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Bloodborne Pathogens Exposure Control Program

The Bloodborne Pathogens Exposure Control Plan is designed to help supervisors and/or designated department representatives understand and meet the provisions for university workers who may have exposure to human blood, blood products, tissues, cells, or other potentially infectious materials.  This plan addresses all provisions of the Occupational Safety and Health Administration's (OSHA) Occupational Exposure to Bloodborne Pathogens Standard (29CFR 1910.1030), and is implemented by the Office of Safety and Risk Management.  

To be compliant with the OSHA Standard requirements at Western Carolina University, the supervisor or department representative must complete the following:

  • Provide the employee with access to the Bloodborne Pathogens Exposure Control Plan.
  • Provide the employee with the option for a free Hepatitis B vaccination.
  • Provide the employee with required personal protective equipment (PPE).
  • Ensure that the employee completes the required safety training.

Employees with occupational exposure to blood, body fluids, or other potentially infectious materials must be offered, and should be encouraged to participate in, the free hepatitis B vaccination program.

  • Employee compliance with the Hepatitis B Vaccination program is monitored by Safety and Risk Management.
  • Employees must read the Hepatitis B Information  and then sign EITHER the Hepatitis B Vaccination Consent OR the Hepatitis B Vaccination Declination and return their form to Safety and Risk Management.
  • Supervisors must ensure that new employees meeting the criteria for occupational exposure risk receive the required training and submit the Hepatitis B vaccination consent or declination form to the Safety Office within 10 working days of initial assignment.
  • The vaccination is administered by WCU's Health Services.  Three doses are required for immunity - an initial dose, a second dose 1 month later, and a third dose 6 months from the date of the initial dose.
  • The supervising department will be billed for the vaccination expense.

All exposure incidents shall be reported, investigated, and documented.  Significant exposure includes contamination by blood or other body fluids or high titers of cell-associated or free virus via:

  • percutaneous, e.g., needle stick, scalpel;
  • permucosal, e.g., splash in the eye or mouth; or
  • cutaneous exposure, e.g., non-intact skin, or involving large amounts of blood or prolonged contact with blood, especially when exposed skin is chapped, abraded, or afflicted with dermatitis.

All blood or body fluid exposures must be washed vigorously and then reported immediately to the supervisor and Health Services.

The supervisor should submit the BBP Post Exposure Incident Report Form to the Safety and Risk Management Office within 24 hours of the incident. 

Following an exposure incident, the exposed employee shall immediately receive (at no cost to the employee) a confidential medical evaluation and follow-up, to include the following elements:

  • Documentation of the route of exposure and the circumstances under which the exposure incident occurred. If the incident involves percutaneous injury from a contaminated sharp, appropriate information shall be entered into the sharps injury log.
  • Identification and documentation of the source individual, unless this is infeasible or prohibited by law. The source individual’s blood shall be tested as soon as feasible, and after consent is obtained, in order to determine HBV and HIV infectivity.
  • The exposed employee’s blood shall be collected and tested as soon as feasible, and after consent is obtained.
  • The exposed employee shall have the opportunity to receive post-exposure prophylaxis (HBV vaccination, etc.) as recommended by the U.S. Public Health Service and/or CDC.

Procedures for evaluating the circumstances surrounding an exposure incident

Supervisors must notify the Safety and Risk Management Office and provide details about the incident within 24 hours.  The Safety and Risk Management Office will review the circumstances of all exposure incidents to determine:

  • Engineering controls in use at the time of the incident
  • Work practices and procedures being performed when the incident occurred
  • The type of device being used
  • Protective equipment used at the time of exposure (gloves, eye shield, etc.)
  • Location of the incident
  • Employee’s training status

The exposure will be reviewed.  Hepatitis B virus (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) infection status of the source patient will be specifically investigated.  The presence of other bloodborne diseases will be evaluated and appropriate protocols instituted, as needed.

Sharps Injury Log

An incident involving percutaneous injury from a contaminated sharp, must be documented in the Sharps Injury Log maintained by the Safety and Risk Management Office.   Information collected includes the type, brand, and purpose of device involved in the incident (if known), the location where the incident occurred, the occupation of the injured employee, an explanation of how the injury occurred, and the source material’s infection status (if available).  The Safety Office will review the exposure.  Other blood or body fluid exposure protocols will be instituted, as indicated.

  • Employees must use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with any blood or other body fluids is anticipated. Each department must assess the exposure potential from procedures performed by their employees and identify all procedures which necessitate routine use of personal protective equipment.  In addition, each employee should critically review their work responsibilities to make informed decisions regarding the appropriate use of personal protective equipment.
  • Appropriate PPE in a range of sizes must be readily accessible at the work site or issued (without cost) to employees.
  • Gloves must be worn when touching blood or body fluids, mucous membranes, non-intact skin of all patients, for handling items or surfaces soiled with blood and body fluids, and for performing venipuncture and other vascular access procedures.
  • Masks and protective eyewear or face shields must be worn to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that are likely to generate splashes or splatters of blood or other body fluids.
  • Appropriate protective gowns or aprons must be worn during procedures that are likely to generate splashes of blood or other body fluids. For procedures during which you anticipate your clothing will be soaked, fluid resistant aprons or gowns must be worn.
  • Shoe covers or boots must be worn in instances where gross contamination with blood/body fluids is reasonably anticipated (i.e. sewage spill).
  • All garments that are penetrated by blood or OPIM shall be removed immediately, or as soon as feasible. All PPE shall be removed before leaving the work area and stored in the designated area.

Employee training is provided by the Safety and Risk Management Office as an on-line training module and “in-person” upon request.  The Office of Safety and Risk Management may be contacted at 828-227-7443 for assistance in implementing procedures or to provide training for employees in Universal Precautions and the Bloodborne Pathogens Exposure Control Plan.

Target Population: All employees with routine, anticipated exposure to blood, body fluids, and other potentially infectious materials (OPIMs). 

Training Objectives:

  • Understand the modes of transmission of bloodborne pathogens, and the philosophy behind Universal Precautions.
  • Have a general understanding of the epidemiology and symptoms of bloodborne diseases.
  • Be familiar with the Western Carolina University Exposure Control Plan and the means by which the employee can obtain a copy of the written plan.
  • Know the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and OPIM.
  • Be familiar with the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment.
  • Know the types, basis for selection, and proper use of personal protective equipment.
  • Be informed about hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccination will be offered free of charge to affected personnel.
  • Be informed of the appropriate actions to take and persons to contact in an emergency involving blood or OPIM.
  • Know the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
  • Be informed on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
  • Know the signs and labels and/or color-coding required by the standard.
  • Be familiar with waste management, laundry, and housekeeping practices specific for Western Carolina University.
  • Understand his/her role and the University's role in the standard.

Training Requirements

  • Training is required for all employees with reasonable exposure risk within 10 working days of initial assignment to the work area involving exposure prone tasks and at least annually thereafter, or when changes in tasks/procedures result in a change of the exposure potential.
  • Departments who wish to provide area-specific or departmental training may do so upon approval of training material by the Safety and Risk Management Office.

Training Records

  • Institutional employee training records will be maintained by the Safety and Risk Management Office.
  • Supervisors, training coordinators, and other persons responsible for providing training to students should retain copies and have documentation available during a site audit.
  • Records will be maintained for 3 years from the date of training.
  • Training records will contain the following: Date of training session, contents or a summary of the training session, name and qualifications of the trainer, and name and 92# of all persons attending the session.
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