SOP 2.7: Bloodborne Pathogen
Household Control Plan Hazardous Waste
1. Introduction .................................................................................. 1
2. Regulatory and contractual requirements ......................................... 1
4. Applicability/staff exposure determination ........................................ 2
5. ECP implementaion and control ....................................................... 3
6. Hepatitis B vaccination ................................................................... 4
7. Labels and recordkeeping………………………………… ............................. 6 Attachments
A. ECP definitions .................................................................................. 8
B. Hand-washing technique……………………………….………………….………… ...... 9
C. Removal of contaminated disposable gloves ......................................... 10
D. Blood clean-up……………………………………………………………………………. ..... 11
E. Hepatitis B vaccine declination ............................................................ 13
F. Bloodborne pathogen exposure incident form ....................................... 14
The purpose of an exposure control plan (ECP) is to eliminate or minimize occupational exposure to blood
or other potentially infectious materials (OPIM) in accordance with the OSHA Bloodborne Pathogens
Standard. For ECP definitions, see Attachment A of this SOP.
2. Regulatory and contractual requirements
Bloodborne pathogen policy is governed by the requirements established in the HHW program and state
agency contract (Exhibit A, part B), Minn. Statute ? 116.78, sub. 2, and OSHA 29 CFR 1910.1020,
1910.1030, 1910.1030(f), 1910.1030(g)(2)(i).
3.1 The ECP Administrator is responsible for coordinating training, which shall be conducted by a
qualified individual who has knowledge of the required subject matter. The Program Manager is the
ECP Administrator and is responsible for implementing this HHW Facility’s plan. ECP training
? conducted before assignment to a task where occupational exposure to blood may take place
and at least annually thereafter.
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? provided when changes (e.g., modification of tasks or procedures, new or revised staff positions,
change in technology) affect the occupational exposure.
? provided at no cost.
3.2 ECP training is an opportunity for interactive questions and answers with the person conducting the session. The ECP training program shall include the following explanations, at a minimum:
? OSHA Bloodborne Pathogen Standard text and how to access a copy during working hours. ? epidemiology, modes of transmission, and symptoms of bloodborne diseases. ? the process staff can use to access or obtain a copy of this Facility’s ECP written plan.
? appropriate methods for recognizing tasks and other activities that may involve exposure to
blood or other potentially infectious materials.
? proper Personal Protective Equipment (PPE) use (e.g., types, location, removal, handling,
selection basis, decontamination, disposal).
? use and limitations of methods that prevent or reduce exposure (e.g., appropriate engineering
controls, work practices, PPE).
? appropriate actions to take and contact information for an emergency involving blood or OPIM. ? Hepatitis B vaccine information (e.g., efficacy, safety, administration method, benefits, offered
at no charge, declination process).
? procedures following an exposure incident (e.g., reporting methods, medical follow-up). ? the follow-up evaluation process required after an exposure incident occurs. ? clean-up procedures for blood and OPIM.
? recognition of biohazard markings (e.g., signs, labels, color coding to denote biohazards).
4. Applicability/staff exposure determination
This Program shall have a bloodborne pathogen ECP or be covered by the employer’s existing
program, if it could be “reasonably anticipated” (as a result of performing job duties) that staff could be exposed to blood or OPIM. This applies to staff performing any of the following functions:
? accepts or handles needles
? is expected to perform first aid
? cleans up blood spills
4.2 ECP components
The exposure determination shall be made without regard to the use of PPE. The ECP shall include: 1. an exposure determination
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2. methods of compliance
3. Hepatitis B vaccination
4. post-exposure evaluation procedures
The ECP Administrator shall be review the plan at least annually, update as needed, and make it
available for staff to review. Safer devices shall be selected as they become available.
5. ECP implementation and control
5.1 Universal precautions
According to universal (or standard) precautions, all blood or OPIM shall be considered potentially
infectious regardless of the perceived status of the source.
5.2 Engineering and work practice controls
Engineering and work practice controls shall be utilized to minimize or eliminate exposure for
Facility staff. Where the potential for occupational exposure remains after institution of these
controls, these practices shall be followed:
5.2.1 Sharps container
No sharps are accepted at this facility. If sharps are inadvertently accepted, they shall be
stored in acceptable sharps containers. Staff shall NOT directly handle sharps at any time. 5.2.2 Hand/body washing
? The purpose of hand washing is to remove any pathogens from the surface of the skin.
For hand-washing instructions, see Attachment B of this SOP.
? Hands shall be washed as soon as feasible after removal of gloves and other PPE.
Interim hand-washing measures (e.g., antiseptic hand cleansers, towelettes) shall be
used where hand-washing facilities are not immediately available. For glove removal
procedures, see Attachment C of this SOP.
? Wash exposed skin as soon as possible after any incident (e.g., skin contact with blood
? Immediately following contact with blood or OPIM, eye and mucous membranes shall
be flushed with water.
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Where occupational exposure remains after institution of engineering and work controls, PPE shall
? utilized and properly disposed of
? provided at no cost to staff
? purchased in appropriate sizes
? maintained and made available for use while administering first aid or cleaning up blood
5.3.1 Selection and use
PPE shall be chosen based on the anticipated exposure to blood or OPIM. The protective
equipment shall be considered appropriate only if it does not allow blood or OPIM to pass
through or reach clothing, skin, eyes, mouth, or mucous membranes under normal
conditions of use and for the duration of time for which the PPE is used.
5.3.2 PPE general precautions
? utilize PPE in occupational exposure situations; see SOP 2.4 PPE.
? remove and replace all equipment or protective clothing that is torn, punctured, or has
lost its ability to function as a barrier against bloodborne pathogens.
? remove all PPE before leaving the work area.
? protective gloves are to be used if there is potential for contact with blood or OPIM.
? alternative gloves shall be provided for staff with glove allergies (latex).
? never wash or decontaminate disposable gloves for reuse or before disposal; for glove
removal procedures, see Attachment C of this SOP.
? eye protection shall be worn to prevent exposure.
5.4 Housekeeping and maintenance
5.4.1 Blood clean-up
To review blood clean-up procedures, see Attachment D of this SOP.
5.4.2 Decontamination and disinfecting
Surfaces or equipment contaminated with blood or OPIM shall be cleaned and
decontaminated as soon as possible, using one of the following methods:
? household bleach diluted between 1:10 to 1:100 with water; dispose of unused solution
following the decontamination process.
? EPA-registered tuberculocidal disinfectants or products registered against Hepatitis B
virus (HBV), used according to label instructions.
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5.4.3 Broken glassware clean-up
Mechanical means shall be used (e.g., brush and dustpan) to clean up broken glassware.
Never pick up broken glassware by hand.
6. Hepatitis B vaccination
The Hepatitis B vaccine shall be:
? made available at no cost to staff covered by this ECP.
? offered after staff has received training and within 10 days of initial assignment of job involving
potential for blood exposure.
If staff chooses to decline the Hepatitis B vaccine, they may later obtain it following the initial
declination. The following procedure shall be followed to document the initial declination:
? complete the “Hepatitis B Declination Form”; see Attachment E of this SOP.
? declination forms shall be maintained by the ECP Administrator.
? Vaccines shall be administered by a licensed healthcare professional (LHCP).
? The vaccine shall be administered in accordance with U.S. Public Health Service (USPHS)
? Hepatitis B booster dose shall be made available if/when recommended by USPHS.
6.4 Post-exposure evaluation and follow-up
6.4.1 Staff responsibilities
? Immediately clean the exposed body area, removing any contaminated clothing.
? Thoroughly wash the affected body area with soap and water. Exposed mucous
membranes shall be thoroughly rinsed.
? Notify the ECP Administrator of any exposure incident.
6.4.2 ECP Administrator responsibilities
? If possible, investigate and document the incident before the end of the work shift.
? Complete the “First Report of Injury” form (provided by employer) and the
supplemental “Bloodborne Pathogen Exposure Incident Form”; see Attachment F of
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? Offer staff a post-exposure evaluation and follow-up within 24 hours of the incident.
Post-exposure evaluations shall be performed at a designated clinic that provides this
type of service. Submit a copy of the completed forms to the clinic.
6.4.3 Testing of source and exposed individual
? Identify the source individual and document their identity, unless identification is not
? If the source individual is already known to be infected, it is not necessary to repeat the
testing of that individual’s blood.
? Obtain consent to arrange for collection of exposed staff’s blood as soon as feasible
after the exposure incident and test for HBV and HIV serological status. ? Make arrangements to have the source individual tested as soon as possible to
determine HIV, HCV, and HBV status.
? If the exposed staff does not give consent for HIV serological testing during the
collection of the blood for baseline testing, preserve the sample for at least 90 days. If
the exposed staff elects to have the baseline sample tested during this waiting period,
perform the testing as soon as feasible.
? Results of the source individual’s testing shall be made available to the exposed staff.
Inform the affected staff of all applicable laws and regulations concerning disclosure of
the identity and infectious status of the source individual.
6.4.4 Clinic responsibilities
? The clinic shall offer post-exposure prophylaxis in accordance with the current
recommendations of the USPHS.
? The clinic shall provide appropriate counseling concerning precautions to take during
the period following the exposure incident.
? The clinic shall provide instruction on which potential illnesses to be alert for and to
report any related experiences.
The following information shall be provided to the clinic by the employer or any other
? A copy of 29 CFR 1910.1030 (if needed)—ECP for anyone responsible for rendering
first aid or CPR on the job.
? A written description of the exposed staff’s duties as they relate to the exposure
? Written documentation of the route and circumstances of the exposure. ? A result of the source individual’s blood test (if available).
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? A copy of the completed “Bloodborne Pathogen Exposure Incident Form.”
? The affected staff’s Hepatitis B vaccine status. 6.4.6 Healthcare professional’s written opinion
? The employer or other designated person shall obtain and provide affected staff with a
copy of the evaluating healthcare professional’s written opinion within 15 days of the
? The written opinion for HBV vaccination shall be limited to whether HBV vaccination
is needed and if the staff has received such a vaccine. The healthcare professional’s
written opinion for the post-exposure follow-up shall be limited to the following
? A statement that the staff has been informed about any medical conditions resulting
from exposure to blood or OPIM which would require further evaluation or treatment.
? A statement that the staff had been informed of the results of the evaluation.
? All other findings of diagnosis shall remain coincidental and shall not be included in
7. Labels and recordkeeping
Affix labels or mark containers of regulated/infectious waste with:
? a biohazard symbol
? the words “Biohazard” or “Infectious Waste” ? colors of fluorescent orange or orange-red with lettering or symbols in a contrasting color
7.2 Medical records
Staff records shall be kept confidential and be maintained for the duration of employment plus 30
years by the employer or other designated person, including the;
1. name and social security number
2. HBV vaccination status, including the vaccination date
3. results of examinations, medical testing, and post-exposure evaluation follow-up
4. a copy of the information provided to the healthcare professional
5. a copy of the healthcare professional’s written opinion limited to information, as described
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7.3 Training records
Training records shall be maintained by the ECP Administrator for at least 3 years and contain the
following training session information:
? date and outline describing the material presented
? name and qualifications of the trainer
? names and job titles of all staff persons attending the training session
? for additional information; see SOP 1.4 HHW Training Requirements.
7.4 OSHA 300
Each exposure incident shall be evaluated by the ECP Administrator to determine if the case meets
OSHA’s recordkeeping (recordable) requirements. The incident shall be recorded on the log if it
meets one of these requirements:
? involves loss of consciousness, transfer to another job, or restriction of work or motion.
? results in the recommendation of medical treatment beyond first aid (e.g. gamma globulin,
hepatitis B immune globulin, hepatitis B vaccine, zidovudine (AZT)), regardless of dosage.
? results in a diagnosis of seroconversion; the case shall not be recorded on the OSHA 300 as
seroconversion, but as an injury (e.g., needle stick, laceration); see SOP 2.2 OSHA
7.5 Sharps injury log
If accepting sharps, this facility shall maintain a sharps injury log for the recording of needle sticks.
The information shall be recorded and maintained in a manner to protect the confidentiality of the
injured staff. The log shall be maintained by the facility manager and follow the same retention
requirements as the OSHA 300 forms; see SOP 2.2 OSHA Recordkeeping/postings/checklist. The
log shall include:
? Type and brand of device involved.
? Work area where incident occurred.
? Explanation of how incident occurred.
? All records shall be made available to staff upon request.
? All records shall be made available to OSHA upon request for examination and copying.
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Blood: human blood, human components, and products made from human blood.
Bloodborne pathogens: pathogenic microorganisms present in human blood that can infect and cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV), Hepatitis C virus
(HCV), and Human Immunodeficiency Virus (HIV).
Contaminated: the presence or the reasonably anticipated presence of blood or other potentially infectious
materials on items or surfaces.
Decontamination: 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 transporting infectious particles
and the surface or item is rendered safe for handling, use, or disposal.
Engineering controls: controls that isolate or remove the bloodborne pathogens hazard from the workplace: e.g., sharps disposal containers, or self-sheathing needles.
Exposure incident: a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials resulting from the performance of a staff member’s duties.
Hand-washing facilities: a facility providing an adequate supply of running potable water, soap, and single-use towels or hot-air drying machines.
Licensed healthcare professional: a person whose legally permitted scope of practice allows him or her
to independently perform Hepatitis B vaccinations and post-exposure evaluation and follow-up.
Occupational exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material that may result from the performance of a staff member’s duties.
Other potentially infectious materials (OPIM): includes human body fluids—semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural 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. Unless visibly contaminated with blood, saliva (except in
dental operations), feces, vomit, and urine are not considered to be OPIM.
Parenteral: piercing mucous membranes or the skin barrier through such events as needle sticks, human bites,
cuts, and abrasions.
Regulated waste: includes (1) liquid or semi-liquid blood or OPIM; (2) contaminated items that would
release blood or OPIM in a liquid or semi-liquid state if compressed; (3) items caked with dried blood or
OPIM that are capable of releasing these materials during handling; (4) contaminated sharps and used needles;
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and (5) pathological and microbiological waste containing blood or OPIM.
Sharps: any object that can penetrate or cut the skin and produce an opening in the skin or a puncture wound
that would expose staff to blood or OPIM.
Source individual: any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the staff.
Universal precautions: an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids (OPIM) are treated as if known to be infectious for HIV, HBV,
HCV, and other bloodborne pathogens.
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