Exposure to blood-borne pathogens plan


This Exposure to Bloodborne Pathogens Plan is provided for any Lynn University employee with the potential for occupational exposure to bloodborne pathogens and other potentially infectious materials as required under 29 CFR Part 1910.1030 of the Occupational Safety and Health Administration. This plan shall be utilized to minimize employee, student, and visitor exposures to bloodborne pathogens and other potentially infectious materials.


In accordance with the Occupational Safety and Health Administration’s (OSHA) federal standard for Bloodborne Pathogens, those members of the campus community identified at high risk for the transmission of infectious disease include members of the Health Center, the Athletic Department, Campus Safety, and Facility Services. These members of the campus community must comply with all segments of this Plan. Failure to do so may result in discipline leading up to and including dismissal.

Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.


Blood- human blood or blood components and products made from human blood.

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

Clinical Laboratory- a work-place where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

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

Contaminated Laundry- laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

Contaminated Sharps- any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontamination- the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

Disinfect- to inactivate virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g. bacterial endospores) on inanimate objects.

Exposure Incident- a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

Hepatitis B Surface Antibody- a serologic marker to determine immunity to hepatitis B. Employees at risk for exposure will be given a blood test to determine presence of this marker after the initial series of three hepatitis B vaccinations will be done between one and two months following vaccine completion.

Hepatitis B Virus- a potentially life threatening bloodborne pathogen transmitted (HBV) through sexual contact, needle sharing, through skin wounds or breaks in the skin and by mucous membrane contact with contaminated blood or blood products which causes an inflammation of the liver. The virus can survive for periods of one week or longer on surfaces contaminated with blood.

Hepatitis B Vaccine- non-infectious yeast-based recombinant injection, given in a series of three doses, intramuscular in the deltoid area of the upper arm at zero, one and six months. The duration of protection and need for booster doses are not yet well defined, but is considered effective for greater than 15 years, according to the CDC. Those individuals vaccinated who develop adequate antibodies after the series may lose detectable antibody, but protection against infection and clinical disease appears to persist. Current medical information indicates that 90% of all adult vaccine recipients develop adequate antibody responses. A number of factors may be involved in non-response to the vaccination. These include vaccine factors such as dose, schedule and injection site and certain host factors such as older age (greater than 40 years), obesity, smoking, male gender, and chronic illness. These factors, if present might be a cause for non response to the vaccination. Further vaccination with a second series of hepatitis B vaccine may produce a positive antibody response in greater than 75% of all second series recipients. Individuals who do not respond to a second series of three vaccines will be considered non-responders or hypo responders. In the event of an exposure incident these individuals will be treated with post exposure prophylaxis.

The vaccine is considered to be 80% to 100% effective in preventing infection or clinical hepatitis in those who have been vaccinated and develop an antibody response.

Common side effects of the vaccine include soreness at the injection site and hypersensitivity.

The recombinant vaccine is genetically engineered from yeast, and contains no human material. Therefore, the vaccine does not contain HIV or live HBV.

Hepatitis C Virus- is the most common chronic bloodborne infection in the United States. It is spread by contact with the blood of an infected person. Persons at risk for having hepatitis C include, IV drug users, those persons who received blood transfusions or solid organ transplants before July 1992, those persons who received blood products for a clotting problems before 1987, kidney dialysis patients or those who have abnormal liver enzymes which might indicate liver disease. It is also spread by sexual contact. There might also be a risk of infection with body piercing or receiving a tattoo.

Hepatitis C often occurs with no symptoms or very mild symptoms. Of every 100 persons infected with hepatitis C, 85 persons may develop long term liver disease, 70 persons may develop chronic liver disease, 15 persons my develop cirrhosis over a period of20 to 30 years, and 5 persons may die from the consequences of long term liver disease such as liver cancer or cirrhosis.

There are no vaccines to protect workers from this disease. Treatment includes use of antiviral agents. The risk of contracting hepatitis C after a needle stick or sharp injury and subsequent exposure to hepatitis C is about 1.8% or 2 persons out of 100 exposed. The range for transmission is about 0 to 10% following an exposure for workers at high risk.

Human Immunodeficiency Virus (HIV)- a blood borne, sexually-transmitted pathogen which damages the body's immune system, allowing other infectious agents to invade the body causing disease and death. HIV is spread via contact with blood and body fluids, non-intact skin, and mucous membranes.

Licensed Healthcare Professional- is a person whose legally permitted scope of practice allows him/her to independently perform activities associated with hepatitis B vaccination and post exposure evaluation and follow-up.

Needle-less System- devices that do not use needles for collection of body fluids, or withdrawal of body fluids after initial venous or arterial access is established, to administer medication or fluids, or any other procedure that involves the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Other Potentially Infectious Materials (OPIM):

Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid whether blood is visible or not.

Any unfixed tissue or organ (other than intact skin) from a human (living or dead).

HIV, HCV, or HBV containing cell or tissue cultures, organ cultures, and culture medium or other solutions, and blood, organs or other tissues from experimental animals infected with HIV or HBV.

Parenteral- exposure occurring as a result of piercing the skin barrier or mucous membrane (e.g. subcutaneous, intramuscular, intravenous routes) through such events as needlestick, human bite, cuts and abrasions.

Personal Protective Equipment (PPE)- Any equipment or clothing designed to create a barrier to protect a person from chemical, medical waste, physical, or mechanical hazard. PPE includes, but is not limited to: chemical goggles, safety glasses with permanent side shields, face shields, gloves, chemical aprons, proper footwear, respirators, chemical boots, hearing protection devices, and hard hats.

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

Safety Devices- products and technology that are designed to prevent needle stick injuries and exposure to bloodborne pathogens.

Sharps with Engineered Sharps Injury Protection- non-needle sharps or a needle with a device for withdrawing body fluid, accessing a vein or artery, or administering medications or other fluids with a built in safety feature or mechanism that effectively reduces the risk or an exposure incident.

Sharps Injury Log- a record for recording percutaneous injuries from contaminated sharps.

Source Individual- any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.

Sterilize- the process by which chemical or physical actions are used to destroy all microbial life.

Universal Precaution- a method of infection control in which all human blood and body fluids are treated as if known to be infectious for HIV, HBV, HCV and other bloodborne pathogens.


I. Compliance Methods

1. Universal precautions will be observed to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.

2. Work practice controls will be utilized to eliminate or minimize exposure to employees. Where occupational exposure remains after implementation of these controls, personal protective equipment shall also be utilized. The following controls will be utilized:

a. Protective gloves will be worn during patient contact.

b. Needles will be disposed of in sharps containers.

c. Specimens and disposable equipment will be disposed of in appropriately marked containers.

d. Protective gloves will be worn when cleaning rest rooms.

e. Bodily fluid spill kits are available in all custodial closets.

f. Double gloves should be worn when cleaning bodily fluid spills.

g. Infectious waste will be placed in red biohazard bags and then placed in designated red biohazard containers.

3. The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows:

a. Physical Plant personnel are responsible for reviewing the effectiveness of controls in cleaning rest rooms, repairing plumbing fixtures, and other maintenance related tasks.

b. The Physical Plant will also ensure that bodily fluid spill clean-up kits are available in all custodial closets.

4. Hand-washing facilities are available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure.

5. Immediately after removal of personal protective gloves or as soon as feasible, employees and students shall wash hands and any other potentially contaminated skin area with soap and water.

6. If employees or students incur exposure to their skin or mucous membranes, those areas shall be washed or flushed with water as appropriate as soon as feasible following contact.

A. Contaminated Equipment

1. Equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible.

2. Everything is either disposable or can be decontaminated.

B. Laundry Procedures

Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in marked bio hazard bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use. All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.

C. Personal Protective Equipment

All personal protective equipment used at the University will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees’ clothing, skin, eyes, mouth, or mucous membranes under normal conditions of use and for the duration of the time that the protective equipment will be used.

Personal protective equipment is kept in all areas designated as having the potential for exposure. Gloves are worn on all occasions where there is potential for contact with bodily fluids. Utility gloves are kept with cleaning supplies and worn by custodians when cleaning restrooms.

All personal protective equipment will be cleaned, laundered, repaired, replaced, and/or disposed of by the employer at no cost to employees.

The OSHA standard also requires appropriate protective clothing to be used, such as lab coats, gowns, aprons, clinic jackets, or similar outer garments. All garments that are penetrated by blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area. All personal protective equipment is disposable and shall be disposed of in properly marked, red biohazard bags and then placed in red receptacles located throughout campus. All reusable equipment is disinfected in a disinfectant solution after each use.

Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes.

Gloves shall be worn for any procedure with the potential for contact with body fluids.

Disposable gloves used at the University are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or immediately if they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability to function as a barrier is compromised.

Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.

University facilities will be cleaned and decontaminated according to the following schedule:

1. Custodians do routine cleaning depending on room usage;

2. Rest rooms are cleaned daily.

Decontamination will be accomplished by utilizing approved disinfectants.

All contaminated work surfaces will be decontaminated after completion of procedures and immediately, or as soon as feasible, after any spill of blood or other potentially infectious materials, as well as the end of the work shift if the surface may have become contaminated since the last cleaning.

All bins, pails, cans, and similar receptacles shall be decontaminated following each use. The person using these receptacles shall be the one responsible for its cleaning. The person doing the clean-up shall wear gloves and use appropriate disinfectant.

Any broken glassware which may be contaminated will not be picked up directly with the hands. Glass shall be collected with dustpan and broom from blood spill kit, located in each area, and placed in red bag container for disposal. The broom and dustpan will be soaked in a disinfectant after use.

All contaminated sharps shall be discarded as soon as feasible in sharps containers.

Regulated waste other than sharps shall be placed in appropriate containers.

D. Needles

Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one-handed technique. All contaminated needles and other sharps are disposed of in red, marked, puncture resistant, leak-free containers.

E. Containers for Reusable Sharps

Immediately after use, or as soon as possible, reusable contaminated sharps are to be placed in appropriate sharps containers. All contaminated needles and sharps that are not to be reused, shall be disposed of in red, marked, puncture resistant, leak-free containers.

F. Specimens

1. Specimens of blood or other potentially infectious materials will be placed in leak-proof containers during collection, handling, processing, storage, and transport of the specimens.

2. The container used for this purpose will be red in color in accordance with the requirements of the OSHA standard. (Note that the standard provides for an exemption for specimens from the labeling/color coding requirement of the standard provided that the facility utilizes universal precautions in the handling of all specimens and the containers are recognizable as containing specimens. This exemption applies only while the specimens remain in the facility.) Universal precautions will be observed at all times.

3. Any specimens that could puncture a primary container will be placed within a secondary container that is puncture resistant.

4. Sharps containers, all contaminated equipment, and all specimens are placed in a red bag that is placed in an appropriately labeled box. These are disposed of through collection by a qualified medical waste disposal service.

5. If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container that prevents leakage during the handling, processing, storage, transport, or shipping of the specimen.

G. Work Area Restrictions

1. In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees and students are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present.

2. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.

3. All procedures will be conducted in a manner that will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods at the University to accomplish this include:

a. Contaminated sharps and other contaminated equipment are disposed of in appropriate containers;

b. Covers are placed on centrifuges and/or coverings are placed on specimen containers.

II. Hepatitis B Vaccine

All employees who have been identified as having exposure 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 10 working days of their initial assignment to work tasks involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine or wishes to submit to antibody testing which shows the employee to have sufficient immunity.

Employees who decline the Hepatitis B vaccine will sign a waiver.

Employees who initially declined the offer to be vaccinated, but who later request it, may have the vaccine provided at no cost.

The Director of the Health Center is responsible for ensuring that employees have been previously vaccinated, receive the vaccine, or sign waivers declining the vaccination. The vaccine is administered by the Health Center. Records documenting the vaccination, or the signed waiver, shall be completed by the Health Center and maintained in the employee’s personnel file.

III. Post-Exposure Evaluation Follow-up

When the employee incurs an exposure incident, it shall be reported to the employee’s supervisor and the Director of Employee Services, or their respective designees, within 24 hours.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.

This follow-up will include the following:

1. Documentation of the route of exposure and the circumstances related to the incident;

2. If possible, the identification of the source individual and, if possible, the status of the source individual;

3. The blood of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity;

4. Results of testing of the source individual will be made available to the exposed employee and the exposed employee will be informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual;

5. The employee will be offered the option of having blood collected for testing of the employee’s HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status;

6. However, if the employee decides prior to that time that testing will or will not be conducted, the appropriate action can be taken and the blood sample discarded;

7. Note: Any employee who wants to participate in the medical evaluation program must have blood drawn;

8. The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service;

9. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to the appropriate personnel; and

10. The Director of Auxiliary Services and the Director of the Health Center have been designated to assure that the Plan outlined here is effectively carried out as well as to maintain records to this Plan.

A. Interaction with Health Care Professionals

A written opinion shall be obtained from the health care professionals who evaluate employees of the University. Written opinions will be obtained in the following instances:

1. When the employee is sent to obtain the Hepatitis B vaccine/results;

2. Whenever the employee is sent to a health care professional following an exposure incident;

3. Health care professionals shall be instructed to limit their written opinions to:

a. Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine.

b. That the employee has been informed of the results of the evaluation, and that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not to reference any personal medical information).

B. Training

Training for all employees who are identified as having a risk of contact with occupational exposure will be conducted prior to initial assignments of tasks where occupational exposure may occur and then annually. Training for employees will include the following explanation of:

1. The OSHA standard for Blood Borne pathogens;

2. The Epidemiology and symptomatology of Blood Borne diseases;

3. The modes of transmission of Blood Borne pathogens;

4. This exposure control plan, i.e., points of the plan, lines of responsibility, how the plan will be implemented, etc.;

5. Control methods that are used at the University to control exposure to blood or other potentially infectious materials;

6. Personal protective equipment available and who should be contacted concerning exposure;

7. Post-exposure evaluation and follow-up;

8. Signs and labels used at the University;

9. Hepatitis B vaccine program at the University;

10. Rubella titer for positive antibodies; and

11. Physical to assess physical status.

IV. Record Keeping

The Office of Employee Services maintains all records required by the OSHA standard. These records will include:

1. Exposure Plan;

2. Observance of Universal Precautions;

3. Hepatitis B Vaccination;

4. Post-exposure Evaluation and Follow-up;

5. Hazard Communication;

6. Information and Training; and

7. Record keeping.

To learn more about this policy or the supporting procedures, please contact Auxiliary Service

Policy updated on: Oct. 24, 2018