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Bloodborne Pathogen Exposure Control

Introduction

To protect employees from exposure to bloodborne biohazardous agents and to ensure that all occupational and research activities are conducted in a manner consistent with Lehigh University's Bloodborne Pathogen Exposure Program and 29 CFR 1910.1030.

Scope

The OSHA Bloodborne Pathogen Standard applies to all occupational exposures which may result in contact with blood or other infectious materials including:

  • Plasma
  • Sera
  • Semen
  • Vaginal secretions
  • Cerebrospinal fluid
  • Synovial fluid
  • Pericardial fluid
  • Pleural fluid
  • Peritoneal fluid
  • Amniotic fluid
  • Saliva (in dental procedures)
and any other body fluids visibly contaminated with blood, and all body fluids in situations where it is difficult to differentiate between body fluids. Also human cell cultures and any unfixed tissue or organ, other than intact skin, of a living or dead human is included.

To be in compliance with the OSHA Bloodborne Pathogen Standard, Lehigh University has developed a Bloodborne Pathogen Exposure Control Plan. The goal of the plan is the elimination of the health risk of workplace exposure to the Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and other bloodborne pathogens through the use of:

  • Work practice controls
  • Engineering controls
  • Protective clothing and equipment
  • Employee information and training
  • Medical Evaluations and follow-up of incidents involving exposure.

Policy
  1. Program Responsibilities

    Responsibilities for Bloodborne Pathogen safety rests at all levels of the University and involves the following individuals or groups:

    1. University President- The President has the ultimate responsibility for the Bloodborne Pathogen Exposure Control Program within the institution and must, with other administrators, provide continuing support for the institutional program.
    2. Provost Council - The Provost's Council shall oversee the University's Biosafety Committee and advise the President on biosafety practices and compliance with the OSHA Bloodborne Pathogen Standard.
    3. University Biosafety Committee- The Biosafety Committee shall report directly to the Provost Council and its duties will include but not be limited to the following:
      1. Give direction to the overall Bloodborne Pathogen Exposure Control Program,
      2. Establish and issue biosafety policies, rules and procedures to protect personnel and property,
      3. Review and act on accident reports and reports from insurance companies, University Safety Committees and regulatory agencies,
      4. Assign and/or conduct special biosafety investigations.
    4. Deans, Directors, Department Chairs, Center/Institute Directors- It is the responsibility of Deans, Directors, Department Chairs, Center/Institute Directors to develop departmental procedures and implement practices to ensure effective compliance with the Bloodborne Pathogen Exposure Control Program.
    5. Principal Investigators (Pls)/Supervisors/Managers- Principal Investigators (PIs)/Supervisors/ Managers have primary responsibility for implementing the Bloodborne Pathogen Exposure Control Program in their operational unit. These individuals are responsible for identifying potentially infectious and biohazardous materials and procedures and carrying out specific control procedures such as equipment and area decontamination schedules and procedures within their area of supervision. They are also responsible for the instruction of students and staff in the potential hazards of biologically derived materials. These individuals will ensure that his/her staff, with the potential for occupational exposure, is offered the HBV vaccine. The selection of individuals participating in the Hepatitis B vaccination program will be the responsibility of this group. Finally, they are responsible for identifying and training new employees on the OSHA Bloodborne Pathogen Standard.
      1. All Lehigh University employees who have the potential to be exposed to bloodborne pathogens shall be trained in the Bloodborne Pathogen Exposure Control Program before they begin their assignment. The training shall also be given to health workers, hired by the University, on an interim basis.
      2. Annual bloodborne pathogen training is required for those individuals in the Bloodborne Pathogen Program.
    6. Environmental Health and Safety
      1. Monitors compliance with the University's safety policies and procedures regarding potentially infectious and biohazardous materials.
      2. Assists University personnel with the selection of safety equipment and work practice controls.
      3. Provides technical guidance to all University employees on matters related to biosafety.
      4. Develops and conducts general training and informational programs to promote techniques for the safe handling and disposal of biohazardous material. Specific training on the safe handling and use of potentially biohazardous materials is the responsibility of the Principal Investigator/Supervisor/Manager.
      5. Investigates reported accidents which may result in personnel or environmental exposure to potentially infectious and biohazardous materials.
      6. Coordinates the off-site disposal of potentially infectious wastes.
    7. University Employees -

      These individuals are responsible for the following:

      1. Complying with safety guidelines and procedures for the task(s) performed in their laboratories/areas.
      2. Reporting of any unsafe condition to the Principal Investigator/ Supervisor/Manager or Environmental Health and Safety.

    8. Facilities Services- Monitors the operation of engineering controls such as fume hoods and coordinates a preventative maintenance program for these controls.

  2. Hepatitis B Vaccine
    1. General Information -

      All Lehigh University employees who have been identified by their Principal Investigator/Supervisor/Manager as having the potential to be exposed to blood or other potentially infectious materials will be offered the Hepatitis B vaccine, at no cost to the employee. The vaccine will be offered within ten (10) working days of their initial assignment to work. The vaccine does not need to be offered if the employee has previously received the complete HBV vaccination series, or if antibody testing revealed that the employee is immune or the vaccine is contraindicated for medical reasons.

      The Hepatitis B vaccination series will be offered through the Lehigh University Student Health Center. The fee for the vaccination series will be billed to the employee's/student's Department. The Student Health Center will not administer the vaccine without a Department charge number and the Hepatitis B Immunization Form.

    2. Supervisory Responsibilities Concerning Hepatitis B Vaccine -

      The Principal Investigator/Supervisor/Manager will ensure that his/her staff, with the potential for occupational exposure, is offered the HBV vaccine. These supervisory individuals are also responsible for identifying tasks/jobs which have an occupational exposure and informing the employee of this potential. The selection of individuals participating in the Hepatitis B vaccination program will be the responsibility of the Principal Investigator/Supervisor/Manager.

      Failure to offer the Hepatitis B vaccine and completion of the necessary paperwork (acceptance of declination of the Hepatitis B vaccine) will be in direct violation of the Federal OSHA Bloodborne Pathogen regulation and will jeopardize Lehigh University's compliance efforts.

    3. Medical Surveillance -

      All Lehigh University personnel will be offered post-exposure follow-ups when they have experienced a significant exposure. A significant exposure shall be defined as the introduction of infectious materials into the skin such as through "needlesticks" or obvious skin cuts or abrasions and contact of potentially infectious materials with mucosal surfaces, such as those of the mouth, eyes or nose. Potentially infectious materials are defined as blood, body fluids, and other fluid visibly contaminated with blood, microbial stocks and cultures and all body fluids in situations where it is difficult to differentiate between body fluids, and materials or equipment that may reasonably come in contact with these materials.

      All cuts and/or needlesticks that occur in potential bloodborne pathogen environments, such as a laboratory or research area, shall be reported to EH&S for investigations.

      Since most employees will not be able to differentiate between fluid types, all body fluids should be treated as potentially hazardous.

      These follow-up examinations will be coordinated through the Lehigh University Student Health Center. The Student Health Center physician will determine if a post-exposure follow-up should be done at Lehigh University's Student Health Center or if a referral to St. Luke's Hospital Occupational Health Department is necessary. This will be addressed on a case-by-case basis and the decision to refer an employee to St. Luke's Hospital will be the decision of Lehigh University's Student Health Care physician.

    4. Medical Recordkeeping and Confidentiality

      Lehigh University has established and will maintain accurate records in accordance with 29 CFR 1910.20 for each employee with an occupational exposure. These records shall include:

      1. The name and social security number of the employee.
      2. A copy of the employee's Hepatitis B vaccination status including the dates of all Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination.

For more information regarding this policy, contact Environmental Health and Safety 610-758-4251.
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