Bloodborne Pathogen Policy

Unit: Environmental Health and Safety
Contact: Juliette Commodore Botoklo
Title: Lab Safety Manager
Effective Date: 1/17/2023
Revision Date: 01/17/2023

Purpose

The University of Alabama (University) is committed to providing a safe and healthful working environment for its faculty, staff, and students. In pursuit of this goal, the following Bloodborne Pathogen Policy is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.”

Policy

Background

Locations that generate, process, store, or use materials that contain or may contain bloodborne pathogens (BBP) are required to adhere to the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (BBP Standard), 29 CFR 1910.1030. This regulation outlines safeguards to protect workers against health hazards associated with bloodborne pathogens. Exposures to blood and other potentially infectious materials (OPIM) occur across a wide variety of occupations. The BBP Standard provides for exposure control plans, engineering and work practice controls, hepatitis B vaccinations, hazard communication training, and recordkeeping, as workers exposed to BBP are at risk for serious or life-threatening illnesses. The Bloodborne Pathogen Policy and resulting Program were established for University employees and students who work with, or may be at risk, occupationally or academically, for exposure to BBP and OPIM. The guidance documents within the BBP Program and the Exposure Control Plan (ECP) specify procedures to provide University employees and students with education and training about BBP and OPIM. These documents also identify procedures and precautions that will reduce the likelihood of accidental exposure to BBP and OPIM.

Exposure Control Plan (ECP)

The ECP is a standardized document to assist the University and its various departments and administrative units in implementing and ensuring compliance with the Bloodborne Pathogen Standard, thereby protecting employees and students. The provided ECP serves as a template document, for departments and administrative units to complete, providing specific information related to their own areas and operations which reflect the involvement of staff members and students.

The implementation of the standardized elements in the ECP is mandatory as the ECP is designed to document procedures that minimize employee/student exposure to BBP. Please refer to the Environmental Health and Safety (EHS) website or the ECP template (PDF) for more details.

Step 1: Risk Appraisal Process - Identifying Employees and Students at Risk

Annually, areas determined by EHS to have employees or students who are likely at risk for occupational or student exposure to BBP (target areas) shall conduct a Risk Appraisal Survey. The Risk Appraisal Survey is conducted in a method developed and outlined by EHS and used to identify job classifications and courses in which employees or students within an administrative unit or department are at risk for occupational or academic exposure to BBP or OPIM. This exposure determination is made without regard to the use of personal protective equipment (PPE). Upon request, an EHS staff member will meet with the individuals charged with completing the surveys to provide guidance and assistance. The completed surveys will be returned to EHS for review.

Periodically, non-target areas will be provided information by EHS to help identify or determine persons at risk.

Step 2: Developing a Specific Control Plan

A written ECP, based upon the provided template, will be developed by each department or administrative unit in which there are employees or students at risk for occupational or administrative exposure to BBP or OPIM. Each individualized ECP will include, without limitation, the following methods of compliance: universal precautions, engineering controls and work practices, personal protective equipment, housekeeping, waste disposal, and laundry. The BBP Policy and the ECP provided by EHS serve as the overall policy and ECP template for the University. However, the ECP must be individualized for each department or administrative unit covered under the policy and readily available for all at risk persons.

Departments and administrative units will follow the template when completing their ECP. All ECPs must outline the Risk Appraisal Process (otherwise recognized as employee exposure determination), methods of implementation and control, methods of Hepatitis B vaccination, the Hepatitis B vaccine declination process, post-exposure evaluation and follow-up, administration of post-exposure evaluation and follow-up, procedures for evaluating the circumstances surrounding an exposure incident, communication of hazards and training, and recordkeeping.

Each department or administrative unit shall submit its ECP to EHS upon completion, and all ECPs shall be reviewed and updated:

At least annually.
Whenever necessary to reflect new or modified tasks and procedures which affect occupational or academic exposure.
To reflect progress or changes in the implementation or use of the needleless systems and sharps with engineered sharps injury protection.
To include new or revised positions with occupational or academic exposure, or new or revised employee positions with responsibilities within the ECP.
To review and evaluate the exposure incidents which occurred since the previous update.
To review and respond to information indicating the ECP is deficient in any area.

Each department or administrative unit shall solicit input from non-managerial employees during its annual ECP review. Such review shall be documented and submitted to EHS during the annual Risk Appraisal Process.

Step 3: Methods of Implementation and Control

Employees and students working in a department or administrative unit covered by the BBP Policy shall receive a copy of the BBP Policy and department/unit ECP during their initial training as a new employee or student. Department/unit ECPs shall also be reviewed during annual refresher training for employees. Additionally, all employees and students can review the BBP Policy or department/unit ECP at any time by contacting EHS at 205-348-5905 or by reviewing the EHS website. Supervisors shall provide employees and students with a copy of the BBP Policy and department/unit ECP upon request.

Step 4: Hepatitis B Vaccination Series

EHS will provide training to employees on hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of administration, and availability. The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the Risk Appraisal Survey section of the Potentially Infectious Material/Bloodborne Pathogens Program Manual as employees who are at risk for occupational exposure. Vaccination is encouraged for employees and students at risk for occupation or academic exposure unless one of the following exists:

Documentation exists that the employee/student has previously received the series.
Antibody titer testing reveals that the employee/student is immune.
Medical evaluation shows that vaccination is contraindicated.

The hepatitis B vaccination series is not required. If an eligible employee/student declines the vaccination, the individual must sign a declination form. Eligible employees/students who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept in the personnel or student file at the administrative unit or departmental level.

Vaccinations will be provided to eligible employees by the University Medical Center, and any eligible students listed under an ECP can receive the hepatitis B vaccination at the Student Health Center. Employees or students who agree to receive the hepatitis B vaccination shall be evaluated by a health care professional prior to initial vaccination to determine if contradictions exist. If contradictions are apparent, the employee or student shall be immediately informed. For specific details related to the appropriate location for employee/student hepatitis B vaccination (i.e., off-campus employees/students), those subject to vaccination must contact their direct supervisor for instruction.

Step 5: Post-Exposure Evaluation and Follow-up

The individual(s) involved in a possible BBP or OPIM exposure incident should immediately clean any open wounds and/or flush all mucous membranes (e.g., eyes, etc.). A confidential medical evaluation and follow-up shall be immediately conducted at University Medical Center or Student Health Center. The health care professional(s) evaluating the patient possibly exposed to BBP shall:

Document the details of the exposure and how it occurred.
Identify and document the source of the exposure (unless identification is infeasible or prohibited by applicable law or regulation).
Obtain the proper consent to make contact with the source individual.
With the source individual's consent, make arrangements to have the source individual 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.
As legally permitted, or with the source individual's consent, convey the source individual's test results to the health care provider treating the employee or student possibly exposed to BBP. Document any such information provided.
With the consent of the employee or student possibly exposed to BBP, collect a blood sample from said employee or student as soon as feasible after possible exposure to test for HBV and HIV serological status. If the employee or student does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least ninety (90) days. If the employee or student elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.
Assure that employees or students possibly exposed to BBP are provided with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (i.e., laws and regulations protecting confidentiality).
Provide appropriate post-exposure medical management.

Following the incident, employees shall immediately contact their direct supervisor and students shall contact the University representative responsible for the course or sponsored activity. Supervisors and representatives shall be responsible for notifying Risk Management of the incident. Employees and students involved shall complete an Injury or Illness Report. These reports are used to document any possible exposures or incidents on campus and are also collected at University Medical Center or Student Health Center where the medical evaluation and follow-up is conducted.

If the possible exposure occurs outside of the normal operating hours for University Medical Center or Student Health Center, and if the incident occurs on campus, then the individual involved should seek medical evaluation at DCH Emergency Room at 809 University Blvd. East, Tuscaloosa, AL 35401. Following the medical evaluation at DCH Emergency Room, the employee or student should schedule a follow-up with the University Medical Center or Student Health Center on the next available date of operation.

If the possible exposure occurs off-campus, the individual involved should seek medical attention at the nearest medical provider and should schedule a follow up with the University Medical Center or Student Health Center on the next available date of operation.

Step 6: Administration of Post-Exposure Evaluation and Follow-up

EHS and Risk Management shall ensure that health care professional(s) providing post-exposure care to employees and students are provided access to the University's BBP Policy. EHS and Risk Management shall also ensure that health care professional(s) providing post-exposure care are provided the following information upon request:

A description of the job duties or academic responsibilities of the employee or student that may be relevant to the possible exposure incident.
Details of the exposure incident, including the route(s) of possible exposure.
If possible, and as legally permitted, the results of the source individual’s blood test.
If legally permitted, relevant employee or student records, including vaccination status.

The University Medical Center or Student Health Center will provide employees or students with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation regarding the possible exposure to BBP.

Step 7: Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

EHS and Risk Management will review the circumstances of all exposure incidents to determine:

Engineering controls in use at the time.
Workplace practices followed.
A description of the device(s) used (including type and brand).
Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.).
Location of the incident (E.R., patient room, etc.).
Procedure being performed when the incident occurred.
Training of employees involved.

EHS will record all percutaneous injuries from contaminated sharps in a Sharps Injury Log.

Step 8: Communication of Hazards and Employee Training

All employees and students who may be subject to occupational exposure to BBP shall receive training upon employment and annually thereafter. Training may be conducted by EHS or the department/administrative unit responsible for oversight and implementation of the BBP Program and the resulting ECP. Additionally, training specific to the worksite is provided by the supervisor responsible for the department or administrative unit. All training is provided at no cost to the employees and students, and is completed during normal working hours. All departmental or administrative unit BBP trainings should be submitted for EHS approval in conjunction with their ECP during the annual Risk Appraisal Survey, or when any modifications are made to the training. Departmental or administrative unit BBP training must be consistent with the OSHA Bloodborne Pathogen Standard.

Training materials regarding the BBP Policy and resulting ECP are available from EHS (1500 Warrior Drive, Tuscaloosa, AL 35487) and upon request through the EHS website.

Step 9: Recordkeeping

Training, vaccination, and exposure records shall be maintained for each employee and student considered part of the BBP Program. The University shall provide employees and students with their records upon request. Medical record requests shall be made to the health care provider and training records may be requested from EHS and/or the department/administrative unit under which the employee or student works.

Any exposure incident is also evaluated to determine if the case meets any additional recordkeeping requirements. This determination and the recording activities are completed by EHS.

All records must be maintained in accordance with the UA Records/Data Retention and Disposal Policy.

Step 10: Hepatitis B Vaccine Declination (Mandatory)

All employees and students identified as having potential exposure to BBP or OPIM must be provided accessibility to the hepatitis B vaccination upon assignment. Employees and students who consent to vaccination will receive the Hepatitis B vaccine at no cost. Vaccines are provided through University Medical Center or Student Health Center. Employees and students who initially decline the vaccine may still receive the vaccine at a later time at no cost.

Employees and students who decline the vaccination must read and sign the Hepatitis B Vaccination Decline to Accept Form (Supplemental Attachment E). The Decline to Accept Form verifies that personnel were informed of the potential health hazards that Hepatitis B virus represents in their environment and that the individual has chosen to decline the Hepatitis B vaccine. Specifically, the form states, "I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me."

Responsibilities

Employees and Students

Employees and students who work with or may be at risk for exposure to BBP or OPIM must comply with the procedures and practices outlined in the ECP.

Environmental Health & Safety (EHS)

EHS will oversee the implementation of the BBP Policy and the resulting ECP. EHS will ensure the BBP is available to all employees. EHS will provide appropriate BBP training and document the required training provided. EHS will review incidents and record all percutaneous injuries from contaminated sharps in a Sharps Injury Log. EHS will review and update the ECP as well as the BBP Policy at least annually, and whenever necessary, to reflect new or modified tasks/procedures which affect occupational or academic exposure.

Individual Departments and Administrative Units

Individual departments and administrative units will provide and maintain all necessary PPE, engineering controls (e.g., sharp containers), labels, and red bags as required by the BBP Standard. The departments and administrative units will also ensure that adequate supplies of equipment are available in appropriate sizes. When an individual department or administrative unit provides training opportunities to their employees or students related to the BBP Policy, Program, departmental/administrative unit ECP, or any other required training elements required by the BBP Policy, Program, or Standard, then the individual department or administrative unit must document the training and provide a copy of this training documentation to EHS.

Individual departments and administrative units must submit their completed ECP annually to EHS for review, following review internally by the supervisor of each affected administrative unit or department (responsible for implementing the BBP Policy). The review of the departmental or administrative unit’s ECP will occur at the time the Risk Appraisal Survey is administered to determine the need for revision to reflect occupational or academic exposure in new job positions, classifications, or activities.

University Medical Center and/or Student Health Center

The University Medical Center and/or Student Health Center will be responsible for ensuring that all medical actions required by the BBP Standard are performed, and that appropriate employee/student health and OSHA records are maintained. This includes maintaining the evaluating health care professional’s written opinion following a possible occupational or academic exposure to a BBP and providing this information to the employee/student within fifteen (15) days after completion of the evaluation.

Training

All employees and students who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases.

Training is documented for each employee or student upon completion of training. EHS will retain training records for a minimum of three (3) years. Training records include:
• The dates training sessions were completed;
• The contents or a summary of training sessions;
• The names and qualifications of persons conducting the training; and
• The names and job titles of all persons attending the training sessions

Employee training records are provided upon request to the employee or the employee’s authorized representative, as is permitted or required by law, within 15 days. Such request should be addressed to EHS at 1500 Warrior Drive, Tuscaloosa, AL 35487.

Definitions

Administrative Unit refers to the units identified which are responsible for conducting annual risk appraisals and implementing the BBP Policy.
Blood means human blood, human blood components, and products made from human blood.
Bloodborne Pathogens are 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), hepatitis C Virus (HCV) and human immunodeficiency virus (HIV).
Engineering Controls means controls (e.g., sharps disposal containers, needleless systems, and sharps with engineered sharps injury protection) that isolate or remove the bloodborne pathogens hazard from the workplace.
Other Potentially Infectious Materials (OPIM) includes blood, as well as other human bodily fluids such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, 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, unfixed tissue or organ (other than intact skin) from a human (living or dead), HIV-containing cell or tissue cultures, organ cultures, and HIV-or HBV-containing culture medium or other solutions; blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Personal Protective Equipment is specialized clothing or equipment worn or used 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 are not considered to be personal protective equipment.

References

Scope

The University of Alabama Bloodborne Pathogen Policy applies to all employees and students that can reasonably anticipate contact with blood or other potentially infectious materials during the performance of their duties at the University.

Office of the Vice President of Finance and Operations

Approved by Cheryl Mowdy, Assistant Vice President for Finance and Operations, 01/17/2023