ATrain Education

 

Continuing Education for Health Professionals

Course Modules

  • Course Introduction
  1. The Hazards of Bloodborne Pathogens
  2. Workplaces Subject to the OSHA Standard
  3. Engineering Controls
  4. Work Practice Controls
  5. Personal Protective Equipment (PPE)
  6. Protecting Employees
  7. Other OSHA Requirements
  8. Reporting Exposure Incidents
  9. Conclusion
  10. Resources and References
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Bloodborne Pathogens: HBV, HCV, and HIV

This course meets the educational requirements for federal OSHA Bloodborne Pathogens Standard training.

Workplace-specific policies, procedures, or training are the responsibility of your employer, who must also provide an opportunity for "interactive questions and answers" with a "person who is knowledgeable" about this subject.

  • Author:
    • Nancy Evans, BS

      Nancy Evans earned a BS degree from Washington University in St. Louis. She is a former senior editor for Mosby/Times Mirror, Addision-Wesley Nursing Division, and Appleton & Lange.

      Nancy is a health science writer with more than four decades of experience in healthcare writing and publishing. A breast cancer survivor since 1991, she has written and spoken extensively about breast cancer issues both nationally and abroad.

      Nancy co-produced, with Allie Light and Irving Saraf, the HBO documentary film Rachel’s Daughters: Searching for the Causes of Breast Cancer; the KQED documentary Children and Asthma; and the documentary Good Food, Bad Food: Obesity in American Children. She is collaborating on a forthcoming consumer guide to planning end-of-life care.

    • Marian McDonald, RN, MSN, CIC

      Marian McDonald earned a BA in Education at Harris-Stowe College in St. Louis, Missouri and an AD in nursing from Santa Rosa Junior College in California. She went on to earn a BSN and an MSN at Sonoma State University.

      Marian is a clinician, mentor, teacher, and consultant. She is board-certified (CIC) in infection control and says she has been "chasing germs" for thirty years! Marian has helped to develop legislation and has served in local, state, and national organizations that promote infection prevention, disaster preparedness and response, and public health.

    • JoAnn O'Toole, RN, BSN

      JoAnn O’Toole, RN, BSN,is a registered nurse, writer, and researcher. While in college at San Jose State University and later at the University of Mexico in Mexico City, she carried a double major in Spanish and journalism and a minor in Latin.

      She currently works in the Emergency Department at Kaiser Hospital in Redwood City, California, a certified stroke center and a sepsis center.

  • Contact hours: 2
  • Pharmacotherapy hours: 1
  • Expiration date: November 1, 2019
  • Course price: $19

Course Summary

Review of precautions that address the transmission of pathogens in healthcare settings. Includes safe handling of sharps, use of PPE, and decontamination of work areas, plus importance of hepatitis B vaccination for workers.

The following information applies to occupational therapy professionals:

  • Target Audience: Occupational Therapists, OTAs
  • Instructional Level: Introductory
  • Content Focus: Category 1—Domain of OT, Client Factors

Criteria for Successful Completion

80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.

Conflict of Interest/Commercial Support

Conflict of Interest/Commercial Support

Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias. No commercial support was received for this activity.

Accreditation Information

Objectives: When you finish this course you will be able to:

  • Explain the hazards of bloodborne pathogens (HBV, HCV, HIV) in the transmission of certain chronic and life-threatening diseases and relate both OSHA and state laws designed to curb them.
  • Outline the actions employers are required by OSHA to take to protect their employees from bloodborne pathogens in the workplace.
  • State how engineering controls reduce risk in the workplace specifically regarding the safe handling and disposal of sharps.
  • Compare and contrast Universal and Standard Precautions and state other work practice controls.
  • Review the selection, provision, and use of personal protective equipment.
  • Summarize the required training of healthcare personnel and identify the common icon and color of hazardous signs and labels.
  • Outline the OSHA requirements for housekeeping, regulated waste, soiled laundry, and vaccination against hepatitis B.
  • Discuss the procedure for promptly reporting an exposure incident.

The Hazards of Bloodborne Pathogens

Bloodborne pathogens are infectious organisms in blood and other body fluids that can cause chronic and life-threatening disease in humans. The main bloodborne pathogens of concern are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the organism that causes AIDS.

The Science

Hepatitis B

Recent investigations of viral hepatitis outbreaks in the United States demonstrate the continued risk posed by lapses in infection-control practices, particularly in healthcare settings (Thompson et al., 2009).

HBV is transmitted by percutaneous or mucosal exposure to the blood or body fluids of an infected person, most often through injection-drug use, from sexual contact with an infected person, or from an infected mother to her newborn during childbirth. Transmission of HBV also can occur among people who have prolonged but nonsexual interpersonal contact with someone who is HBV-infected (eg, healthcare workers) (CDC, 2010).

Infection may be acute and later cleared or it may become chronic, carried for a prolonged period or for life. Infection may be completely free of symptoms, produce mild or moderate illness, or be rapidly fatal. Most people who are chronically infected are without symptoms.

Serious complications (eg, cirrhosis, liver cancer) are more likely to develop in chronically infected people. In the United States, approximately 1.2 million people have chronic HBV infection and are sources for HBV transmission to others; however, since the 1980s the incidence of acute hepatitis B has declined steadily, especially among vaccinated children (CDC, 2011).

 

chart: incidence of hepatitis B, by year, US, 1980-2011

Source: CDC: 2011.

Effective hepatitis B vaccines have been available in the United States since 1981. In addition to hepatitis B vaccination, efforts have been made to improve care and treatment for people living with hepatitis B. In the United States, 804,000 to 1.4 million people are estimated to be infected with the virus, most of whom are unaware of their infection status (CDC, 2008).

To improve health outcomes for these people, CDC issued recommendations in 2008 to guide hepatitis B testing and public health management of people with chronic hepatitis B infection. These guidelines stress the need for testing people at high risk for infection, conducting contact management, educating patients, and administering FDA-approved therapies for treating hepatitis B (CDC, 2008).

Since publication of the 2008 recommendations, treatment options for HBV infection have expanded. Several drugs are now administered orally (a major advancement in how treatments are administered for this infection), leading to viral suppression in 90% of patients taking one of these new oral medications.

The risk of transmission of HBV following a positive needlestick varies from 6% to 30%, depending on the degree of infectivity of the source individual. Healthcare workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection.

For an unvaccinated person, the risk from a single needlestick or a cut exposure to HBV-infected blood ranges from 6% to 30% and depends on the hepatitis B e-antigen (HBeAg) status of the source individual. Individuals who are both hepatitis B surface antigen (HBsAg)-positive and HBeAg-positive have more virus in their blood and are more likely to transmit HBV (CDC, 2013b).

Hepatitis C

[This section taken largely from CDC, 2013b.]

Hepatitis C virus (HCV) is transmitted primarily through percutaneous exposure, most commonly by injection-drug use. People newly infected with HCV are usually asymptomatic, so acute hepatitis C is rarely identified or reported. With an estimated 3.2 million chronically infected people nationwide, HCV infection is the most common bloodborne infection in the United States.

HCV infection becomes chronic in approximately 75% to 85% of cases. Chronic HCV infection is the leading indication for liver transplants in the United States. Most people with chronic HCV infection are asymptomatic; however, many have chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer. Chronic liver disease in HCV-infected people is usually insidious, progressing slowly without any signs or symptoms for several decades.

Based on limited studies, the estimated risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%, or 1 in 50. The risk following a blood splash to mucous membranes is unknown but is believed to be very small; however, HCV infection from such an exposure has been reported.

There is no vaccine or post exposure prophylaxis against HCV. Prevention of exposure is the only protection against it.

HIV

Human immunodeficiency virus (HIV) is the virus that causes AIDS (acquired immune deficiency syndrome, first identified in 1981). Many years may pass between the time of infection before symptoms of illness begin or are identified. Individuals who have the virus but are not yet sick have no symptoms and many do not know that they are infected. Medications can slow the course of the disease, and there are medications that can be taken after exposure to reduce the likelihood of infection (PEP).

 

chart: Rates of Adults and Adolescents with Diagnosed HIV, US, 2010

Source: CDC, n.d.

The average risk for HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3% (about 1 in 300). Stated another way, 99.7% of needlestick/cut exposures to HIV-contaminated blood do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to average 1 in 1000 (CDC, 2013b). These are encouraging statistics—unless you are the one. The risk is low but it is not zero.

Who Is At Risk?

It is not at all rare for people to carry more than one of the three viruses just discussed, since these pathogens are spread by similar routes: blood-to-blood contact, sexual contact, and injecting-drug use.

In addition to hepatitis B, hepatitis C, and HIV, other less-common bloodborne pathogens include:

  • Hepatitis delta (HDV)
  • Malaria
  • Syphilis
  • Babesiosis
  • Brucellosis
  • Leptospirosis
  • Arboviral infections
  • Relapsing fever
  • Creutzfeldt-Jakob disease
  • Adult T-cell leukemia/lymphoma (caused by HTLV-I)
  • HTLV-I-associated myelopathy
  • Diseases associated with HTLV-II
  • Viral hemorrhagic fever (OSHA, 2011a)

Some of the listed diseases are extremely rare in the United States; however, today’s mobility of individuals and families means that rare diseases can travel globally. Healthcare workers need to be aware of their possible risk of exposure to rare diseases as well as those common to their own country.

The most important thing to remember about all three of the main viruses is that most people infected with them are asymptomatic. This is why it is critical to avoid contact with the blood and body fluids of all individuals, since there is no easy way to tell those infected from those who are not.

Those who are at risk include:

  • People who have contact with blood or body fluids in their personal lives, whether through sexual activity, by injected drug use, or by other mechanisms.
  • Patients who may have exposure to the blood or body fluids of caregivers by unintended means
  • People who have contact with blood or body fluids in their work life (occupational exposure)

 

Source: CDC, 2013.

Chronic Infectious Diseases in the United States, 2009

Disease

People infected
(estimated)

Annual new infections

HIV/AIDS

1.1 million

50,000

Hepatitis B

1.4 million

33,000 estimated

Hepatitis C

3.2 million

17,000 estimated

Science related to bloodborne pathogens is reliably available from the Centers for Disease Control website. To reach their website specific to bloodborne pathogens issues, click here.

The Law

OSHA Bloodborne Pathogens Standard

Law regarding bloodborne pathogens is based on the federal OSHA Bloodborne Pathogens Standard, 29 CFR 1910-1030, originally passed into law in 1992 and amended in 2001. All the requirements of the Bloodborne Pathogens Standard are designed to protect workers from exposure to bloodborne pathogens (OSHA, 2013a).

State Laws

State legislation has been enacted in twenty-two states to improve healthcare worker safety related to needle sticks. These laws add provisions not included in the federal OSHA Bloodborne Pathogen standard and/or coverage of public employees not regulated by OSHA. These laws contain unique requirements such as surveillance programs, cost-benefit analyses, strict requirements for safety device use, and the use of statewide advisory boards.

Implementation of state laws differs regarding development of related regulations and dates when they become effective. State-by-state provisions are available online (OSHA, 2011b). Some resources for state laws are listed in the References.

Compliance with the federal law and any applicable state law is required of all workplace settings where healthcare workers may be exposed to blood or body fluids on the job.

Workplaces Subject to the OSHA Standard

The federal OSHA Bloodborne Pathogens Standard specifies that “each employer having an employee(s) with occupational exposure as defined by paragraph (b) of this section shall establish a written Exposure Control Plan designed to eliminate or minimize employee exposure.” Paragraph (b) says:

Occupational Exposure means 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. (OSHA, 2013a)

In other words, if any workers may reasonably expect to have contact with blood or body fluids on the job, this law does apply to their workplace. All healthcare workers—both licensed and non-licensed—risk exposure to bloodborne pathogens, whether they work in hospitals, nursing homes, home care, or correctional institutions.

Work Areas of Special Concern

Research has identified home care and correctional institutions as work areas with increased risk of bloodborne pathogen transmission. Work practices such as extended work schedules and understaffing also increase the risk of percutaneous injuries (Trinkoff et al., 2007).

Home Care

Earlier discharge from hospitals means that patients are going home “sicker and quicker,” and may have health needs that demand complex nursing skills. Studies show that both RNs and aides/personal care assistants (PCAs) are experiencing sharps injuries at significant levels. One study found that 14% of RNs reported one or more sharps injuries in the previous three years. These injuries were associated with lack of compliance with Standard Precautions, recapping of needles, exposure to household stressors, exposure to violence, and mandatory overtime (Gershon et al., 2009).

Another study found that PCAs are at increased risk when performing nursing-related activities for which they are inexperienced and/or lack training (Lipscomb et al., 2009). A third study showed that 35% of nurses and 6.4% of aides experienced at least one sharps injury during their home healthcare career. Procedures contributing to sharps injuries were injecting medications, administering finger sticks and heel sticks, and drawing blood. Sharps disposal, contact with waste, and patient handling also contributed to sharps injuries. Sharps with safety features were not used much (Quinn et al., 2009), despite requirements of recent laws. Two of the studies found that nearly half of the sharps injuries were not formally reported.

Another study evaluated the experiences of 355 home healthcare nurses and 30 Medicare Certified Home Healthcare Agency and hospice employers in one state and found that some employer policies and nurse practices were out of compliance with OSHA Bloodborne Pathogens Standard. Thirty-eight home healthcare nurses from 12 of the 30 employers reported sharps injuries within the past year but the employers reported only 18 such injuries in that same year (Scharf et al., 2009). More effective education, training, and enforcement of OSHA standards are needed to reduce the incidence of sharps injuries in these areas of practice.

An Exposure Control Plan that includes safety sharps and training on how to use them correctly is required by the Bloodborne Pathogens Standard. Talk with your employer if you are concerned about exposure risk on the job.

Correctional Institutions

All healthcare workers risk occupational exposure to bloodborne pathogens but those who work in correctional facilities face additional challenges:

  • Jails and prisons can be unpredictable work settings.
  • Security issues are often a higher priority than infection control.
  • Inmates may have a higher rate of bloodborne diseases. The rate of AIDS in prison is 2.5 times the rate in the U.S. general population. (USDOJ, 2009)

Correctional healthcare workers may be bitten or stabbed during an inmate assault, punctured with a used needle, or splashed in the face with blood. Any of these situations can expose workers to bloodborne diseases (CDC, 2013b). Education and training of correctional healthcare workers is essential to prevent exposure in these high-risk work settings.

Research and Production Facilities

The OSHA Bloodborne Pathogens Standard includes a section on protection of workers of these specialized types of work sites where risk of exposure to HBV and HIV is significantly higher (OSHA, 3013a). Protective measures for these worksites are much more stringent. If your workplace is not this type of facility, these more stringent requirements do not apply to it.

Exposure Control Plans

[Material in this section is largely from OSHA, 2013a.]

Employers are required to create and implement a written exposure control plan (ECP) specific to each workplace to eliminate or minimize employee exposures. The plan must be updated annually to reflect technological changes that help eliminate or reduce exposure to bloodborne pathogens. In the plan, employers must include information about the infection control system used in the workplace.

The ECP should contain annual documentation of consideration and implementation (if feasible) of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure. Employers must also document that they have solicited input from non-managerial workers in identifying, evaluating, and selecting engineering controls. The ECP must be available to workers. You may legally ask your employer how you can review it.

The exposure control plan should also include a written exposure determination that includes those job classifications and positions in which employees have the potential for occupational exposures. The exposure determination should be made without taking into consideration the use of personal protective clothing or equipment. Employees who are required or expected to administer first aid must be included.

In addition to possible presence in blood, bloodborne pathogens may be present in other potentially infectious material (OPIM). OPIM includes:

  • 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
  • Any 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; and blood, organs, or other tissues from experimental animals infected with HIV or HBV

OSHA (the law) requires Universal Precautions for the OPIM listed above. Note that the list does not specify precautions with urine or feces, which may be heavily loaded with bacteria other than the bloodborne pathogens about which we are concerned here.

Standard Precautions, as described by the CDC, are broader than Universal Precautions, covering more bacteria and viruses than the three—HBV, HCV, and HIV—that are of primary concern as bloodborne pathogens. Standard Precautions specify that contact with all body fluids from all patients should be avoided. These will be reviewed in more detail in Module 5.

OSHA requires the use of Engineering Controls, Work Practice Controls, and Personal Protective Equipment—in that order, because the most effective protections for workers take priority.

Engineering Controls

[Material in this section is largely from OSHA, 2013a.]

Engineering controls are devices that isolate or remove the bloodborne pathogen hazard from the workplace. They include:

  • Hand washing, that sends pathogens on hands down the drain and out of the workplace
  • Elimination of hazardous materials from the workplace, such as the replacement of a hazardous chemical with a safer one or needleless systems for injection
  • Devices that contain the hazard, such as specimen containers, safety sharps, sharps disposal containers, and red bags

Engineering controls, including facilities for hand washing, must be maintained or replaced on a regular schedule to ensure their effectiveness. When handwashing facilities are not available, an antiseptic hand cleanser should be provided. Hands must be washed after gloves are removed or any time there is skin contact with blood or other body fluids.

Specimen containers should not leak; if there is a possibility of leakage a secondary container must be used.

Safety When Handling Sharps

[Material in this section is largely from OSHA, 2013a.]

The federal OSHA Bloodborne Pathogens Standard was amended in 2001 to add the provisions of the Needlestick Safety and Prevention Act of 2001 (public law 106-430). Since then, safety syringes are required for use whenever possible in healthcare facilities. This legislation mandates that institutions conduct annual product reviews of sharps safety devices and that non-managerial employees be involved in the decision-making process.

An estimated 800,000 needle sticks and other sharps injuries are reported each year but the CDC believes that even more such injuries go unreported. Researchers at Johns Hopkins University reported that nearly 60% of medical school graduates surveyed had been stuck by a needle during medical school but half of them did not report the injury to hospital officials. The primary reason for not reporting was the amount of time and paperwork involved in making a report. Those surveyed had trained to become surgeons at seventeen medical centers in the United States (Sharma et al., 2009).

Two-thirds of nurses report being accidentally stuck by a needle while working and three-fourths of them were contaminated needle sticks. Although the overwhelming majority of nurses knew the workplace protocol concerning needle stick injuries, only 7 out of 10 reported the incident (ANA, 2008).

Evaluation and implementation of safer medical devices must be documented in the exposure control plan. Safer medical device lists can be accessed through websites maintained by the California Division of Occupational Safety and Health SHARP program, the National Association for the Primary Prevention of Sharps Injuries, and the International Healthcare Worker Safety Center.

Care must be used whenever handling sharps, especially contaminated sharps. Needlesticks and other sharps injuries carry extra risk of exposure since they bypass the protection of intact skin.

The best way to prevent cuts and sticks is to minimize contact with sharps. That means:

  • Not using a sharp when an alternative method is available
  • Activating safety sharps immediately following completion of use
  • Disposing of used sharps immediately

A needlestick or a cut from a contaminated scalpel can lead to infection by one of the bloodborne viruses. Risk of infection varies by which pathogen is involved.

Puncture-resistant containers must be available nearby to hold contaminated sharps. When reusable sharps must be used, puncture-resistant transport containers must not require employees to reach a hand into the holding container.

Recapping, bending, or removing needles should not be done unless there is no feasible alternative or if required for a specific medical procedure. If recapping, bending, or removal is necessary, workers must use either a mechanical device or a one-handed technique. If recapping is required, a one-handed “scoop” technique may be used, using the needle itself to pick up the cap, pushing cap and sharp together against a hard surface to ensure a tight fit.

There has been considerable media attention about disease outbreaks caused by unsafe injection practices. The CDC has reported nearly 50 outbreaks linked to unsafe injection practices, with more than 150,000 patients affected since 2001. These outbreaks have included transmission of hepatitis B and C as well as bacterial infections.

Syringes and needles must be used for only one patient in every circumstance. This is a matter of protecting patients from diseases spread by injection. It is a matter of good science and is not addressed by OSHA. For more detail, refer to the CDC website section Safe Injection Practices Prevent Infections.

Sharps Containers

[Material in this section is largely from OSHA, 2013a.]

Containers of used sharps are regulated waste and must be handled as specified in the Standard. They must be puncture-resistant, closable, and 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 be easily accessible and they must be maintained upright to keep liquids and sharps inside.

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

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.

Employees should use caution when handling full containers of used sharps, looking carefully for needles that may have punctured the container. Lids should be closed before discard and transportation.

If there is a chance of leakage from the primary container, a secondary container that is closable, labeled, or color coded and leak resistant should be used.

Work Practice Controls

Work practice controls are intended to reduce the likelihood of exposure by changing the way a task is performed. They include appropriate procedures for handwashing, sharps disposal, lab specimen handling, laundry handling, and contaminated material cleaning (OSHA, 2013c). Work practice controls are commonly described in written procedures in the workplace.

Universal vs. Standard Precautions

[Material in this section is largely from OSHA, 2013c.]

The OSHA Bloodborne Pathogens Standard specifies “Universal Precautions shall be observed to prevent contact with blood or other potentially infectious materials.” When you can’t tell the difference, “all body fluids should be considered potentially infectious.”

Source: CDC, 2013c.

Comparison of Universal and Standard Precautions

 

Universal precautions

Standard precautions

First proposed year

1992

1996

Proposed by

Federal OSHA

CDC

Authority is based on

Federal law

science

Protects

Workers only (not patients)

Workers and patients

Use precautions with

ALL patients

ALL patients

Protects from

Bloodborne pathogens only

Viruses, bacteria and protozoa

Stay out of

Blood and listed OPIM (see module 3)

All body fluids, mucous membranes and non-intact skin

Broadness of requirements

Limited to OSHA requirements

Broader than Universal Precautions

Is it legal to use Standard Precautions? Standard Precautions includes all the requirements of Universal Precautions and more. When you use Standard Precautions, you are in full compliance with OSHA’s requirement to use Universal Precautions.

The key provision of both types of precautions is that workers must avoid contact with blood and body fluids of all patients, regardless of diagnosis, because most people who do carry a bloodborne pathogen have no symptoms and often do not know themselves that they are an unknown carrier. Avoid contact with blood and body fluids of all patients to protect yourself, your other patients, your co-workers, and your family.

Other Work Practice Controls

[Material in this section is largely from OSHA, 2013c.]

The Bloodborne Pathogens Standard specifies other work practice controls:

  • Eating, drinking smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is reasonable likelihood of occupational exposure to body fluids. Some work places post signs where body fluids, used gloves, and specimens are not allowed, and permit eating and/or drinking in those areas.
  • Procedures involving blood or OPIM shall be performed in a manner to minimize splashing or generation of droplets. Mouth pipetting is specifically prohibited.

Personal Protective Equipment (PPE)

When to Wear PPE

[Material in this section is largely from OSHA, 2011.]

PPE is specialized clothing or equipment worn by an employee for protection against hazards that remain after engineering controls and work practice controls are in place. PPE is not the first line of defense! The employer must provide personal protective equipment, ensure that the employee uses and must clean, repair, and replace this equipment as needed.

The worker must decide when to wear PPE because exposure is likely. This is usually easy to determine:

If it is wet and not yours, stay out of it!

If exposure seems reasonably likely, you have the right to protect yourself with PPE. Wearing basic PPE is not optional.

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

Gloves shall be worn when:

  • It can reasonably be anticipated that the employee may have hand contact with blood, OPIM, mucous membranes and non-intact skin
  • Performing all vascular access procedures or procedures involving uncontained blood, such as finger or heel sticks
  • Gloves must be changed between patients (CDC, 2013c)

Single use gloves cannot be washed or decontaminated for reuse. Utility gloves may be decontaminated if they are not compromised. They should be replaced when they show signs of cracking, peeling, tearing, puncturing, or deteriorating.

Traditionally, latex gloves are used to avoid contact with blood or OPIM. However, some workers are allergic to latex. In most circumstances, nitrile or other glove alternatives may be used in place of latex gloves. Employers are required to provide non-latex alternatives to employees with sensitivities to latex and other materials.

Employees should wear eye and mouth protection such as goggles and masks, glasses with solid side shields, and masks or face shields when splashes, sprays, splatters, or droplets of blood or OPIM pose a hazard to eyes, nose, or mouth.

Gowns, aprons, surgical caps and hoods, and shoe covers or boots are needed when splash, spray, or gross contamination is expected. This may occur, for example, during labor and delivery.

Employers must provide the PPE and ensure that their workers wear it. This means that if a lab coat is considered PPE, it must be supplied by the employer rather than the employee. The employer also must clean or launder clothing and equipment and repair or replace it as necessary. This includes, but is not limited to dentistry, phlebotomy or processing of any body fluid specimen, and postmortem procedures.

Personal protective clothing and equipment must be appropriate for the level of protection needed for the expected exposure. For example, gloves would be sufficient for a laboratory technician who is drawing blood, whereas a pathologist conducting an autopsy would need considerably more protective clothing.

Personal protective equipment may be required during the care of any patient so it must be routinely available in patient care areas, not just on isolation carts. You may need to wear a mask and eye protection during the care of a patient on Standard or Universal Precautions. Availability of PPE is required by the OSHA Standard. If you are not sure where to obtain it, ask your employer.

Exception

The employer shall ensure that the employee uses appropriate PPE unless the employer shows that the employee temporarily and briefly declined to use PPE when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of healthcare or public safety services or would have posed an increased hazard to the safety of the worker or co-worker.

When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future. In other words, if using PPE would increase danger to the person receiving care or to the worker, then the worker may decline to use the PPE, but situations like this must be reported and investigated.

Decontaminating and Disposing of PPE

[Material in this section is largely from OSHA, 2013c.]

Employees must remove personal protective clothing and equipment before leaving the work area or when the PPE becomes contaminated. If a garment is penetrated, workers must remove it immediately or as soon as feasible. Used protective clothing and equipment must be placed in designated containers for storage, decontamination, or disposal.

While use of PPE cannot prevent all exposures, wearing it properly and when needed can greatly reduce potential exposure to all bloodborne pathogens.

Protecting Employees

Information and Training

[Material in this section is largely from OSHA, 2013c.]

All new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood or OPIM are required to receive training prior to assignment to tasks where occupational exposure may occur. Training typically includes information on the hazards associated with blood and OPIM, the protective measures to be taken to minimize the risk of occupational exposure, and information on the appropriate actions to take if an exposure occurs.

Retraining is required annually, or when changes in procedures or tasks affecting occupational exposure occur. Employees must be provided access to a qualified trainer during the training session to ask and have answered questions as they arise.

OSHA’s Bloodborne Pathogens Standard specifies the content which must be addressed in annual re-training, appropriate in content and vocabulary to educational level, literacy, and language of employees. Employees should request work-place-specific information from their employers if it has not already been provided.

Annual training must address:

  • An accessible copy of the regulatory text of this standard and an explanation of its contents
  • A general explanation of the epidemiology and symptoms of bloodborne diseases
  • An explanation of the modes of transmission of bloodborne pathogens
  • An explanation of the employer’s ECP and the means by which the employee can obtain a copy of the written plan
  • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and OPIM
  • An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and PPE
  • Information on the types, proper use, location, removal, handling, decontamination and disposal of PPE
  • An explanation of the basis for selection of PPE
  • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge
  • Information on the appropriate actions to take and people to contact in an emergency involving blood or OPIM
  • An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical followup that will be made available
  • Information on the post exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
  • An explanation of the signs and labels and/or color coding required
  • An opportunity for interactive questions and answers with the person conducting the training session, who must be knowledgeable in the subject matter covered

Hazard Signs and Labels

[Material in this section is largely from OSHA, 2013c.]

 

image: biohazard symbol

The standard requires warning labels affixed to containers of regulated waste, refrigerators and freezers, and other containers used to store or transport blood or OPIM. The labels must use the word BIOHAZARD and be fluorescent orange or orange-red, affixed in a manner that prevents their loss. Red bags or red containers may be substituted for labels. This applies only to research and production labs.

Note that the biohazard sign is a good reminder that bloodborne pathogens may be present. However, bloodborne pathogens may also be present in many areas that do not have biohazard signs, both within healthcare facilities and in the general public. For this reason, it makes sense to minimize contact with body fluids and to protect any breaks in the skin, including mouth and eyes, at all times.

Other OSHA Requirements

Housekeeping

[Material in this section is largely from OSHA, 2013c.]

The Standard requires employers to maintain the workplace in a clean and sanitary condition, using schedules and procedures for cleaning and decontamination. Equipment and work surfaces must be cleaned and decontaminated after contact with blood or OPIM, immediately or as soon as feasible. If protective coverings are used they should be replaced as soon as contaminated or at the end of the work shift. Waste containers should be cleaned and decontaminated on a schedule and as needed. Contaminated broken glass must not be picked up by hand.

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. For example, different cleaning and decontamination measures would be used for a surgical operatory and a patient room. Similarly, hard-surface flooring and carpeting require separate cleaning methods. More extensive efforts will be necessary for gross contamination than for minor spattering. Likewise, such varied tasks as laboratory analyses and normal patient care require different techniques for cleanup.

Employees must clean (1) when surfaces become obviously contaminated; (2) after any spill of blood or OPIM; and (3) at the end of the work shift if contamination might have occurred. Thus, employees need not decontaminate the work area after each patient-care procedure, but only after those that actually result in contamination.

Before any equipment is serviced or shipped for repairing or cleaning, it must be decontaminated to the extent possible. If some areas remain contaminated, the equipment must be labeled, indicating which portions are still contaminated. This enables employees and those who service the equipment to take appropriate precautions to prevent exposure.

Regulated Waste

Proper handling of regulated waste is essential to prevent unnecessary exposure to blood and OPIM. All regulated waste must be placed in closeable, leakproof containers or bags that are color-coded (red-bagged) or labeled to prevent leakage during handling, storage, and transport. Disposal of waste shall be in accordance with federal, state and local regulations.

Regulated waste includes:

  • Liquid or semi-liquid blood or OPIM that cannot feasibly be flushed
  • Contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed
  • Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling
  • Contaminated sharps
  • Pathological and microbiological wastes containing blood or OPIM

Safety sharps and containers for disposal of used sharps are both engineering controls and regulated waste, once used. Used syringes or sharps must never be discarded into a red bag—only into the puncture-resistant containers required by the Bloodborne Pathogens Standard.

Containers used to store regulated waste must be closable and suitable to contain the contents and prevent leakage of fluids. 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 federal, state and local laws.

Soiled Laundry

[Material in this section is largely from OSHA, 2013c.]

Contaminated laundry shall be handled as little as possible with a minimum of agitation. It must be bagged or contained at the location where it was used and shall not be sorted or rinsed at the location of use. Containers of soiled laundry should be color-coded or labeled to permit all employees to recognize the containers as holding soiled linen and therefore requiring the use of Universal Precautions. If the bag may leak, a secondary leak-proof container must be used.

Laundry workers must wear PPE and have sharps containers available in the event that a sharp may be within the soiled laundry.

Guidance regarding laundry handling and washing procedures in the healthcare setting can be found in CDC Guidelines for Environmental Infection Control in the Healthcare Facilities, 2003.

Hepatitis B Vaccination

[Material in this section is largely from OSHA, 2013c.]

The employer must make hepatitis B vaccination available to all employees with occupational exposure to bloodborne pathogens within 10 days of assignment, at no charge to the employee. This includes healthcare workers, emergency responders, morticians, first-aid personnel, law enforcement officers, correctional facilities staff, laundry workers, and others.

The vaccine is given as a series of three injections, the second and third injections given 1 month and 6 months after the first one. All three must be received for full protection. The vaccine has an excellent record of safety and effectiveness, protecting workers against a disease that may cause no symptoms, mild symptoms, or serious even fatal disease, and that can be spread to others. You may decline the vaccine and will be asked to sign a declination form, as required by the Standard, to verify that you were offered the vaccine. You may change your mind and receive the vaccine later even if you declined at first.

To ensure immunity, it is important for individuals to receive all three injections. As of 2013, the CDC says that for people with normal immune status who have been vaccinated, booster doses are not recommended. The vaccine causes no harm to those who are already immune or to those who may be HBV carriers. Testing to verify immunity following completion of the vaccine series is recommended by the CDC, but is not required.

Reporting Exposure Incidents

[Material in this section is largely from OSHA, 2013c.]

An occupational exposure is defined as a percutaneous (through the skin) injury such as a needlestick or cut with a sharp object or contact of mucous membrane or non-intact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or OPIM. Intact skin is a good barrier against these viruses. For exposure to occur there must be some sort of break in the skin, a “portal of entry,” such as a needlestick, cut, dermatitis, or exposure of a mucous membrane.

Factors influencing the risk of infection include:

  • Whether the exposure was from a hollow-bore needle or other sharp instrument
  • Whether the exposure was to non-intact skin or mucous membranes such as the eyes, nose, or mouth
  • The amount of blood that was involved
  • The amount of virus present in the source’s blood
  • Which virus is involved—hepatitis B can be much more infectious than hepatitis C or HIV.

The OSHA Bloodborne Pathogens Standard requires medical followup for workers who have an exposure incident. Exposures should be reported within 1 hour if possible to allow for prompt intervention to reduce risk of infection if that is indicated.

Follow the protocol of your employer. Wash the exposed area with soap and water, or use an eye-wash station in the event of an eye-splash. Then report the exposure to the department or individual at your workplace who is responsible for managing exposure. Your employer should let you know how to do this as part of your orientation. If you do not know or are not sure, ask. If you know the name of the individual who was the source of the exposure, take it and information of any device involved, for example the brand of safety sharp in use, with you when you report the exposure. You will be asked about the situation that led to the exposure. These facts are needed for followup and prevention of similar exposures to others (OSHA, 2013a).

Reporting is also important because part of the followup includes testing the blood of the source individual to determine HBV and HIV infectivity, if this is unknown and if permission for testing can be obtained. There are now at least four FDA-approved tests available for rapid HIV antibody testing that can confirm negative HIV status within an hour after blood is drawn from a source individual.

An employer’s failure to use rapid HIV antibody testing of the source individual could be considered a violation of paragraph 1910.1030(f)(3)(ii)(A) in the OSHA standard (OSHA, 2007). The exposed employee must be informed of the results of these tests. Employers must tell the employee what to do if an exposure incident occurs.

Medical Evaluation and Followup

[Material in this section is largely from OSHA, 2013c.]

The Bloodborne Pathogens Standard requires employers whose employees may have exposure to body fluids on the job to have a system in place for managing occupational exposures. This system must be available without delay, 24 hours per day, 7 days per week. This requirement may be challenging for employers who are not health-care providers, such as correctional facilities, firefighters, and first-aid providers. It is often managed by contractual arrangement.

Knowledge of the way to access this system is required as part of your orientation to the job and as part of your annual update education. If you do not know how to do it on your job, ask.

Employers must provide free medical evaluation and treatment to employees who experience an exposure incident. A licensed healthcare provider will evaluate the exposure and advise on how to prevent further spread of any potential infection. If known, the source patient’s blood will be tested for HBV, HCV and HIV, with appropriate consent.

The blood of the exposed employee will also be tested with their consent, or the employee may choose to have blood drawn but not tested until later. The employer must hold this specimen for at least 90 days. This baseline specimen is needed to determine if any later disease is related to the exposure or may have been present before the exposure.

The healthcare provider will share information from testing with the employee and will prescribe appropriate treatment in line with current U.S. Public Health Service recommendations. If the source individual was HBV- or HIV-positive or in a high-risk category, the exposed employee may be offered post exposure prophylaxis (PEP), medication that can be taken following exposure to reduce risk of infection. There is no available PEP against hepatitis C. Hepatitis B vaccine should always be offered following any exposure incident unless the employee is already immune.

Because of the complexity of selecting HIV/PEP regimens, consultation with people having expertise in antiretroviral therapy and HIV transmission is strongly recommended. The National PEP Hotline is available 24/7 at no cost to treating professionals at 888 448 4911.

Written Opinion

In addition to counseling the employee, the healthcare 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 the employee received vaccination. The employer must provide a copy of the report to the employee within 15 days of the completion of the evaluation. The healthcare 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.

Recordkeeping

[Material in this section is from OSHA, 2013c.]

The OSHA Bloodborne Pathogens Standard specifies recordkeeping requirements for employers that include confidential medical records for employees with occupational exposures, records of training provided, and a sharps injury log that documents every sharps injury in detail.

Conclusion

Transmission of bloodborne pathogens in the work setting is a risk wherever workers may have contact with blood or body fluids as a result of their duties. The science is clear. There have been cases of hepatitis B, hepatitis C, and HIV resulting from occupational exposures. Risk of transmission has been greatly reduced by implementation of the requirements of the OSHA Bloodborne Pathogens Standard in 1992. The requirements of the law closely follow the recommendations of the CDC, based on current scientific understanding of these diseases. All the requirements of the OSHA Bloodborne Pathogens Standard must be followed in any workplace where workers may be exposed to bloodborne pathogens as part of their duties.

Resources and References

Resources

OSHA Bloodborne Pathogens Standard
800 321-OSHA (6742)
http://osha.bloodbornepathogens.us/

Fact Sheets on OSHA Standard available
in single copies from regional offices or:
OSHA Publications
Room N-3101
200 Constitution Avenue NW
Washington, DC 20210

To report unsafe working conditions or
safety/health violations to OSHA, contact
nearest OSHA office or phone
800-321-OSHA (6742)
TTY 877 889 5627
https://www.osha.gov/html/Feed_Back.html

OSHA’s mailing address is:
U.S. Department of Labor
Occupational Safety & Health Administration
200 Constitution Avenue
Washington, D.C. 20210

References

National

American Nurses Association (ANA). (2008, June 24). Workplace Safety and Needlestick Injuries Are Top Concerns for Nurses. Press release. Retrieved from www.nursingworld.org.

Centers for Disease Control and Prevention (CDC). (2013a). Hepatitis. Retrieved August 21, 2013 from http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf/

Centers for Disease Control and Prevention (CDC). (2013b). Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C. Retrieved July 23, 2013 from http://www.cdc.gov/niosh/topics/bbp/surveillance.html.

Centers for Disease Control and Prevention (CDC). (2013c; latest update 2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Retrieved January 6, 2010 from http://www.cdc.gov/ncidod/dhqp/gl_isolation _standard.html.

Centers for Disease Control and Prevention (CDC). (2011, September). Viral Hepatitis Surveillance, United States, 2011. Retrieved August 21, 2013 from http://www.cdc.gov/hepatitis/hbv/statisticshbv.htm.

Centers for Disease Control and Prevention (CDC). (2010). Viral Hepatitis Surveillance, United States, 2010. Retrieved August 21, 2013 from http://www.cdc.gov/hepatitis/statistics/2010surveillance/Commentary.htm.

Centers for Disease Control and Prevention (CDC). (2008). Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR 2008;57(No. RR-08).

Gershon RR, Pearson JM, Sherman MF, et al. (2009). The prevalence and risk factors for percutaneous injuries in registered nurses in the home healthcare sector. American Journal of Infection Control 37(7):525–33.

Lipscomb J, Sokas R, McPhaul K, et al. (2009). Occupational blood exposure among unlicensed home care workers and home care registered nurses: Are they protected? American Journal of Industrial Medicine 52(7):563–70.

Occupational Safety and Health Administration (OSHA). (2013a; latest update 2001). OSHA Bloodborne Pathogens Standard. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051.

Occupational Safety and Health Administration (OSHA). (2011). A Guide to Bloodborne Pathogens in the Workplace. Retrieved August 21, 2013 from http://www.nclabor.com/osha/etta/indguide/ig7.pdf.

Occupational Safety and Health Administration (OSHA). (2011). Overview of State Needle Safety Regulation. Retrieved August 21, 2013 from http://www.cdc.gov/niosh/topics/bbp/ndl-law.html

Occupational Safety and Health Administration (OSHA). (2007). Bloodborne Pathogens Standard, Standard Interpretations: Use of rapid HIV antibody testing on a source individual after an exposure incident. Retrieved from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=25619.

Quinn MM, Markkanen PK, Galligan CJ, et al. (2009). Sharps injuries and other blood and body fluid exposures among home healthcare nurses and aides. American Journal of Public Health 99(S3:S7):10–17.

Scharf BB, McPhaul KM, Trinkoff A, Lipscomb J. (2009). Evaluation of home healthcare nurses’ practice and their employers’ policies related to bloodborne pathogens. American Association of Occupational Health Nurses Journal 57(7):275–80.

Sharma GK, Gilson MM, Nathan H, Makary MA. (2009). Needlestick injuries among medical students: incidence and implications. Academic Medicine 84(12):1815–21.

Thompson ND, Perz JF, Moorman AC, Holmberg SD. (2008). Nonhospital healthcare-associated hepatitis B and C virus transmission: United States, 1998–2008. Ann Intern Med 150:33–39.

Trinkoff AM, Le R, Geiger-Brown J, Lipscomb J. (2007). Work Schedule, Needle Use, and Needlestick Injuries Among Registered Nurses. Infection Control & Hospital Epidemiology 28:156–64.

United States Department of Justice (USDOJ). (2009). Rate of Confirmed AIDS in Prison 2.5 Times the Rate I the U.S General Population. Retrieved August 21, 2013 from www.ojp.usdoj.gov/newsroom/pressreleases/2009/bjs10026.htm.

For Individual States

California. Bloodborne Pathogens. Exposure Control Plan for Bloodborne Pathogens. Access at http://www.dir.ca.gov/title8/5193.HTML §5193.

Iowa. Iowa School Occupational Exposure to Bloodborne Pathogens and Needlestick Prevention. Access at educateiowa.gov/index.php?option=com.

Michigan. Bloodborne Infectious Diseases. Part 554. Access at http://www.michigan.gov/documents/CIS_WSH_part554_35632_7.pdf.

Missouri. Bloodborne Pathogens Guideline for Exposure Control Plan and Staff inservice. Access at http://health.mo.gov/living/families/schoolhealth/pdf/GuidelinesForBloodbornePathogens.pdf.

New Jersey. PEOSH Revised Bloodborne Pathogens Standard 29 CFR 1910.1030. Access at http://www.state.nj.us/health/eoh/peoshweb/bbpsib.pdf

New Mexico. New Mexico State Standards 57:47124. Access at http://www.nmschoolhealthmanual.org/shm_17.pdf.

New York. New York State Department of Health Policy Statement and Guidelines to Prevent Transmission of Bloodborne Pathogens from Infected Health Care Personnel through Medical/Dental Procedures. Appendix B. Access at http://www.health.ny.gov/publications/1852/appenb.htm.

North Carolina. A Guide to Bloodborne Pathogens in the Workplace. Access at http://www.nclabor.com/osha/etta/indguide/ig7.pdf or http://www.nclabor.com/osha/etta/A_to_Z_Topics/bloodborne_faq1.pdf.

Oregon. Bloodborne Pathogens: Questions and Answers about Occupational Exposure. Access athttp://www.cbs.state.or.us/osha/pdf/pubs/2261.pdf.

Pennsylvania. Pennsylvania HB 454 was signed into law as Act 96. Access at https://www.ects.org/Human_Resources/BloodBorne.pdf.

Texas Bloodborne Pathogen Law:

Locate Health and Safety Code, then click Chapter 81, Communicable Disease, then click subchapter H, Bloodborne Pathogen Exposure Control Plan 81.301 through 81.307.

Texas Dept of State Health Service Bloodborne Pathogen Rules in the Texas Administrative Code:

Go to Title 25 Health Service, then to Part 1, Department of State Health Services, then to Chapter 96, Bloodborne Pathogen Control 96.101 through 96.501.

Washington State. WAC, Bloodborne Pathogens, pp. 296-823. Access at http://www.lni.wa.gov/wisha/rules/bbpathogens/.