Bloodborne Pathogens Program - University of Iowa Hospitals and ...

Bloodborne Pathogens Program
The University of Iowa Date(s) Revised: 2/2011
Haley Sinn Ph.D., Biological Safety Officer, Responsible Official (RO), Ph. 335-9553
Caitlin Ross Assoc. Biol. Safety Officer, Alt. Responsible Official (ARO), Ph. 353-5679
Deborah Kratz Biosafety Specialist, Ph. 353-5678
For Assistance with:
Bloodborne Pathogen Program, consultation
Bloodborne Pathogen Program, train the trainer
Bloodborne Pathogen Program, training materials
Medical Consultation & Examinations
EHS
EHS
EHS
UEHC
The Occupational Safety and Health Administration (OSHA) issued the Bloodborne Pathogens (BBP) Standard to protect
workers from occupational exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus
(HIV), and other bloodborne pathogens. The Standard requires that employees regard blood and certain other bodily
fluids from any individual as potentially infectious, thus applying the concept of universal precautions. Reasonably
anticipated contact with blood and other potentially infectious materials is what places an individual "at risk" of exposure to
bloodborne pathogens.
Application
The BBP Standard applies to any employee whose job entails reasonably anticipated contact with blood, blood products,
and other potentially infectious materials (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; 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; blood, organs or other tissues from experimental animals
infected with HIV or HBV). A wide variety of jobs involve a potential for exposure, including patient contact, laundry
workers, custodians cleaning blood spills and transporting biohazard waste containers, laboratorians, first aiders,
equipment repairers, athletic trainers, etc.
Cell lines from ATCC are not tested sufficiently to exempt them from possible BBP exposure and as a result, all
employees who work with human cell lines are also considered “at risk”.
Researchers working with non-human primate (NHP) blood, tissues, or other bodily fluids are recommended to use
universal precautions when handling this material.
Program Elements – Departmental Responsibilities
Initially departments must:
o identify all "at risk" employees;
o designate an Exposure Control Officer (ECO);
o provide BBP training for all "at risk" employees annually; and
o offer "at risk" employees Hepatitis B Virus vaccination within 10 working days of initial assignment and
training.
Written Program
A written Exposure Control Plan (ECP) must be prepared and implemented that includes:
o exposure determinations;

o
o
o
o
methods of compliance, e.g. use of Universal Precautions, work practice controls, engineering controls
and personal protective equipment (PPE);
medical surveillance;
training; and
post-exposure procedures.
EHS has developed a Bloodborne Pathogens Exposure Control Plan template to assist departments in
completing their Exposure Control Plans. This word document provides a standard format and guides
departments where department/area specific information must be added, or where appropriate, sections can be
deleted.
Exposure Control Officer (ECO)
Each department will designate an individual as their ECO. Responsibilities of the ECO include:
o reviewing and updating the exposure determination for the department, identifying all “at risk” employees;
o annually reviewing and updating the Exposure Control Plan, communicating all changes to personnel;
and
o ensuring all persons “at risk” of BBP exposure within their department receive the necessary training and
vaccinations
o providing all persons “at risk” of BBP exposure within their department the location of the written program
Periodically, EHS will offer a training session for the ECO’s.
Medical Surveillance
Departments must provide the Hepatitis B vaccine series to "at risk" employees, at no cost to the employee. The
University Employee Health Clinic (UEHC) at 356-3631 provides this service. However, an MFK must be provided
to UEHC to cover the cost of the vaccine. If an employee declines the vaccine, a waiver must be signed and will
be kept on file by UEHC.
Post-exposure evaluation and follow-up are provided by UEHC, call 356-3631.
Training
Each department is responsible for training its employees who are determined to be at risk of occupational
exposure. Training courses for “at risk” employees are available online through EHS, located at:
https://research.uiowa.edu/ehs/training. There are 4 different BBP courses available, make sure the employee(s)
takes the course appropriate for each department:
o BBP for Lab Workers is designed for laboratory employees and students upon initial training.
o BBP for Non-lab Workers is designed for non-laboratory staff, such as Athletics, Residence Services,
Public Safety, etc. upon initial and annual refresher training.
o BBP for College of Public Health is designed only for College of Public Health faculty, staff and
students upon initial training.
o BBP Refresher is designed as a refresher course for laboratory employees and students across campus
(CPH and others). The refresher course may be taken annually only if staff has already completed the
BBP for Lab Workers or BBP for CPH courses during their initial training.
If you have any questions as to which course should be completed, please call EHS (5-8501).
When completing BBP for Lab Workers and BBP for Non-lab Workers courses online, additional, site-specific,
departmental information must be provided in order to be in regulatory compliance with OSHA. A site-specific
training form is available within the course content; it is the responsibility of the employee, along with their
supervisor or designated work area trainer, to complete the site-specific training and maintain a copy of this
record.
A few departments on campus offer BBP training from within the department. Staff and students attending this
training do not need to complete EHS’s online BBP course.
General requirements for training are that it must be:
o at the time of initial assignment to tasks where occupational exposure may take place;
o conducted annually thereafter; and
o given when changes or modifications in procedures occur that affect the employee's occupational
exposure.

Topics to be covered in all information and training programs include:
o regulatory text of the standard;
o Exposure Control Plan, including location;
o epidemiology and symptoms of bloodborne pathogens;
o modes of transmission of bloodborne pathogens;
o methods for recognizing tasks and activities that place employees at risk;
o use and limitations of methods of control to prevent occupational exposure;
o basis for selection of PPE and information on the types, proper use, location, removal, handling,
decontamination, and disposal of PPE;
o information on the HBV vaccine and benefits of being vaccinated;
o post-exposure follow-up procedures and evaluation the employer must provide for the employee;
o explanation of signs, labels, and tags used to denote biohazards; and
o spill response procedures.
Additional training is required for personnel working in HIV and HBV Research Laboratories and Production
Facilities.
Documentation
Accurate records must be maintained of:
o the written Exposure Control Plan;
o Exposure Incident Forms;
o training syllabus and attendance records; and
o medical surveillance.
References
Bloodborne Pathogens Exposure Control Plan template
Annual Program Review Form
Exposure Incident Form
OSHA BBP29CFR1910.1030
Biohazard Waste Guide (This guide was created using Adobe Acrobat Writer. Please download Adobe Acrobat Reader now if you do not
have it.)