Bloodborne Pathogen Exposure Control Plan

Policy Statement

The Exposure Control Plan is to be used as the primary reference document for and is applicable to all Adelphi University employees who may receive occupational exposure to a bloodborne pathogen.

Reason for Policy

Adelphi University is committed to providing a safe and healthful environment for all employees, students, visitors, patients, and contractor employees. Accordingly, Adelphi University has prepared this Exposure Control Plan (ECP) to ensure compliance with the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, 29 CFR 1910.1030.

Who Is Governed by this Policy

Faculty, Staff, and Student Workers

Policy

Roles and Responsibilities

The Office of Environmental Health and Safety (EH&S) at Adelphi University is responsible for the implementation of the ECP in collaboration with departmental management from all affected departments at its three campuses.

Each responsible department head, manager and/or supervisor, in collaboration with EH&S, will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard and will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.

It is the responsibility of each employee who is determined to have occupational exposure to blood or other potentially infectious materials (OPIM) to comply with the procedures and work practices outlined in this Exposure Control Plan (ECP).

Employee Exposure Determination

In an effort to provide the highest level of protection for our employees, all employees within a covered job classification/title are considered covered by the ECP. Criteria used to determine occupational exposure include:

• Provide treatment or render first aid to student athletes.
• Clean-up blood or OPIM spills or handle materials/equipment potentially contaminated with blood or OPIM.
• Work with human blood, blood products, or other potentially infectious materials.
• Work with tissue or cell cultures known to contain HIV, HBV, HCV, or other bloodborne pathogens. (Not currently performed at Adelphi)
• Work with any human cell lines known to be infected with a bloodborne pathogen or OPIM (see attached OSHA Standard Interpretation, June 21, 1994). (Not currently performed at Adelphi)
• Work with animals/animal blood in research that is known to be infected with HIV or HBV (see attached OSHA Standard Interpretation, October 15, 2002).
• Clinical activities with the potential for exposure to blood or body fluids that may contain bloodborne pathogens or OPIM. Work in close proximity to where any of the above activities are conducted.

Based on a careful review of job titles and work procedures, Adelphi University considers all employees within the following job classifications/titles to have a reasonably anticipated occupational exposure to bloodborne pathogens during the performance of work duties:

Job Classification/Title	Department
Head Athletic Trainer	Athletics
Assistant Athletic Trainers	Athletics
Recreation Manager & Staff	Athletics
Equipment Manager	Athletics
Laundry Workers	Athletics
Nurses*	Health Services
Emergency Medical Technicians*	Health Services
Exercise Science	Athletics
Custodial Services	Facilities Management
Maintenance Workers	Facilities Management
Public Safety Officer*	Public Safety
Biology Professors ***	Biology
Preschool Employees	Alice Brown’s Early Learning Center
Field Nurses*	Department of Nursing Education

*Currently trained by outside trainers
***Biology Faculty not working with any human blood or body fluid) Reviewed annually (2015-2020)

Methods of Implementation and Control

Universal Precautions

All employees covered by the ECP will utilize Universal Precautions in their work duties to protect against bloodborne pathogens. Universal Precautions is an approach to infection control requiring that all human blood and OPIM be treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

Exposure Control Plan (ECP)

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during the employee’s initial training session.  All employees have an opportunity to review the ECP at any time during their work hours by contacting their immediate supervisor or EH&S (516 788-32420). If requested, Adelphi will provide an employee with a copy of the ECP free of charge and within 15 days of the request. The ECP will be placed on Adelphi’s Intranet in the Environmental Health and Safety Section. EH&S is responsible for reviewing and updating the ECP annually to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. This policy will be sent to the Safety Committee to be reviewed and approved annually.

OSHA regulations are subject to change in both their directive components and interpretative statements. EH&S will communicate these changes to departments covered by the ECP and other personnel with oversight responsibilities for day-to-day operations, by e-mail, distribution of printed material, and changes in the content of its Bloodborne Pathogen Training Program.  

Engineering Controls and Work Practice Controls

Engineering Controls are devices or equipment that isolate or remove hazards, reducing the risk of infection.

1. Sharps Containers serve as the primary engineering control to reduce the risk of accidental injury from sharps, such as discarded needles, scalpels, blades, slides, and other sharp objects. Containers are to be located as close as feasible to the point of use to facilitate the immediate disposal of used sharps. Do not overfill containers.
2. Red Bag Waste Receptacles serve as the primary engineering control to reduce the risk of accidental exposure from blood- and OPIM-contaminated waste materials (e.g., gloves, towels, gowns, etc.). Facilities Management Department will provide receptacles and red bags for collection of Regulated Medical Waste.
3. Safe Needle Devices include needleless systems and sharps with engineered sharps injury protection, defined on page 3 and 4. In November of 2000, requirements for assessing the feasibility of incorporating commercially available engineering controls, such as ‘safe needles’, were added to the Standard. These devices allow for either the elimination of needles or automatic shielding of needles to reduce the risk of percutaneous injuries.
4. Centrifuge Safety Devices (sealed rotors, safety cups-gasket containers into which centrifuge tubes are placed) prevent the release of infectious aerosols, particularly if a tube breaks. Substitute plastic or plastic-clad centrifuge tubes/micro capillary columns for glass whenever possible.
5. Biological Safety Cabinets (BSCs) reduce the risk of exposure to splashes and aerosols of potentially infectious materials. OSHA regulations are subject to change in both their directive components and interpretative statements. EH&S will communicate these changes to departments covered by the ECP and other personnel with oversight responsibilities for day-to-day operations, by e-mail, distribution of printed material, and changes in the content of its Bloodborne Pathogen Training Program.

Work Practice Controls

Work Practice Controls are methods/techniques used by employees to minimize exposure to bloodborne pathogen or OPIM thereby reducing the risk of infection.

1. Use Universal Precautions -assume all human blood, certain human body fluids and other potentially infectious materials contain HIV, HBV, HCV or other bloodborne pathogens.
2. Remove gloves when visibly contaminated and wash hands immediately after removal; wash other body parts as soon as possible after skin contact with potentially infectious materials.
3. Do not recap, break, or bend needles or scalpels that have been used. Place all disposable sharps in the appropriate sharps containers, never into a red bag.
4. Handling, cleaning, and sterilizing reusable sharps must be done with extreme caution. For example, pre-soaking instruments in a disinfectant solution before cleaning will reduce (but not totally eliminate) infectious organisms on the instruments.
5. Eating, drinking, application of cosmetics and handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens or OPIM is reasonably anticipated. Food or beverages may not be stored in laboratory refrigerators/freezers.
6. Perform operations with blood and OPIM in a manner that minimizes splattering and aerosol generation. When this is not possible, conduct such operations in a Biological Safety Cabinet (BSC). This includes filling tubes, and loading/unloading safety cups or rotors inside a BSC.
7. Use secondary containers (trays, specimen transport bags) to prevent leaks and spills during collection, handling, processing, storage, or transport of infectious materials.
8. Decontaminate equipment prior to servicing, moving or shipping. Items not completely decontaminated must bear a label noting the contaminated area.
9. Use mechanical pipetting devices only; Do not mouth pipette.
10. Replace glass items with plastic ones; use pipettes or canulas to aspirate liquids instead of needles.
11. Inform non-laboratory personnel, outside contractors, etc. of the presence of infectious materials in the laboratory and ensure that their presence does not put them at risk of exposure.

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) is provided by each affected department and available to each affected personnel at no cost to the employee. Training in the proper selection and use of PPE is provided through EH&S and the employees direct supervisors, but it is the primary responsibility of the employee to properly utilize such PPE whenever the potential for occupational exposure exists. It is the responsibility of the affected department’s management to ensure that PPE of sufficient size, type and quantity is available and accessible to all affected employees and ensure that such employees utilize PPE as appropriate. In most instances, the minimum level of PPE consists of a lab coat/gown, gloves, and eye protection (either safety glasses with side flaps and brow-bars) for anyone working with potentially infectious materials.

In addition to understanding the appropriate uses of various types of PPE, it is equally important to realize that all PPE items have limitations that should be considered in making a selection.

The “appropriateness” of PPE depends on the risk involved in a particular operation, which in turn can be assessed by addressing the following questions:

1. When the identity of the infectious agent is known, what is its natural route of infection?
2. How hazardous is the agent, in terms of ease of transmissibility and severity of illness?
3. What are chances of accidental exposure for different types of activities?
4. Are needles or other sharp objects used, contributing to the risk of percutaneous injury?
5. If handling liquids, what is the likelihood of splashes or aerosols being created?

• Gloves –  It is recommended that two pairs of impermeable gloves should be worn when touching or handling blood and body fluids or when the potential exists for direct skin contact with blood, other potentially infectious material (OPIM),mucous membranes or non-intact skin. Always inspect for holes and tears before donning. They are subject to losing their “barrier protection” quality with prolonged use or as the result of exposure to laboratory chemicals. Change gloves frequently during prolonged operations and as soon as possible if they become torn, or contaminated. The gloves used for handling infectious materials do not provide protection against percutaneous injury. GLOVES MUST NOT BE WORN OUTSIDE OF THE WORK AREA/LABORATORY. Utility gloves may be decontaminated for reuse if their integrity is not compromised. Discard them if they show signs of cracking, peeling, tearing, puncturing, or deterioration. Never wash or attempt to decontaminate disposable gloves for reuse.
• Glove selection – Gloves designed for barrier protection are not always the appropriate choice for handling hazardous chemicals. Manufacturers or laboratory supply companies can furnish information on gloves that protect against hazardous chemicals. The BEST Glove Company has a free download of their selection charts.
• Latex allergies –  Approximately 8% of health care workers have been sensitized to latex rubber proteins or the chemicals used in manufacturing the gloves. EH&S can provide information on substitutes for latex gloves that provide the same level of barrier protection as latex without putting the wearer at risk for sensitization. Always use non-powdered gloves regardless of the glove material used. Latex proteins adsorbed onto airborne powder increase the risk of sensitization and can exacerbate pre-existing allergic symptoms.
• Laboratory coats/gowns – provide a protective barrier between an employee’s clothes and potential exposure sources. Laboratory coats/gown either fastens in the front or in the rear, with coats/gowns that fasten in the rear offering greater protection than front-fastening ones. Laboratory coats are not to be worn outside of the laboratory if they are visibly stained with blood or OPIM or have been used while working with any pathogen.
• Eye protection – safety glasses with side shields and brow bars are the minimum eye protection for handling blood or OPIM that have the potential of becoming airborne. They do not protect from large splashes. Splash-proof goggles, by virtue of their tighter fit around the eyes, are required for activities with an elevated risk of splash exposure. Face shields, worn in conjunction with goggles are appropriate in the highest risk situations.
• Fluid-resistant masks – provide protection against droplet/splash exposure of the nose and mouth. They do not provide a barrier to infectious organisms transmitted by inhalation (e.g., tuberculosis).
• Head and shoe covers – appropriate in situations where a high degree of splashing is anticipated.

Additional PPE precautions:

Remove protective equipment, especially gloves, before leaving the work area and as soon as feasible after a garment becomes contaminated.

Place used disposable protective equipment in red bags for disposal. Reusable items (laboratory coats, uniforms, towels) should be kept in red bags, with the Universal Biohazard sign affixed, until laundered.

Segregation and Disposal of Regulated Medical Waste

1. Contaminated sharps must be disposed of immediately after use in designated sharps containers, which are puncture proof. Sharps containers must be easily accessible and as close as feasible to the immediate area where sharps are used. The following items used in student instruction, patient/athlete care or research activities are considered contaminated sharps when contact with blood or OPIM has occurred or is believed to have occurred: hypodermic needles, syringes, scalpel/scalpel blades, razor blades, lancets, slides and cover slips, serological pipettes (glass or plastic), capillary tubes (glass or plastic), broken glassware and blood vials. Essentially, any contaminated item that may tear or puncture a red bag is considered a contaminated sharp. As a best management practice, Adelphi also requires that sharps that have not been contaminated also be disposed of in sharps containers to avoid any confusion or possible accidental contact. Once full, the sharps container must be placed inside a rigid, red bag waste receptacle by the user prior to transport and disposal. Sharps containers are available in several sizes for wall-mounting, for bench-top use and in a floor model. Containers must not be filled beyond capacity or to the point where sharps protrude through the opening and syringes and needles must never be separated or bent and needles must never be recapped prior to disposal.
2. Red bag waste, which includes non-sharp items (soft items) that are contaminated with blood or OPIM such as gloves, gowns, paper towels, must be disposed of in containers which are rigid, leak resistant, of sufficient strength to prevent tearing or bursting under normal conditions of use and handling and shall bear the universal biohazard symbol. Such containers shall be lined with a minimum of one red bag into which regulated medical wastes shall be deposited for disposal. Red bags shall also bear the universal biohazard symbol. The generator of red bag waste shall tie or tape the red bag closed when full, and close the container (i.e., tape cardboard box or tightly close lid of plastic container) in preparation for transport and disposal by Adelphi’s regulated medical waste contractor.
3. Laundry (e.g., lab coats, sheets, towels, athletic uniforms) contaminated with blood or OPIM should be handled as little as possible, with minimal agitation. Contaminated laundry should be placed in a red bag if not laundered immediately. Universal Precautions should be employed when handling laundry, so gloves must be worn by anyone handling laundry. Lab coats, sheets and towels that are soaked with blood or OPIM should be managed as red bag waste, as opposed to laundered.

Housekeeping/Cleaning/Disinfection

Work surfaces must be decontaminated immediately after a spill, at the end of procedures, and at the end of the day if the surface may have become contaminated with blood or OPIM during the course of the day. A list of approved sterilants and disinfectants* can be obtained from the Environmental Protection Agency or by contacting the EH&S coordinator.

*Approved refers to manufacturer’s right to use terms such as “disinfectant”, “tuberculocidal”, “sporicidal”, etc. on the product label, based on demonstrated anti-microbial activity in specified tests. A 10% solution of household bleach, prepared fresh daily, provides effective decontamination for routine housekeeping and spill response.

Cleaning/Decontamination Procedures

• Always read manufacturers’ label information concerning organisms inactivated, use procedures, and dilution; full strength products may be ‘hazardous chemicals’ prior to dilution.
• Discard protective coverings such as plastic wrap and aluminum foil when contaminated.
• Regularly inspect and decontaminate reusable receptacles (bins, pails, and cans) that may have become contaminated. Decontaminate immediately upon noting visible contamination.
• Use tongs, forceps, or a brush and dustpan to pick up broken glass; even when wearing gloves.
• Store or process reusable sharps in puncture-resistant containers.
• Place regulated medical waste in containers provided by the Maintenance Control Center.

Liquid Disinfectants: Uses and Limitations

Disinfectant	Disinfection Level	Bacteria	Lipophilic Viruses	Hydrophilic Viruses	M. Tuberculosis	Fungi	Comments
Alcohols (ethyl and isopropyl) 60-85%	inter-mediate	+	+	–	+/-	+	Not sporicidal; evaporates quickly so adequate contact time may not be achieved, high concentrations of organics diminishes effectiveness; flammable
Phenolics (0.4% – 5%)	inter-mediate	+	+	+/-	+	+	Not sporicidal; phenol penetrates latex gloves; eye/skin irritant; remains active upon contact with organic soil; may leave residue.
Glutaraldehyde (2-5%)	high	+	+	+	+	+	Used to sterilize surgical instruments that cannot be autoclaved; strong odor; sensitizer; use with adequate ventilation. Not for use on environmental surfaces
Quaternary Ammonium (0.5-1.5%)	low	+	+	–	–	+/-	May be ineffective against Psuedomonas and other gram-bacteria; recommendation limited to environmental sanitation (floors, walls). Low odor, irritation.
Iodophors (30-1,000 ppm iodine)	inter-mediate	+	+	+	+/-	+/-	Inactivated by organic matter
Chlorine (100-1,000 ppm)	inter-mediate	+	+	+	+/-	+	Not sporicidal; inactivated by organic matter; solutions of hypochlorite (Clorox) must be prepared daily; corrosive; eye and skin irritant.

Medical Services

Hepatitis B Vaccination

The immunization series involves three intramuscular injections over a six-month period. The vaccine is effective > 95% of the time when all three doses are given and immunity is thought to be life-long once a titer has been demonstrated. Hepatitis B vaccination may be contraindicated for those with yeast allergy (the immunogenic antigen is cultivated in cells of S. cerevisiae); pregnant women should consult their physician before receiving the vaccine.

EH&S, with the assistance Health Services, will provide training to employees regarding Hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability.

Adelphi is required to offer the Hepatitis B vaccination series to all employees identified as “at risk” for occupational exposure to bloodborne pathogens, as specified in the Exposure Determination section of the ECP. The Hepatitis B vaccination series is available to all affected employees at no cost after training and within 10 days of initial assignment, by appointment and during normal working hours, at the Health Services , located in Waldo Hall. 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. However, if an employee chooses to decline vaccination, the employee must sign a declination form (see Appendix A). Employees who decline may request and obtain the vaccination at a later date at no cost. All documentation of an employee’s vaccination acceptance or refusal is maintained by Human Resources and Health Services under Health Insurance Portability and Accountability Act (HIPAA) guidelines.

Communication of Hazards

Labels and Signs

The Universal Biohazard symbol is affixed to all red bags, sharps containers, other regulated medical waste containers and equipment used at Adelphi for collection/storage of blood or OPIM. Only items labeled with the Universal Biohazard symbol shall be used for collection/storage of blood- or OPIM-contaminated materials. Employees are to immediately notify EH&S if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels. All laboratories covered by the Bloodborne Pathogens Standard and those working at Biological Safety Level-2 or higher must display a sign at the entrance to the work area incorporating the features required for “Labels” as well as: the name of the infectious agent(s); special requirements for entering the area; and, the name and campus office phone number of the responsible person.

Information and Training

Each department affected by this regulation is responsible for Bloodborne Pathogens training for all employees covered by this plan. EH&S or Health Services will provides training to new employees or transferred employees who are identified as “at risk” based on an exposure determination. Training sessions cover the following information:

1. requirements of the OSHA Bloodborne Pathogens Standard
2. epidemiology, transmission, and symptoms of bloodborne diseases
3. information on the Exposure Control Plan
4. methods that can be used to recognize and evaluate tasks and activities with potential exposure
5. use and limitations of the different methods of control including, but not limited to, engineering controls, work practices, proper waste disposal, and selection and use of protective equipment
6. what constitutes an exposure incident and appropriate actions and procedures to follow if an exposure occurs and details on the provision of post-exposure evaluation and medical consultation
7. Hepatitis B vaccine including efficacy, safety, method of administration, and that the vaccine will be free of charge to employees
8. signs and labels required by the standard questions and answers
9. questions and answers

Recordkeeping

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records.” Health Services is responsible for maintenance of the required medical records. These confidential records are kept at the Health Services for at least the duration of employment plus 30 years. 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 Health Services Director. In addition to other OSHA record keeping requirements, the medical record will include:

1. the name and employee ID number of the exposed employee
2. a copy of the employee’s Hepatitis B vaccinations and any records relative to the employee’s ability to receive the vaccination
3. a copy of all results of examinations, medical testing, and follow-up procedures as required by the Standard; and
4. a copy of all healthcare professional’s written opinions as required by the Standard

An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination is performed by Health Services and EH&S and the recording activities are done by Human Resources.

Adelphi also maintains a sharps injury log for the recording of percutaneous injuries from contaminated sharps (see Appendix B). The information in the sharps injury log is recorded and maintained to protect the confidentiality of the injured employee. These activities are consistent with “safe needle” legislation enacted in November 2000. The sharps injury log shall note:

1. the date of the injury
2. the type and brand of the device involved
3. the department or work area where the incident occurred
4. an explanation of how the incident occurred

This log is reviewed at least annually by the Health Services Director as part of the annual evaluation of the program and is maintained for at least five (5) years following the end of the calendar year that they cover. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

Training Records

Training records are completed for each employee upon completion of training. These documents will be kept by Human Resources for at least three (3) years. The training records will include:

1. the date of the training session.
2. the name and title of person conducting the training.
3. the name and job title of each person attending the training.

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 the EH&S Coordinator or the department of Human Resources.

Definitions

Blood –  human blood, human blood components, and products made from human blood, including medications derived from blood, such as immune globulins, albumin, and factors 8 and 9.

Bloodborne pathogens – pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV), human immunodeficiency virus (HIV), and Hepatitis C virus (HCV).

Contaminated – the presence or the reasonably anticipated presence of blood or other potentially infectious materials is located on an item or surface.

Contaminated laundry – laundry which has been soiled with blood, body fluid, sharps and- or any other potentially infectious materials.

Contaminated sharps –  any contaminated object that can penetrate the skin including but not limited to, needles, scalpels, broken glass or capillary tubes, and dental wires.

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 transmitting infection and the surface or item is rendered safe for handling, use, or disposal.

Engineering controls –  controls (e.g., sharps disposal containers, self-sheathing needles, and safer medical devices such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.

Exposure incident –  a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties. “Non-intact skin” includes skin with dermatitis, hangnails, cuts, abrasions, chafing, acne, etc.

Handwashing facilities – a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

Needleless systems – a device that does not use needles for (A) the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established, (B) the administration of medication or fluids, or (C) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Occupational exposure – reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

Other potentially infectious materials (OPIM) – (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Parenteral –  piercing of mucous membranes or the skin through such events as needlesticks, human bites, cuts, and abrasions.

Personal protective equipment (PPE) – specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard is not considered to be personal protective equipment.

Production facility –  facility engaged in industrial-scale, large-volume or high concentration production of HIV or HBV.

Regulated medical waste (RMW) – liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

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

Source individual – any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

Sterilization –  the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal precautions – an approach to infection control requiring that all human blood and OPIM be treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

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

Procedures

Exposure Incident, Post Exposure Evaluation and Follow-up

Exposure Incident: An exposure incident is defined as parenteral, non-intact skin or mucous membrane (e.g., eye, nose, mouth) contact with human blood or other potentially infectious materials. An exposure to blood or OPIM should be regarded as an urgent medical circumstance. The guidelines for Post-Exposure Prophylaxis (PEP) call for treatment initiation, and if warranted, within several hours following exposure, however treatment with chemo prophylactic drugs is voluntary. Post Exposure Prophylaxis will be provided at no expense to any employee who is exposed in the course of their work activities.

If possible, immediately following a potential exposure the exposed individual should perform initial first aid (e.g., clean the wound, flush eyes or other mucous membrane, etc.). If not possible, the exposed individual should seek immediate medical attention at Health Services or the nearest emergency room/medical facility for evaluation:

• Adelphi Main Campus – Go to Health Services
• Manhattan Center – Go to the nearest Emergency Room
• Hauppauge Center – Go to the nearest Emergency Room
• Hudson Valley Center – Go to the nearest Emergency Room

Post Exposure Evaluation: During the medical evaluation the particulars of how the exposure occurred and the routes of exposure (e.g., as to whether skin is intact or not) shall be shared by the exposed employee with the licensed healthcare professional performing the evaluation. A detailed assessment of the incident will be obtained from the exposed employee to determine the risk from the exposure, including the infectious status of the source individual, if obtainable, and immune status of the exposed employee. This information will be used to determine the relative benefits of taking antiretroviral therapy and to offer counseling, treatment and tracking for other infectious agents. If the initial medical evaluation is performed at Health Services and the exposure scenario suggests that antiretroviral therapy is indicated, the employee must be sent immediately to the nearest hospital emergency room where antiretroviral therapy can be administered. After consent, an exposed employee’s blood will be collected for baseline testing. If indicated, testing on a voluntary basis, for anti-HIV and anti-HCV antibodies will be conducted at six weeks, 12 weeks, six months, and twelve months. All test results are confidential and shared only with the tested employee.

In the event of an exposure incident an attempt must be made by the employee and the employee’s supervisor to identify the source individual and arrange for consent to have the person tested as soon as possible to determine HIV, HCV, and HBV infectivity. If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed. If the source individual has been determined and agreed to testing, the exposed employee must 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).

The Health Services Director ensures that healthcare professional(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 and provides the employee with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation.

Forms

• Hepatitis B Virus Vaccination Declination
• Sharps Injury Log

Related Information

This policy does not have related information at this time. Upon periodic policy review this area will be evaluated to determine if additional information is needed to supplement the policy.

Document History

• Last Reviewed Date: February 10, 2023
• Last Revised Date: February 10, 2023
• Policy Origination Date: July 01, 1992

Who Approved This Policy

Adelphi University Environmental Safety Committee in 2023.