or additions. Changes shall be made and communicated as soon as the need is recognized. In addition, the plan shall undergo formal documented review not less than annually.

  • E. The Exposure Control Plan provides for the following:

    • 1. Determining the risk classification into which each job in the facility best fits and the identification of which specific tasks associated with a job create the risk of exposure to bloodborne pathogens.

    • 2. Methods of compliance with the Rule covering:

      • a. Handwashing facilities

      • b. Waste management including storage and disposal of sharps and potentially infected materials or equipment

      • c. Handling of body fluids

      • d. Availability and suitability of protective equipment

      • e. Housekeeping related to equipment, work areas and surfaces, protective coverings, waste and waste disposal containers and laundry.

      • f. Hepatitis B vaccination (or waivers) and post-exposure follow-up.

      • g. Communication of hazards to employees through training, signs and labels.

Section 1 of Table Contents


NAME:_______________________________ DATE:____________________________ 
ADDRESS:____________________________ PHONE NUMBER(work):______________ 
        ____________________________ PHONE NUMBER(home):______________
DATE OF INCIDENT:_____________________________________________________ 

DESCRIPTION OF INCIDENT:______________________________________________ 

NAME OF FIRST PERSON ON SCENE:________________________________________ 
NAME OF MEDICAL ATTENDANT:____________________________________________
MEDICAL ATTENTION GIVEN):                                              

THE FUTURE:                                                            

NAME/TITLE OF PERSON PREPARING REPORT:________________________________
SIGNATURE:_____________________________ TELEPHONE NUMBER:_____________

Section 1 of Table Contents


  • A. Among the more common bloodborne diseases that you could be exposed to on the job are non-A hepatitis, non-B hepatitis, hepatitis B and delta hepatitis, as well as syphilis, malaria and human immunodeficiency virus. The two most significant are hepatitis B (HBV) and human immunodeficiency virus (HIV).

    • 1. HBV

      • a. Hepatitis means "inflammation of the liver." Hepatitis B virus is the major infectious bloodborne hazard faced by workers on the job. If you become infected with HBV, you may suffer from flu-like symptoms so severe that you may require hospitalization or you may feel no symptoms at all. Your blood, saliva and other body fluids may be infectious and you might spread the virus to sexual partners, family members and even unborn infants. There is a vaccine available to reduce or eliminate risk of infection.

    • 2. HIV

      • a. The human immunodeficiency virus attacks the body's immune system causing the disease known as AIDS, or Acquired Immune Deficiency Syndrome. Currently there is no vaccine to prevent this infection. A person infected with HIV may carry the virus for several years without developing symptoms but will eventually develop AIDS. An infected person may suffer from flu-like symptoms, fever, diarrhea and fatigue; and eventually AIDS-related illnesses including neurological problems, cancer and other opportunistic infections are easily contracted as the body's ability to fight off illness decreases. Although HIV can be transmitted through contact with blood and some body fluids, it is NOT transmitted by touching, feeding or working around persons who carry the disease.

      • b. The pathogens which can transmit these diseases may be present in the blood and other body fluids such as saliva, semen and vaginal secretions. Pathogens may also be present in cerebrospinal, synovial, pleural, peritoneal, pericardial,amniotic and any other fluids contaminated with blood. Unfixedtissue or organs from living or dead humans, cell, tissue or organ cultures and other biological matter from laboratoryexperiments have also proven to be sources of some pathogens.

      • c. These pathogens can enter and infect the human body through openings in the skin including cuts, nicks, abrasions, dermatitis or acne. Infection can also result from punctures or cuts caused by sharp contaminated objects such as needles, scalpels, broken glass, exposed ends of dental wires or any other object that can puncture or cut skin. Infection can also gain access to the body through mucous membranes of the eyes, nose and mouth when these areas are touched with contaminated hands or implements. The HBV virus is particularly dangerous since it can survive on dried surfaces at room temperature for at least one week. This means that a surface can be dangerously contaminated without any visible signs if the work areas are not thoroughly cleaned immediately after being contaminated with infectious material.

      • d. The rule provides guidelines but does not offer protection unless the staff and administration work faithfully to adhere to and improve policies, engineering controls and work procedures used when there is an exposure risk. Know the policies and be alert to protect yourself and your co-workers.

      • e. This manual contains a copy of the rule. The rule includes definitions of terms, but the print is small and difficult to read. We have included the definitions on the next pages in order to make it easier for you to find and read them if you should have questions.

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  • A. The following definitions, taken from the OSHA Rule are provided for easy reference and apply throughout this plan.

    • 1. Bloodborne pathogens

      • a. Pathogenic microorganisms that are present in humanblood and that can infect and cause disease in persons who are exposed to blood containing these pathogens.

    • 2. Clinical laboratory

      • a. A workplace where diagnostic procedures or other screening procedures are performed on blood or other potentially infectious materials.

    • 3. Contaminated

      • a. The presence or the reasonably anticipated presence ofblood or other potentially infectious materials on an object or surface.

    • 4. Contaminated laundry

      • a. Laundry which has been soiled with blood or other potentially infectious materials or may contain contaminated sharps.

    • 5. Contaminated sharps

      • a. Any object contaminated with blood or other potentially infectious material that is capable of penetrating the skin.

    • 6. Decontamination

      • a. The use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or object to the point at which they are no longer capable of transmitting infectious particles.

    • 7. Engineering controls

      • a. Controls that isolate, minimize or remove a workplace hazard.

    • 8. Exposure incident

      • a. A specific exposure to the eye, mouth, other mucousmembrane, or puncture exposure to blood or other potentially infectious materials that results from the performance of an employee's duties.

    • 9. Handwashing facilities

      • a. A facility providing an adequate supply of running water, soap and single-use towels.

    • 10. Licensed health care professional

      • a. A person whose legally permitted scope of practiceallows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure Follow-up.

    • 11. Occupational Exposure

      • a. Reasonably anticipated skin, eye, mucous membrane orpuncture contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

    • 12. Personal protective equipment

      • a. Specialized clothing or equipment worn by an individual to protect him or her from a hazard.

    • 13. Regulated waste

      • a. Any one of the following:

        • 1) Liquid or semi-liquid blood or other potentially infectious materials

        • 2) Contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed

        • 3) Objects caked with dried blood or other potentially infectious materials which are capable of releasing these materials during handling

        • 4) Contaminated sharps

        • 5) Pathological and microbiological wastes containing blood or other potentially infectious materials.

    • 14. Source individual

      • a. Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.

    • 15. Sterilize

      • a. The use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

    • 16. Universal precaution

      • a. A method of infection control in which all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens.

    • 17. Work-practice controls

      • a. Controls that reduce the likelihood of exposure by altering the manner in which a task is performed.

Section 1 of Table Contents

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