What protections are required for employees who come in contact with bloodborne pathogens?
OSHA estimates that 5.6 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV, which causes AIDS), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) place workers at risk for infection with bloodborne pathogens.
OSHA defines blood to mean human blood, human blood components, and products made from human blood.
Human body fluids including:
-- 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
-- all body fluids in situations where it is difficult or impossible to differentiate between body fluids
l Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
l 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.
"Occupational exposure" is defined as skin, eye or mucous membrane contact with blood or other potentially infectious materials that can reasonably be expected to result from the performance of an employee's duties. Where there is occupational exposure, employers must observe "universal precautions," which means treating all human blood and certain body fluids as if they are known to be infectious for HIV, HBV, HCV and other bloodborne pathogens.
Whether employees are potentially exposed must be determined without regard to protective clothing and equipment that they may be using. Therefore, when dealing with blood-soiled laundry, only employees subject to the bloodborne pathogens standard must comply with the standard's provisions.
Revised bloodborne pathogens standard. OSHA revised the bloodborne pathogens standard, effective April, 18, 2001, to address the need for employers to select safer medical devices to prevent needlestick injuries. The updated standard requires employers to consider safer needle devices during the annual review of the employer's exposure control plan. Employers are required to solicit frontline employee input in the identification, evaluation and selection of safer devices. In addition, employers are required to maintain a log that tracks injuries from contaminated sharps while protecting the confidentiality of injured employees.
Scope and application of the standard. Health care occupations potentially exposed to bloodborne pathogens include physicians, dentists, dental employees, phlebotomists, nurses, morticians, paramedics, medical examiners, laboratory and blood bank technologists and technicians, housekeeping personnel, laundry workers, employees in long-term care facilities and home care workers. Public safety workers who may be occupationally exposed include firemen, policemen and prison workers. However, OSHA emphasizes that application of the standard is not limited to workers in the listed occupations and that those listed are covered only if they have occupational exposure to bloodborne pathogens.
Hepatitis B virus. The Centers for Disease Control recommend post-vaccination antibody testing following the hepatitis B virus vaccination series for all healthcare workers who have blood or patient contact and are at an ongoing risk for injuries with sharp instruments or needlesticks. Under CDC guidelines, healthcare workers may include "first responders." Thus, a public safety officer subject to OSHA's bloodborne pathogens standard who meets the CDC criteria may be subject to testing for the hepatitis B surface antigen. OSHA recommends that antibody testing be done for all occupationally exposed employees within a period of one to two months following the vaccination.
Hepatitis C virus (HCV). OSHA has determined that the hepatitis C Virus (HCV) is a bloodborne pathogen covered by the bloodborne pathogen standard. However, not all of the provisions of the standard apply to cases involving HCV. Sections 1910.1030(d)(3)(ii)(A)-(C) and 1910.1030(d)(3)(iii) only apply to testing for HBV and HIV after an exposure incident. Section 1910.1030(e) only applies to HIV and HBV research laboratories and production facilities. Section 1910.1030(f)(1),(2),(4)(i) and (5)(i) only apply to HBV vaccination, information provided to a health care professional, and a health care professional's written opinion. Section 1910.1030(g)(1)(ii) only applies to signs in HIV and HBV research laboratories and production facilities. Section 1910.1030(g)(2)(vi)(I) only applies to training about the HBV vaccine and 1910.1030(g)(2)(ix) only applies to training in HIV and HBV laboratories and production facilities. Section 1910.1030(h)(ii)(B) only applies to keeping records of an employee's vaccination status.
Home healthcare. Agencies employing health care workers who perform their duties in patients' private homes cannot be required to ensure that employees use proper work practices, handle regulated wastes appropriately, and wear necessary protective equipment while working. However, the agency must comply with the provisions of the standard requiring development of an exposure control plan covering all of these areas and must provide employees with safe means of handling or replacing sharp instruments and with personal protective equipment and must train employees on all aspects of the plan. OSHA has prepared a model exposure control plan for hospices and home health care agencies.
Emergency response workers. The CDC issued guidelines in March 1994 under the Ryan White Care Act for emergency response workers who may be exposed to life-threatening diseases during an emergency. The guidelines apply to HBV and HIV, including AIDS. The guidelines contain information for determining whether an exposure to one of the diseases has occurred.
First aid. Humanitarian gestures by an employee, such as assisting a coworker who is bleeding as the result of a fall, are considered to be "Good Samaritan" acts not covered by the standard, as long as the employee's job duties do not include giving medical aid. On the other hand, if any employee is trained in first aid and designated by the employer to render medical assistance as part of his job duties, the standard applies and the employer must prepare a written exposure control plan and train the affected employee
Exposure control plan. Each employer with one or more employees who are occupationally exposed to bloodborne pathogens must develop a written exposure control plan designed to eliminate or minimize employee exposures. The plan must include the employer's determination of which job assignments and which individual employees are covered by the standard, the schedule for implementing control measures and procedures for evaluating the circumstances surrounding an exposure incident, as well as procedures for hepatitis B vaccination, post-exposure follow-up, communication of hazards to employees, and recordkeeping. The plan must be updated at least annually and whenever new tasks and procedures affect occupational exposure and must be accessible to employees.
OSHA issued a directive in 1999 to ensure uniform enforcement of the standard. The revised directive emphasizes the importance of an annual review of the employer's bloodborne pathogens program and the use of safer medical devices to help reduce needlesticks and other sharps injuries. OSHA does not advocate one particular device over another, but the directive indicates that citations will be issued if the exposure control plan does not indicate that effective engineering controls, such as safety needles and similar devices, have been considered and implemented to eliminate or minimize exposure.
Methods of control. The primary methods of preventing occupational transmission of bloodborne pathogens are work practice controls, which reduce the likelihood of exposure to bloodborne pathogens by altering the manner in which a task is performed, and engineering controls, which remove the hazard or isolate it from employees.
Work practice controls include prohibiting the recapping of needles by a two-handed technique; banning eating, drinking and smoking in work areas where there is a likelihood of occupational exposure; and checking and decontaminating equipment prior to servicing. Other work practice controls include prohibiting pipetting or suctioning of blood by mouth, preventing the storage of food or drink in refrigerators and cabinets where blood or other infectious materials are kept, requiring employees to wash hands when gloves or other personal protective equipment are removed, and performing procedures involving blood or other infectious materials so as to minimize splashing, spraying and spattering.
Engineering controls include self-sheathing needles, puncture-resistant disposal containers for contaminated sharp instruments, resuscitation bags and ventilation devices. Although OSHA does not advocate any particular safety devices, an employer will be cited if it does not periodically review new commercial safety devices that are available and implement improved devices.
Handling used needles. The breaking or shearing of contaminated needles is prohibited. Recapping, removing or bending needles is also prohibited unless the employer can show that no alternative exists. When required by a medical procedure, recapping, bending or removal must be done by mechanical means, using a one-handed technique. OSHA policy is that the standard does not preclude the use of well-designed mechanical needle recapping devices used in accordance with a well-conceived exposure control plan. Although primary reliance should be placed on immediate discarding of disposable unrecapped sharps into a readily accessible approved sharps container after use, immediate discarding is not always feasible or appropriate. In those cases, the exposure control plan can provide for the use of mechanical recapping devices and self-sheathing needles, as long as the plan identifies the appropriate role for these devices and the circumstances particular to the facility or operation requiring their use.
Personal protective clothing and equipment. To the extent that work practice and engineering controls do not eliminate employee exposures, personal protective clothing and equipment must be used. Appropriate PPE may include gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks or other ventilation devices. To be considered "appropriate," the equipment must prevent blood or other potentially infectious materials from reaching the employee's work clothes, street clothes, and undergarments, as well as skin, eyes, mouth or other mucous membranes. Employers must provide appropriate PPE at no cost to employees and require its use.
l Gloves must be worn when employees are anticipated to have contact with blood or other infectious materials, when performing vascular access procedures, and when handling or touching contaminated items.
l Face and eye protection must be worn whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated.
l All PPE must be removed prior to leaving the work area and placed in an designated area or container
Exposure incidents. The standard specifies procedures to be followed after any "exposure incident" --a specific incident involving an employee's eye, mouth, other mucous membrane or nonintact skin contact with blood or other potentially infectious materials. Evaluations and follow-up must be made immediately available at no cost to the employee. Follow-up must include a confidential medical evaluation, documentation of the circumstances of the exposure, identification and testing the source individual if feasible, testing the exposed employee's blood with his consent, post-exposure treatment, counseling, and evaluation of reported illnesses.
Postexposure prophylaxis (PEP). The U.S. Public Health System (PHS) issued consolidated and updated recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) have been issued by the CDC (June 2001) with an additional update for HIV in September 2005 due to a change in the postexposure prophylaxis (PEP) regimen.
HBV postexposure management. Recommendations for HBV postexposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure. PEP with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person. The recommendations provide guidance to clinicians and exposed HCP for selecting the appropriate HBV PEP.
HCV postexposure management. Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for PEP of hepatitis C. For HCV postexposure management, the HCV status of the source and the exposed person should be determined, and for HCP exposed to an HCV positive source, follow-up HCV testing should be performed to determine if infection develops.
In addition, the report outlines several special circumstances (e.g., delayed exposure report, unknown source person, pregnancy in the exposed person, resistance of the source virus to antiretroviral agents, or toxicity of the PEP regimen) when consultation with local experts and/or the National Clinicians' Post-Exposure Prophylaxis Hotline ([PEPline] 1-888-448-4911) is advised. Occupational exposures should be considered urgent medical concerns to ensure timely postexposure management and administration of HBIG, hepatitis B vaccine, and/or HIV PEP.
The PHS recommendations for HBV and HCV were published in the June 29, 2001, Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (Vol. 50, No. RR-11). An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.
HIV postexposure management. Recommendations for HIV PEP include a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person's virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person's virus is unlikely to be resistant is recommended.
The CDC Morbidity and Mortality Weekly Report, issued September 30, 2005 (Vol. 50, No. RR-9) updates U.S. Public Health Service recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens have been changed. The report emphasizes adherence to HIV PEP when it is indicated for an exposure, expert consultation in management of exposures, follow-up of exposed workers to improve adherence to PEP, and monitoring for adverse events, including seroconversion. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns.
Disinfectants for decontamination. Disinfectants registered and approved by the Environmental Protection Agency (EPA) for both HIV and HBV meet the requirement in OSHA's bloodborne pathogen standard and are appropriate disinfectants to clean contaminated surfaces, provided such surfaces have not become contaminated with agents, volumes, or concentrations of agents for which higher level disinfection is recommended. According to an OSHA directive, the effectiveness of the disinfectant is governed by strict adherence to the instructions on the label
Hepatitis vaccinations. Employers must offer HBV vaccinations to all employees with occupational exposure. Employees who choose not to be vaccinated must sign a declination form, but may later elect to accept the vaccine. Vaccinations must be provided at no cost to employees, including transportation costs. The vaccinations must also be made at a reasonable time and place for employees, which means during normally scheduled work hours
The bloodborne pathogens standard does not currently require a hepatitis B vaccination booster after employee exposure occurs. However, antibody testing is required approximately two months after an employee finishes the vaccination series, as recommended by the United States Public Health Service Centers for Disease Control and Prevention.
Recordkeeping. Employers must maintain an accurate record of occupational exposure for each employee, including the worker's HBV vaccination status and the results of examinations, tests, and postexposure evaluations. Employers must also keep records of exposure incidents, postexposure follow-up, and employee training.
OSHA has clarified that for purposes of the work-related injury and illness log, a needlestick, laceration, splash or other exposure to bodily fluids should be recorded as an occupational injury when the incident results in a recommendation for medical treatment beyond first aid or a diagnosis of seroconversion (.03 ).
The recordability of needlestick injuries is governed by OSHA's recordkeeping requirements and the bloodborne pathogens standard. To be recordable, needlestick injuries must be work-related, and result in one of the following: a fatality; lost workdays; the need for medical treatment beyond first aid; loss of consciousness; restriction of work or motion; or transfer to another job. The bloodborne pathogens standard requires that employers document the circumstances under which exposure incidents occur and the routes of exposure.
Handwashing facilities. Medical exam rooms where contact with blood can be reasonably anticipated or a medical practice that conducts routine pelvic or rectal exams must provide handwashing facilities for employees under the bloodborne pathogens standard. The use of gloves as personal protective equipment may not be enough to protect against bloodborne pathogens. However, exam rooms where procedures are limited to simple noninvasive procedures do not need handwashing facilities or even the use of gloves.
Labeling. Standard warning labels must be attached to containers of regulated waste, refrigerators and freezers containing blood and other infectious materials and other containers used for storage, transportation or shipping of contaminated laundry and other materials. The warning label must be fluorescent orange, contain the biohazard symbol and the word "BIOHAZARD."
Training. Employees must receive training in bloodborne pathogen hazards, the requirements of the standard, and the employer's exposure control plan. The training is to be given before employees are assigned to tasks with occupational exposure, at least annually thereafter, and whenever modifications of tasks or procedures affect the employee exposure.
Healthcare workers' guide. The Centers for Disease Control and Prevention (CDC) has published informational literature for healthcare workers on the hazards associated with exposure to blood. The literature addresses hepatitis B virus, hepatitis C virus and human immunodeficiency virus. Exposure may occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with the patient's blood. The publication addresses all phases of worker exposure to bloodborne pathogens: preventative measures, exposure and postexposure procedures. To obtain a copy of the CDC's publication, entitled "Exposure to Blood: What Healthcare Workers Need to Know (July 2003)," contact the Public Health Foundation at 877-252-1200 (toll free).
Reprinted with permission. © CCH
What protections are required for employees who come in contact with bloodborne pathogens? What protections are required for employees who come in contact with bloodborne pathogens? OSHA estimates that 5.6 million workers in the health care industry and related occupations...
What protections are required for employees who come in contact with bloodborne pathogens?
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