Wright State University - Department of Environmental Health & Safety
Exposure Control Plan
For Bloodborne Pathogens
In Accordance with
OSHA Standard 29 CFR 1910.1030
Revision 2008 (2)
July 7, 2008
The enclosed document represents the Exposure Control Plan to be employed at Wright State
University in all areas where employees and/or students are occupationally exposed to
State employees are now covered by the Ohio Public Employment Risk Reduction Program
(PERRP). The State of Ohio has simply accepted current OSHA Standards and has promulgated
them as the Ohio PERRP Rules. The PERRP Rules will not require additional or new
recordkeeping, etc. The program will continue to be administered as it was originally designed.
The success of the program is measured by the absence of incidents involving actual contact with
blood and other potentially infectious materials. To achieve success will require the active
support and involvement of all individuals covered by the Exposure Control Plan. Please work
with us to provide a safe and healthy working environment for our employees and students.
Wright State University
Department of Environmental Health & Safety
Exposure Control Plan for Bloodborne Pathogens
Revision 2008 (1)
Table of Contents
Enforcement of the Exposure Control Plan ...............................................................................4
Program Accessibility ................................................................................................................4
Exposure Determination ............................................................................................................6
Methods of Implementation and Control ...................................................................................7
Universal Precautions ..........................................................................................................7
Engineering Controls ...........................................................................................................8
Work Practices ...................................................................................................................11
Personnel Protective Equipment/Clothing .........................................................................13
Contaminated Waste ................................................................................................................16
Equipment/Instruments Contaminated with Infectious Materials ...........................................17
Needlestick Safety and Prevention / Reporting of Needlesticks .............................................19
Post Exposure Evaluation and Follow-Up ...............................................................................21
Hepatitis B Vaccination Program ............................................................................................22
Requirements for HIV and HBV Research and/or Production Facilities ................................26
Review and Updating of the Exposure Control Plan ...............................................................28
Appendix A - Definitions.........................................................................................................29
Appendix B - Job Positions and Tasks at Risk of an Occupational Exposure .........................31
Appendix C – Hepatitis B Vaccination Declination Form ......................................................32
Appendix D – Disinfection and Sterilization Procedures ........................................................33
Appendix E – Infectious Waste Management Guide ...............................................................34
Wright State University Infectious Waste Strategy ........................................................39
Ohio Environmental Protection Agency Definitions of Infectious Waste......................43
Infectious Waste Containment and Cleanup Procedures ................................................45
Wright State University Sharps Management Plan ........................................................48
Appendix F – Additional Information and Documents of Interest ..........................................50
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The purpose of this Exposure Control Plan, in conjunction with other already existing safety and
health policies, is to provide a working environment that limits occupational exposure to
potentially infectious materials. All employees should be aware that any exposure to human
blood or other potentially infectious materials could result in disease and/or death, and therefore,
employees should take all necessary precautions identified in this plan.
This Exposure Control Plan covers all employees who could be "reasonably anticipated," as a
result of performing their job duties, to contact human blood or other potentially infectious
materials (OPIM). OPIMs are defined by OSHA as human semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids
in situations where it is difficult or impossible to differentiate between body fluids; any fixed
tissues or organs other than intact skin from a human (living or dead) and human
immunodeficiency virus (HIV)-containing culture medium or other solutions as well as blood,
organs, or other tissues from experimental animals infected with HIV or HBV.
Because of the diverse operations that occur in the areas of health care, teaching and research, it
is necessary that this Exposure Control Plan be supplemented by written procedures for each
work area, which clearly cover all the requirements of the Exposure Control Plan that are
pertinent to the specific work area.
Wright State University is responsible for the implementation of the Exposure Control Plan for
the institution. The Department of Environmental Health and Safety will maintain, review, and
update the Exposure Control Plan at least annually, and whenever necessary to include new or
modified tasks and procedures or upon updating the OSHA Standard (29CFR1910.1030).
Employees who are determined to have occupational exposure to blood or other potentially
infectious materials (OPIM) must comply with the procedures and work practices outlined in this
Exposure Control Plan.
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Enforcement of the Exposure Control Plan
Employee compliance with the Exposure Control Plan will be assured with appropriate
reinforcement, remedial training, and possible disciplinary corrective actions.
A copy of this Exposure Control Plan will be available and accessible to all university employees
that have been identified as being at risk. This Plan is available for review and copy from the
Department of Environmental Health and Safety web site (www.wright.edu/admin/ehs.http/bbp).
Those university employees not having access to the internet can also request a printed copy of
this plan by contacting the Department of Environmental Health and Safety, at (937) 775-2215.
The following have a responsibility to the implementation the university Exposure Control Plan.
Department chairpersons and/or Directors
Responsibilities as a Person-in-Charge
Provide a safe laboratory facility or work place to minimize risk of exposure to
Responsible for all respective departmental laboratory and associated facilities
Responsible for all personnel under their direction and for those personnel to comply
with the information contained within the university Exposure Control Plan.
Faculty members, principal investigators or laboratory supervisors
Responsibilities as a Person-in-Charge
Provide and promote a safe work environment for conducting research
Conduct only laboratory activities approved by the university
Develop and maintain a laboratory procedure manual to supplement to university
Exposure Control Plan
Review the university Exposure Control Plan, initially and annually as long as potentially
at risk of exposure
Require all new laboratory personnel attend all relevant training before working in the
Identify persons in the laboratory who are at risk of exposure to bloodborne pathogens
Review laboratory procedures for changes in potential risk or exposure, advise laboratory
personnel of changes and provide for appropriate training.
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Contact the Department of Environmental Health and Safety for employee bloodborne
pathogen training and review of the university Exposure Control Plan.
Ensure laboratory specific safety training for laboratory staff has been completed,
initially and annually, for all laboratory personnel at risk of potential exposure.
Provide training to laboratory personnel for the proper clean up of spills involving
Report all accidents, injuries and near accidents to the Department of Environmental
Health and Safety as directed by university guidelines and policies.
Laboratory Research Associates, Graduate Students, Student Employees
Conduct only laboratory approved activities.
Complete appropriate training for safe work practices specific to the workplace
Complete initial and annual bloodborne pathogen training
Accept / decline offered immunizations
Promote safe work practices
Attend training courses as directed by supervisory faculty, staff, Director or Departmental
Timely report all accidents or injuries and near accidents to the faculty member in charge
and to the Department of Environmental Health and Safety
Other Employees at Risk not in a Laboratory
Complete appropriate safety training for the work environment
Complete annual and refresher bloodborne pathogen training
Accept or decline immunizations.
Promote safe work practices
Inform supervisor or other person in charge of unsafe conditions or work practices
Report in a timely fashion all occupational injuries or accidents or near accidents to
Occupational Health Physician
Coordinate with the Department of Environmental Health and Safety to provide
recommended immunizations according the university Occupational Health Program.
Provide expert medical advice and consultation in the event of an exposure to human
blood, OPIM or contaminated cultures.
Environmental Health & Safety (EH&S)
Conduct annual laboratory assessment/audits
Conduct risk assessments for potential risks of exposure.
Provide / coordinate initial and annual training of the university Exposure Control Plan.
Annual review of the Exposure Control Plan
Oversee the implementation of the Exposure Control Plan.
Manage the university Occupational Health Program for required immunizations and
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Perform laboratory safety audits, job hazard analysis, assisting the Institutional Biosafety
Officer in evaluation of work practices associated with biological materials,
Investigate reported accidents and injuries and those involving potential exposure to a
bloodborne pathogen or OPIM
Emergency response in the event of a spill or other potential exposure situation.
Contact the immediate Person-in-Charge to ensure compliance with all university
guidelines, policies and procedures as they apply to the work environment,
The bloodborne pathogen standard requires the university determine which classification of
employees are reasonably anticipated to have an occupational exposure to bloodborne pathogens
or other potentially infectious materials (OPIM). The determination of who is at risk of an
exposure is made without regard to the use of personal protective equipment.
Any employee who has duties which potentially would expose them to human blood or other
potentially infectious materials or are expected to have a reasonably anticipated risk of exposure
to bloodborne pathogens will be included in the Exposure Control Plan. Appendix B of this
Exposure Control Plan lists tasks and procedures recognized as presenting an exposure risk to an
Job classifications determined to have a reasonably probability of an occupational exposure to
bloodborne pathogens, either by the nature of the occupation or by specific procedures or tasks
which an employee is required to perform as part of their job are under this Exposure Control
Plan. Job classifications in which all employees have an occupational risk are listed in Appendix
B of this Exposure Control Plan. Included in the job classifications are those in which only some
are at risk.
Information regarding job classifications, tasks and procedures covered by the provisions of the
Exposure Control Plan will be reviewed and updated annually as part of the plan. If a supervisor
has an employee who has a reasonably anticipated risk of bloodborne pathogen exposure but the
employee’s job classification is not included in Appendix B, the supervisor should notify the
Department of Environmental Health and Safety as soon as possible for review and
consideration. In the event a task or procedure changes and it either increases or eliminates the
risk of an exposure the Department of Environmental Health and Safety should be notified in
order for a risk analysis to be made and documented.
Anytime a procedure or task is modified and may change the potential risk of an exposure, the
changes are to be reviewed by the responsible supervisor. After review, information of the
changes is forwarded to the Department of Environmental Health and Safety for possible action.
As appropriate, with procedural or task changes it is the responsibility of the supervisor review
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and update written procedures and provide any additional training needs to address new
procedures with affected personnel.
Methods of Implementation and Compliance
The university is committed to providing a safe and healthful work environment for all
employees, students and visitors. In pursuit of this endeavor, this Exposure Control Plan (ECP) is
provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance
with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens."
The ECP is a key document to assist the university in implementing and ensuring compliance
with the standard, thereby protecting the employees, students and visitor. This ECP includes the
implementation of various methods of exposure control, including:
Work Practice Controls
Personal Protective equipment/Clothing
A. Universal Precautions
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
1. Employees with Exposed Rashes, Dermatitis, or Lesions
Employees who have open wounds, sores, rashes, dermatitis, or other exposed lesions
should be referred to the supervisor for evaluation before being allowed to perform any
duties that may potentially expose them to blood or bloodborne pathogens. Employees with
open skin rashes, wounds, or erythemas, or other non-intact skin areas, shall not be
permitted to work without these areas being adequately protected from exposure.
All employees shall wash their hands following every incident of potential exposure to
blood, body fluids, or other potentially infectious materials. Hands must be washed using
an approved disinfectant soap. Hand washing is one of the most important elements of the
Exposure Control Plan.
Hand washing is one of the most important steps in preventing the spread of contamination.
Before leaving a laboratory or other area where materials are handled or manipulated,
remove gloves and wash your hands using an appropriate soap.
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3. Protective Equipment Used in Universal Precautions
Universal Precautions require appropriate equipment and clothing for specific exposure
potential as follows:
Potential Exposure to Potential Exposure to Body Body Trunk Exposure Face
Face and Head Extremities Shields
Face Shields Gloves Fluid Impervious Gowns
Goggles Fluid Impervious Lab Coats Fluid Impervious Lab Coats
Masks Shoe Coverings Fluid Impervious Aprons
Head Covers Fluid Impervious Gowns
Proper protective equipment requirements will be stated in written procedures based on a
task risk assessment compiled by the Department of Environmental Health and Safety and
the facility supervisor.
B. Engineering Controls
Engineering controls shall be used to eliminate or minimize employee exposure. Where
occupational exposure remains after institution of these controls, personal protective
equipment shall also be used.
Emergency eye washes are required to be readily accessible. Safety showers may be
required as determined by the Department of Environmental Health & Safety.
Engineering controls shall be examined and maintained or replaced on a regular schedule to
ensure their effectiveness.
In November 2000 the OSHA Bloodborne Pathogen Standard was amended to incorporate
the use of safety devices as engineering controls, to have a device identification/evaluation
selection process and to provide employee training for use prior to implementation.
Additional information on the use of Needlestick prevention devices can be found belong
in the section titled “Needlestick Safety and Prevention / Reporting of Needlesticks” and in
Appendix G of this Plan.
Engineering controls shall be consistent with the potential level of exposure anticipated. If
the exposure potential is minimal and the likelihood of exposure is very low, less stringent
personal protective equipment may be considered in conjunction with administrative
controls and training to maintain the reduced hazard level. The determination of
appropriate personal protection and administrative control shall be made by the Person-In-
Charge in conjunction with the Department of Environmental Health & Safety and must be
provided in writing to the department.
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1. Hand washing Facilities
Readily accessible hand washing facilities shall be provided where the potential exists for
exposure to a contaminated material.
If a situation arises where hand washing facilities will not be in the proximity of the task
involving blood or other potentially infectious materials, antiseptic hand cleansers or
towelettes are used. Hands shall be washed with soap and running water as soon as
Employees must wash their hands or other exposed body areas with an adequate
disinfecting soap immediate after removing gloves or other protective equipment and
clothing used as a barrier against exposure to bloodborne pathogens.
Employees must wash hands and any other skin with soap and water, or flush mucous
membranes with water immediately, or as soon as feasible, following contact of such body
areas with blood or other potentially infectious materials.
2. Needles and Sharps Disposal
Contaminated needles and sharps are identified as any object having come into contact with
human blood or other potentially infectious materials that can penetrate the skin including,
but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends
of dental wire. Contaminated needles and sharps shall be used, handled and disposed in a
manner to minimize the potential for exposure or injury.
Contaminated needles and sharps shall not be bent, broken, recapped, sheared or removed
unless it can be demonstrated that no alternative procedure is feasible. If necessary,
recapping or needle removal is to be done using a one-handed technique.
All contaminated needles and sharps shall be disposed of immediately, or as soon as
feasible, in labeled, rigid-walled receptacles designed for disposal of such equipment. The
approved sharps containers used for disposal of contaminated sharps and needles shall be:
Conspicuously labeled with the BIOHAZARD label or be red in color and labeled
Leak-proof on the sides and bottom
Closed and sealed prior to removal to prevent spillage
Approved sharps containers shall be easily accessible to all personnel and shall be located
as close as feasible to the immediate area where contaminated sharps are generated, used or
can be reasonably anticipated to be found. Containers must be kept upright throughout use
and shall be replaced when they become three-quarters full. When moving containers of
contaminated sharps from the area of use, the containers shall be: - closed immediately
prior to removal or replacement. - placed in a secondary container if leakage is possible.
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The second container must be closeable, leak-proof, and be red in color or have appropriate
biohazard warning labels.
A full contaminated sharps container for disposal shall be handled according to the
university Infectious Waste Management Guide. The sharps containers are to be closed
and are to be placed in a labeled Infectious Waste box for disposal. Infectious waste nor
contaminated sharps containers are not permitted to be autoclaved for disposal as regular
trash. If procedures used in the work place include autoclaving prior to disposal the
procedure is only a pre-treatment for disposal as infectious waste, there are no exceptions.
Refer to Appendix D, Infectious Waste Management Guide, of this Plan for additional
The faculty investigator, research staff or other responsible laboratory staff person is
responsible for the purchase of the Sharps containers to be used for collecting contaminated
infectious sharps. Approved Sharps containers may be purchased through the University
Lab Stores, other local vendors or other on-line vendors.
3. Biohazard Sign Posting
Biohazard signs must be posted in all work areas where infectious materials are present.
Biohazard signs must include the universal biohazard symbol with the word "Biohazard"
and be orange-red. Signs shall be posted at the entrance to work areas. A hazard warning
sign incorporating the universal biohazard symbol shall be posted on all access doors.
4. Controlled Access to Work Areas
Access to work areas where blood or other potentially infectious materials are present shall
be limited to authorized persons. Authorized personnel signs will be used. Written policies
and procedures shall be established whereby only persons who have been advised of the
potential biohazard, who meet any specific entry requirements, and who comply with all
entry and exit procedures shall be allowed to enter the work areas.
5. Protective Coverings
Protective coverings used to protect work surfaces or equipment must be changed
whenever evidence of contamination by blood or other potentially infectious materials is
evident. Protective coverings that are minimally contaminated can be changed at the end of
each work shift.
6. Storage Bins, Pails, Cans, Receptacles
All bins, pails, cans, and similar receptacles intended for reuse that have a reasonable
likelihood of contamination with blood or other potentially infectious materials shall be
inspected and decontaminated on a regularly scheduled basis and shall be cleaned and
decontaminated immediately, or as soon as feasible, upon visible contamination.
Disinfection shall be accomplished at least daily.
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7. Broken Glassware
Broken glassware that has been exposed to potentially infectious materials shall be handled
using mechanical means that do not allow the hands to come into contact with the glass.
Contaminated glassware is to be disposed in an appropriate labeled sharps container and
ultimately placed in an infectious waste box for disposal.
8. Biohazard Labels
Warning labels, including the orange or orange-red biohazard symbol, must be affixed to
containers of regulated waste, refrigerators, and freezers and other containers that are used
to store or transport blood or other potentially infectious materials. Red bags or containers
may be used instead of labeling provided that a red container or storage unit is not used for
other purposes within the facility.
Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or
other method that prevents their loss or unintentional removal.
9. Exemptions From Labeling
Individual containers of blood or potentially infectious materials that are placed inside an
appropriately labeled container for transport, storage, or shipment are explicitly exempt
from the labeling requirement.
Refrigerators/freezers used to store blood and body fluids must have appropriate biohazard
warning signs. No food stuffs or medications shall be stored in these refrigerators/freezers.
C. Work Practice Controls
Work practice controls shall be used to eliminate or minimize employee exposure.
Work practice controls shall be consistent with the potential level of exposure. If the
exposure potential is minimal and the likelihood of laboratory exposure is very low, less
stringent personal protective equipment will be considered. The determination of
appropriate personal protective equipment to be used with safe work practices shall be
made by the Person-in-Charge in conjunction with the Department of Environmental
Health and Safety. A written risk assessment to justify and support the use of personal
protective equipment with work procedures will be done and approved by the associated
Department Chair, the Principal Investigator and the Department of Environmental Health
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1. Eating, Drinking, Smoking, Applying Cosmetics or Medications
Eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses, or
applying other body lotions or salve is prohibited in work areas where there is a reasonable
likelihood of occupational exposure to bloodborne pathogens or other potentially infectious
material(s). Affected work areas include the laboratories where human blood, body fluids
or other potentially infectious materials are collected, handled, manipulated or contained as
well as areas where it is reasonable anticipated these materials could be present.
Smoking in any university building, unless otherwise stated, is prohibited by State law.
Food, drink, cosmetics or other materials used for personal consumption or care shall not
be stored in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops
where blood or other potentially infectious materials, other biological, chemical or
radiological research materials are in use or stored.
2. Mouth Pipetting/Suctioning
Mouth pipetting/suctioning of blood or other potentially infectious materials is absolutely
3. Procedures for Minimizing Sticks from Needles and Sharps
Needles or sharps should never be recapped, bent, broken, or otherwise manipulated by
hand. However, if a contaminated syringe must be used for multiple procedures the
syringe can be recapped by using a one-handed procedure keeping hands or fingers away
from the tip of the syringe. When using a sharp or needle, avoid distractions and
concentrate on the procedure being performed to minimize accidents. After use, all needles
and sharps must be disposed of promptly into a rigid disposable container designed for this
purpose. Exchange the needle or sharps disposal holder when the receptacle is no more
than three-fourths full.
Where appropriate, the use of needlestick prevention devices shall be considered and
reviewed and implemented as a means of further reducing the probability of a contaminated
needlestick or sharps exposure.
4. Reusable Sharps
The use of reusable sharps shall be discouraged whenever possible. Disposable sharps shall
be utilized whenever available and determined to be satisfactory for the intended use. If
reusable sharps are required to be used, they must be placed in appropriate containers
immediately, or as soon as feasible, after use and they must not be stored or processed in a
manner that requires to reach by hand into the containers where these sharps have been
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5. Procedures to Minimize Splashing and Aerosols of Blood or Body Fluids
Whenever potentially hazardous materials are handled, special precautions shall be taken to
minimize the spraying, splashing, or aerosolization of the hazardous material (blood, body
fluids, or materials visibly contaminated with blood or body fluids). For receptacles
containing blood or body fluids, the cover should be made of a material that will prevent
splashing when opening the receptacle. If handling blood or body fluid soaked materials,
do not move the materials in a quick manner. If receptacles such as blood tubes are to be
stored, a cap or seal shall be placed on the container to eliminate spills.
6. Specimen Containers
Specimens of blood or other potentially infectious materials shall be placed in puncture-
resistant containers that prevent leakage during collection, handling, processing, storage,
transport, or shipping. Specimen containers shall be clearly marked for easy identification
as specimen containers.
Since Universal Precautions are observed when handling all specimens, containers of
blood, blood components or blood products that are labeled as to their contents and have
been released for clinical use are exempt from labeling requirements. However, warning
labels must be affixed when specimens/containers leave the facility.
If the outside of the specimen container becomes contaminated, the container must be
placed within a second container that prevents leakage during handling, processing,
storage, transport, or shipping. Color- coded biohazard warning labels must be affixed to
the second container if it is taken outside the facility.
D. Personal Protective Equipment/Clothing
When there is a potential for occupational exposure to bloodborne pathogens, the employer
shall provide, at no cost to the employee, appropriate personal protective equipment
including gloves, gowns, laboratory coats, face shields, masks, eye protection,
mouthpieces, resuscitation bags, pocket masks, or other ventilation devices as appropriate
for the type of exposure.
Personal protective equipment, such as face shields and eye protection, shall be maintained
and cleaned, as required, by the individual user. Employees must use appropriate personal
protective equipment except under rare and extraordinary circumstances. Exceptions may
occur if, in the professional judgment of the employee, the use of personal protective
equipment would have prevented the delivery of health care or public safety services or
would have posed an increased hazard to the safety of the worker or co-worker. WHEN
SUCH AN INCIDENT OCCURS, A WRITTEN REPORT MUST BE FILED AND THE
CIRCUMSTANCES MUST BE INVESTIGATED TO DETERMINE WHETHER
CHANGES CAN BE INSTITUTED TO PREVENT FUTURE OCCURRENCES.
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The employer shall purchase, clean, launder, repair, replace, and dispose of all personal
protective equipment and clothing as needed to maintain its effectiveness and at no cost to
the employee. PERSONAL PROTECTIVE CLOTHING SHALL NOT BE TAKEN
HOME FOR CLEANING, LAUNDERING, OR FOR ANY OTHER REASON.
Protective equipment will be considered appropriate if it does not permit blood or other
potentially infectious materials to pass through or reach the employee's work clothing,
street clothing, undergarments, skin, eyes, mouth, or other mucous membranes under
normal conditions of use and for the duration of time the equipment is normally used. If the
employees street or work clothing become contaminated it must be removed as soon as
possible and laundered by the employer. UNDER NO CIRCUMSTANCES MAY ANY
CONTAMINATED CLOTHING BE WORN HOME BY AN EMPLOYEE. Spare clothing
shall be available for employees to wear home.
The supervisor, in concert with the Department of Environmental Health and Safety, will
identify and determine the necessary types and styles of safety equipment and clothing to
be provided and the maintenance and cleaning procedures for the safety equipment and
The supervisor shall develop a written schedule for cleaning personal protective equipment
and clothing, identifying the method and the frequency of decontamination and cleaning.
Personal protective equipment/clothing shall be available to the employee at the work site
in the sizes necessary. Personal protective equipment/clothing may also be issued directly
to the employee. Whenever the personal protective equipment or clothing is unsuitable or
not properly fitted, the employer shall provide the appropriate equipment or clothing to
ensure safe practice.
1. Use and Changing of Personal Protective Equipment/Clothing
As a general guideline to the use and changing of personal protective equipment and
clothing, the following standards shall apply:
If protective equipment is penetrated by blood or other potentially infectious materials,
the protective equipment shall be removed immediately, or as soon as feasible, and
replaced with a clean protective article.
ALL PERSONAL PROTECTIVE CLOTHING AND EQUIPMENT SHALL BE
REMOVED PRIOR TO LEAVING THE WORK AREA. When the personal protective
equipment is removed it shall be placed in an appropriately designated area or container
for storage, washing, decontamination, or disposal
Gloves must be worn when it can be reasonably anticipated that the hands may become
exposed to blood or body fluids, when handling or touching contaminated items or
surfaces, and when performing venipuncture and other vascular access procedures.
Gloves must be changed between procedures if they become contaminated, or as soon
as feasible if they are torn, punctured, or if their ability to function as a barrier is
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compromised. Disposable gloves are single use and shall not be washed or disinfected
In areas where procedures involve patients or other human subjects, gloves are to be
changed between persons and procedures if they become contaminated, or as soon as
feasible if they are torn, punctured, or if their ability to function as a barrier is
compromised. Disposable gloves are single use and shall not be washed or disinfected
Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall
be readily accessible to those employees who are allergic to gloves normally provided.
2. Gowns, Aprons, Lab Coats
Gowns, aprons, laboratory coats, clinic jackets, or other protective clothing shall be worn
whenever the potential exists that work clothing, street clothing, undergarments, skin, or
other body surfaces may be exposed to blood or body fluids. Safety clothing shall be
sufficient to protect the wearer from the exposure potential that exists. If moderate to large
quantities of blood or body fluids are possible, the safety clothing shall be impervious to
soaking by blood or body fluids. The type and characteristics of specific garments will be
determined by the task and degree of potential exposure anticipated and defined in the
procedures of each work area. Laboratory coats will be long-sleeved, cover the chest
(round neck), and be worn closed. LABORATORY COATS WILL BE WORN ONLY IN
LABS AND REMOVED BEFORE LEAVING THE WORK SITE.
3. Masks, Face Shields, Goggles
Masks and eye shields shall be worn when the potential for exposure to blood or body
fluids is possible because of aerosols or splashing. Laboratory activities that produce
aerosols should be performed in approved bio-cabinets. Any routine laboratory activity that
could produce uncontained splashing or aerosol of potentially infectious material requires
approval of the Department of Environmental Health and Safety.
Masks are required for procedures involving prolonged contact with coughing patients,
suctioning of patients, endoscopies, surgical procedures, sorting and transferring blood or
body fluid specimens, embalming, or other similar procedures. If a respirator mask is to be
worn it must be fit tested for the wearer according to the university Respiratory Protection
Plan. Contact the Department of Environmental Health and Safety for additional
information or to arrange for a risk assessment to determine the need.
ANSI approved protective eyewear, such as goggles or face shields, shall be worn for any
tasks where the potential for eye contamination by blood or body fluids is present. This
contamination may occur as a result of splashing, production of aerosols, or other contact.
Procedures such as blood specimen handling/transfer, surgical procedures, and all other
similar procedures require the use of goggles or face shields
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Each worksite shall be maintained in a clean and sanitary manner. Each department that is
at risk for exposure to blood or other potentially infectious materials shall have a written
plan and schedule for cleaning and disinfecting potentially infected areas including the
methods and products to be used in the cleaning process.
All equipment and work areas and surfaces shall be decontaminated with the appropriate
disinfectant after completion of procedures where contamination has occurred or after any
spill of blood or other potentially infectious materials.
All work surfaces shall be decontaminated at the end of each work shift.
Spills must be decontaminated immediately.
Contaminated waste shall be handled using Universal Precautions and the appropriate personal
protective equipment. All contaminated waste shall be placed in containers that are clearly
marked with the biohazard label or in red bags. Any contaminated waste that may leak or is a
fluid shall be placed into a second labeled receptacle to protect against leaks during transport and
handling. All contaminated waste shall be labeled as required by Environmental Health and
Contaminated laundry may include a variety of articles the employee may come in contact with
in the course of work responsibilities or by chance in the nature of environment of an academic
Clothing contaminated with human blood or other potentially infectious material shall be
handled in a fashion to minimize further contamination or possible contact. When handling
contaminated laundry appropriate personal protective equipment shall be worn to minimize the
potential of direct contact with the laundry. Appropriate personal protective equipment will
include gloves, gowns, and face protection when the potential for splatter exists. When handling
contaminated laundry the principals of Universal Precautions shall apply.
Disposable articles not to be decontaminated shall be placed directly into an infectious waste box
for disposal. Follow proper technique for removal of contaminated clothing to minimized
contact or aerosolizing material release.
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Reusable personal protective equipment, personal clothing or other laundry exposed to human
blood, body fluids or potentially infectious material are to be treated with an approved
disinfectant prior to cleaning or laundering. Allow the disinfectant to remain in contact with the
contaminant for the recommended contact time before placing clothing in the laundry or hand
A laundry facility is available on site of the main campus for handling contaminated laundry.
The facility is located in Room 134 of the Biological Sciences Building. Articles of clothing
requiring to be laundered are to be disinfected, decontaminated or chemically neutralized before
using the facility. At off site locations other arrangement will need to be coordinated to
minimize the potential exposure to others in the workplace or at home.
In situations where laundry is heavily contaminated or is very wet with the likelihood of
materials soaking through do not attempt to disinfect, remove the contaminated laundry and
double bag in a labeled biohazard bag. A decision will be made to either disinfect or dispose of
All contaminated laundry shall be placed in red bags and transported in these bags.
Any laundry to be sent off-site for processing must be transported either in containers labeled
with the biohazard label. No contaminated laundry shall be transported off site to a commercial
facility or to a public laundromat without consent of the facility operators and the Department of
Environmental Health and Safety.
Equipment/Instruments Contaminated with Infectious Materials
Equipment or instruments that are contaminated with blood or other potentially infectious
material shall be disinfected daily or as required by the instrument manufacturer's product
Instruments and equipment shall be disinfected immediately following exposure to contaminated
materials, or as soon as reasonably possible following the completion of the procedures that are
Equipment and instruments must be disinfected prior to servicing or shipping. If all components
of the instrument or equipment cannot be disinfected completely, a biohazard label must be
attached to the instrument or equipment indicating which parts were not disinfected and remain
All departments shall convey this information to other employees, service personnel, transporters
of the instrument or equipment, and the manufacturer, as appropriate, prior to handling,
servicing, or shipping. Safety measures must be taken to minimize exposure during shipping and
Page 17 of 50
All employees with the potential for an occupational exposure to bloodborne pathogens must
attend a training program about the epidemiology, modes of transmission and symptoms of
bloodborne pathogen diseases. The training will be provided during working hours at no cost to
the employee. Initial training shall be provided prior to initial assignment to tasks where an
occupational exposure may take place.
Annual training for all employees shall be provided within one year of their previous training.
Additional training shall be provided when changes, such as modifications of tasks or
procedures, or the institution of new tasks or procedures affect the employee's occupational
exposure. The additional training may be limited to addressing the new exposure created or to
additional information on procedures. Additional training does not replace annual refresher
training unless it also includes at a minimum the information listed below.
Materials used in the training shall be appropriate in content and vocabulary to the educational
level of those receiving the training, and the person conducting the training shall be
knowledgeable in the subject matter.
The training program covers, at a minimum, the following elements:
A copy and explanation of the OSHA Bloodborne Pathogen Standard (29CFR1910.1030)
An explanation of this Exposure Control Plan and the locations where the Plan will be
available for employees to review, method of obtaining a copy of the program.
A general explanation of the epidemiology and symptoms of bloodborne diseases
An explanation of the modes of transmission of bloodborne pathogens;
An explanation of methods to recognize tasks and other activities that may involve exposure
to human blood and OPIM, including what constitutes an exposure incident
An explanation of the use and limitations of methods that prevent or reduce exposure
including appropriate engineering controls, work practices, and personal protective
An explanation of the types, uses, location, removal, handling, decontamination, and disposal
of personal protective equipment,
An explanation of the basis for selecting appropriate personal protective equipment;
Information on the Hepatitis B vaccine, including information on its efficacy, safety, method
of administration, the benefits of being vaccinated, and that the vaccine will be offered free
Information on the appropriate actions to take and persons to contact in an emergency
involving blood or OPIM
An explanation of 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
Information on the post-exposure evaluation and follow-up that the employer is required to
provide for the employee following an exposure incident
Page 18 of 50
An explanation of the signs and labels and/or color coding required by the standard and used
at this facility to identify biohazards
An opportunity for interactive questions and answers with the person conducting the training
Needlestick Safety and Prevention
Reporting of Needlesticks
In November 2000 the OSHA Bloodborne Pathogen Standard was amended to incorporate the
use of safe needle devices as engineering controls. The use of safe needle devices is required
where appropriate. The identification, evaluation and selection of a safer needle for use in the
workplace shall involve non-management employees. An evaluation process shall be
implemented and selections of preferred devices shall be documented and reviewed at least
annually or as new technology is made available. Documentation of the selection of preferred
devices shall be maintained in the workplace. Documentation shall be made available to
inspection by regulatory agents or representatives of the universityn. Employees are to be
trained in the proper use of the safer needles prior to implementation.
In the event of a needlestick, puncture or laceration from a contaminated sharp a Sharps Injury
Form Needlestick Report from the State of Ohio Public Employment Risk Reduction Program
(PERRP) must be completed and forwarded to the Department of Environmental Health and
Safety. The two page Needlestick Report Form is available at the State of Ohio, Department of
Commerce, Bureau of Occupational Health and Safety website,
http://www.ohiobwc.com/downloads/blankpdf/SH-12.pdf or through the Department of
Environmental Health and Safety by calling 775-2215.
Sharps reporting, SB183, and PERRAC
The Ohio 123rd General Assembly passed Senate Bill 183 which added provisions to the Public
Employment Risk Reduction Act requiring the reporting of needlestick or sharps injuries. In
addition, the Public Employment Risk Reduction Advisory Commission (PERRAC) is required
to develop a list of safe needlestick devices.
A sharps injury log will be maintained in the Department of Environmental Health and Safety to
record injuries resulting from exposure to contaminated sharps.
Post-Exposure Evaluation and Follow-Up
When an employee believes they have had a potential exposure to blood or other potentially
infectious material (OPIM) in the work area by a spill, splash, leak, needlestick, cut, abrasion
contact, contact with a mucus membrane or other exposure, the employee must report the
incident to the appropriate supervisor. Along with the supervisor, the Department of
Page 19 of 50
Environmental Health and Safety must be contacted for scheduling an immediate medical
evaluation and consultation with the university’s Occupational Health Physician.
The supervisor will, after medical evaluation and treatment has been provided, complete and file
a written Occupational Accident/Injury Incident Report with the Department of Environmental
Health and Safety. The Accident/Injury Incident Report is to be forwarded to the Department of
Environmental Health and Safety by the end of the next business day following the incident. The
employee and supervisor shall cooperate in any further investigation of the incident.
All employees requiring exposure-related medical attention shall be sent to the Department of
Environmental Health and Safety. All scheduling for medical attention shall be done by the
Department of Environmental Health and Safety. In the event of a potential blood or OPIM
exposure occurring after normal business hours, weekend or on a holiday the employee should
go to the local emergency room for initial treatment following administering initial first aid to
remove the potential contaminant. Incidents occurring outside of normal business hours of the
university must be reported to the Department of Environmental Health and Safety during the
next normal business day.
A potential exposure due to an injury from a potentially contaminated sharp will require
completion of the university Accident/Injury Incident Report as well as a PERRP Sharps Injury
Form Needlestick Report. Copies of the Accident/Injury Report and the Sharps Injury Form may
be obtained by calling the Department of Environmental Health and Safety (775-2215),
accessing the Forms page of the Department of Environmental Health and Safety web site
(http://www.wright.edu/admin/ehs/forms.htm) or by using the web site listings for the respective
documents as listed in the Appendix F of this Plan.
An employee with a potential exposure to blood or OPIM is directed to take initial action to
minimize their chance of an exposure. Initial first aid treatment in exposure situations includes:
Flushing eyes or other mucus membrane for 15 minutes with water (emergency eye wash
station) or by using normal saline solution.
Washing exposed skin with a cut, scrape, puncture, rash, acne or dermatitis with mild soap
and water for a period of 15 minutes
Remove any contaminated clothing and wash skin to remove potential contact
Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the
following activities will be performed as part of the evaluation and follow-up procedures for
generating a report of the incident:
Document the routes of exposure and how the exposure occurred
Identify and document the source individual (unless the university can establish that
identification is infeasible or prohibited by state or local law)
Obtain consent and make arrangements to have the source individual tested as soon as
possible to determine HIV, HCV, and HBV infectivity; document that the source individual's
test results were conveyed to the university’s Occupational Health Physician
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If the source individual is already known to be HIV, HCV and/or HBV positive, new testing
need not be performed
Assure that the exposed employee is provided with the source individual's test results and
with information about applicable disclosure laws and regulations concerning the identity
and infectious status of the source individual (e.g., laws protecting confidentiality)
After obtaining consent, collect exposed employee's blood as soon as feasible after exposure
incident, and test blood for HBV and HIV serological status
If the employee does not give consent for HIV serological testing during collection of blood
for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed
employee elects to have the baseline sample tested during this waiting period, perform testing
as soon as feasible.
Administration of Post-Exposure Evaluation and Follow-Up
Following an exposure incident, the following information shall be provided to the Occupational
Health Physician or the physician evaluating the exposure incident:
A copy of the OSHA Bloodborne Pathogen Rule (29 CFR Part 1910.1030);
A description of the exposed employee's duties as they relate to the exposure incident;
A description of the substance(s) to which the employee may have been exposed and the
circumstances under which the exposure occurred;
Documentation of the route(s) of exposure and circumstances under which exposure
occurred; photos may be helpful in some cases;
Results of the source individual's blood testing, if available; and
All medical records relevant to the appropriate treatment of the employee, including
vaccination status, those given and maintained through the university Occupational Health
The employee shall be provided with post-exposure prophylaxis as determined by the attending
physician, and an evaluation of reported illness.
If deemed necessary by the attending physician, counseling, (concerning the likelihood of
contracting a disease, the medical assistance available, i.e., immunization, gamma globulin) shall
be provided at no cost to the employee. Information regarding the need for hepatitis B vaccine
shall be provided to the employee.
The Department of Environmental Health and Safety shall be provided with a copy of the
Occupational Health Physician’s or other evaluating physician’s written opinion within 15 days
of the completion of the evaluation. The evaluation must not reveal specific findings or
diagnoses unrelated to the exposure but will include:
Page 21 of 50
Whether hepatitis B vaccination is indicated for the employee, and if the employee
received the HBV vaccination;
That the employee has been informed of the results of the evaluation;
That the employee has been told about any conditions resulting from exposure to blood or
other potentially infectious materials that require further evaluation or treatment; and
All other findings shall remain confidential (not sent to the Department or the university)
and shall not be included in the written report.
Procedures for Evaluating the Circumstances
Surrounding an Exposure Incident
The Department of Environmental Health and Safety will review the circumstances of all
exposure incidents to determine:
Engineering controls in use at the time
Work practices followed
A description of the device being used and the working condition
Personal protective equipment or clothing that was being used at the time of the exposure
incident (gloves, eye shields, etc.)
Location of the incident (Lab, animal room, incidental space, etc.)
What procedure was being performed when the incident occurred
Status of employee training, all relevant training current.
The Department of Environmental Health and Safety will record all percutaneous injuries from
contaminated sharps in the Sharps Injury Log. An Occupational Injury/Illness Report and a
Sharps Injury Form Needlestick Report shall be completed by the supervisor and forwarded to
the Department of Environmental Health and Safety within forty-eight hours of the injury.
If it is determined that revisions or changes need to be made, the Department of Environmental
Health and Safety will ensure that appropriate changes are made to this plan.
Hepatitis B Vaccination Program
Documentation of acceptance or declination of the vaccination is kept on file in the Department
of Environmental Health and Safety Occupational Health Program files. Vaccination will be
provided by the Occupational Health Physician chosen by the Department of Environmental
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Health and Safety. See the Appendix E for the location of the Occupational Health Physician
Office and for the form to accept or decline to receive the hepatitis B vaccination series. In
accordance with the OSHA Standard and this Exposure Control Plan, all employees who are
identified as being at risk of a potential exposure to human blood or other potentially infectious
materials in the course of their employment must complete the Hepatitis B Declination Form,
regardless if they accept or decline to receive the vaccination.
All employees identified in the exposure determination section of this plan or who have
occupational exposure to blood or body fluids shall be offered a hepatitis B vaccination at no
cost to that employee.
If the employee desires to receive the vaccination, the employee must be vaccinated following
training on the hepatitis B vaccination efficacy, safety, method of administration, availability and
benefit. The hepatitis B vaccination series is available at no cost after training and within 10
days of initial assignment to employees identified in the exposure determination section of this
plan. Vaccination is encouraged unless: 1) documentation exists that the employee has
previously received the series, 2) antibody testing reveals that the employee is immune, or 3)
medical evaluation shows that vaccination is contraindicated.
The vaccine shall be provided at a reasonable time and place for the convenience of the
employee. The vaccination shall be provided in accordance with State law, shall be performed by
or under the supervision of a licensed physician or other authorized health care professional, and
shall be provided in accordance with the current recommendations of the United States Public
Health Service. All laboratory procedures performed in association with the immune state of the
employee shall be performed by a CLIA-certified laboratory at no cost to the employee.
The health care professional responsible for an employee's hepatitis B vaccination shall be
provided with a copy of OSHA's final rule on occupational exposure to bloodborne pathogens
(29 CFR Part 1910.1030).
Following hepatitis B vaccinations, the Occupational Health Physician's Written Opinion will be
limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was
A. Pre-screening of Employees
Pre-screening shall not be a prerequisite for participation in the hepatitis B vaccination
B. Employee Refusal of Hepatitis B Vaccine
An employee who chooses to decline the vaccination must complete and sign a declination
form stating they do not desire to participate in the vaccination program. A copy of the
declination form can be found in Appendix E, Hepatitis B Vaccination Declination Form,
of this program. Any employee initially declining to participate in the program may
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request to receive the vaccine at a later date by indicating their desire to be vaccinated and
completing a new declination form. An eligible employee requesting a vaccination
following an initial declination shall receive the vaccine within 10 days of written notice.
C. Booster Doses of Vaccine
If, at a later date, booster doses of the vaccine are recommended by the United States
Public Health Service, those employees identified as being at risk will be offered such
boosters at no cost for the vaccine or vaccination.
Employee training records shall be maintained in the Department of Environmental Health and
Safety for a period of at least three years. The training records will include:
Dates of the training sessions;
The contents or a summary of the training session;
The names and qualifications of those conducting the training session; and
The names and job titles of all individuals attending the training sessions.
Employee training records are provided upon request to the employee or the employee's
authorized representative within 15 working days.
The medical records are maintained for each employee with the potential for occupational
exposure in accordance with 29CFR1910.20, “Access to Employee Exposure Medical Records.”
The Department of Environmental Health and Safety maintains the required medical records as
part of the Occupational Health Program. These records are kept confidential and are kept for
the duration of employment plus thirty (30) years.
Employee medical records are provided upon request of the employee or to anyone having
written consent of the employee within 15 working days. Such requests should be sent to the
Manager of the Occupational Health Program in the Department of Environmental Health and
Safety. The records must also be made available to the PERRP administrator upon request or as
required by law.
An accurate medical record shall be established and maintained for each employee with
occupational exposure to bloodborne pathogens.
Page 24 of 50
The record shall contain:
The name and social security number of the employee;
A copy of the employee's hepatitis B vaccination status. This record shall include the
dates of all hepatitis B vaccinations and any information and medical records relative to
the employee's ability to receive vaccination;
A copy of all results of examinations, medical testing, and follow-up procedures
performed as part of the Wright State University Occupational Health Program;
A copy of the health care professional's written opinion following an exposure incident;
A copy of the information provided to the health care professional that performs a post-
Employee medical records must be kept in complete confidence. No part of the employee record
may be released without written consent from the employee except as required by law.
An exposure incident is evaluated to determine if the case meets OSHs Recordkeeping
Requirements (29 CFR 1904). This determination and the recording activities are done by the
Department of Environmental Health and Safety.
Sharps Injury Log
In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from
contaminated sharps are also recorded in the Sharps Injury Log. All incidences must include at
The date of the injury
The type and brand of the devices involved
The department or work area where the incident occurred
An explanation of how the incident occurred.
This log is reviewed at least annually as part of the annual evaluation of the program and is
maintained for at least five years following the end of the calendar year that they cover. If a
copy is requested by anyone, it must have any personal identifiers removed from the report.
Preservation of Records
In the event that the employer ceases doing business, all employee records associated with safety
and health shall be transferred to the successor business. In the event that there is no successor,
the employer shall notify the PERRP administrator, at least three months prior to their disposal
and transmit to the administrator, if required by the administrator to do so, within that three
Page 25 of 50
Requirements for HIV & HBV Research
Laboratories and Production Facilities
This section applies to research laboratories and production facilities engaged in the culture,
production, concentration, experimentation and manipulation of HIV and HBV. It does not apply
to clinical or diagnostic laboratories engaged solely in the analysis of blood, tissues or organs.
The requirements listed here apply in addition to other requirements of the OSHA Standard and
of the university Exposure Control Plan.
Research laboratories engaged in the culturing or concentrating the human immunodeficiency
virus (HIV) or hepatitis B virus (HBV) are required to comply with the university Exposure
Control Plan (ECP).
A Standard Operating Procedures (SOP) guide specific for the facility must be prepared to
address the additional requirements that follow. It is the responsibility of the facility manager to
periodically review and to at least annually update and revise the SOP. Personnel working in
the laboratory must read the biosafety manual and SOPs and must follow the outlined practices
Research laboratories and production facilities shall meet the following criteria:
A. Standard microbiological practices are used.
Waste generated in a research laboratory or a production facility shall be handled in accordance
to the policies consistent with the Ohio EPA, the Institutional Biosafety Manual and the facility
B. Special practices include
1. Laboratory doors will be kept closed when work involving HIV or HBV is in progress.
2. Contaminated materials that are to be transported are carried in a durable leak proof, labeled
or color coded container that is closed prior to being removed from the work area.
3. Access to the work area shall be limited to authorized persons. Written policies and
procedures shall be established whereby only persons who have been advised of the potential
biohazard, who meet any special entry requirements and who comply with all entry and exit
procedures will be allowed in the work areas.
4. When other potentially infectious materials or infected animals are present in the work area
or containment module, a hazard warning sign incorporating the universal biohazard symbol
shall be posted on all access doors. The hazard warning sign shall comply with the OSHA
5. All activities involving other potentially infectious materials shall be conducted in biological
safety cabinets (BSC) or other physical containment devices within the containment module.
No work with these other potentially infectious materials shall be conducted on the open
Page 26 of 50
6. Laboratory coats, gowns, smocks, uniforms or other appropriate protective clothing shall be
used in the work area and animal rooms. Protective clothing shall not be worn outside of the
work area and shall be decontaminated before being laundered.
7. Special care shall be taken to avoid skin contact with other potentially infectious materials.
Gloves shall be worn when handling infected animals and when hand contact with other
potentially infectious materials is unavoidable.
8. Before disposal all waste from the work area and from affected animals shall be
decontaminated by a method such as autoclaving prior to disposal by a method approved by
the Ohio EPA.
9. Vacuum lines shall be protected with liquid disinfectant traps and HEPA filters or filters of
equivalent or superior efficiency and which are checked routinely and maintained or replaced
10. Hypodermic needles and syringes shall be used only for parenteral injection and aspirations
of fluids from laboratory animals and diaphragm bottles. Extreme caution shall be used when
handling needles and syringes. Needles should not be bent, sheared or recapped. Needles
shall be placed in an appropriate sharps container and inactivated (by steam sterilization or
chemically) prior to disposal. Needle-locking syringes should be used.
11. All spills shall be immediately contained and cleaned up by the appropriate professional staff
or others properly trained and equipped to work with potentially concentrated infectious
12. A spill or accident that results in an exposure incident shall be immediately reported to the
laboratory director, other responsible person and to the Department of Environmental Health
13. A biosafety manual shall be prepared or adopted and periodically reviewed and updated at
least annually or more often if necessary. Personnel shall be advised of potential hazards,
shall be required to read instructions on practices and procedures and shall be required to
C. Containment Equipment
1. Certified Biological Safety Cabinets (Class I or II) or other appropriate combinations of
personal protection or physical containment devices, such as special protective clothing,
respirators, centrifuge safety cups, sealed centrifuge rotors, and containment caging for
animals, shall be used for all activities with the other potentially infectious materials that may
pose a threat of exposure to droplets, splashes, spills or aerosols.
2. Biological safety cabinets shall be certified when installed, serviced, whenever moved and at
3. Any containment device, centrifuge safety cups, centrifuge rotors or other equipment to
contain droplets, splashes, spill or aerosols shall be properly disinfected prior being released
4. Biological Safety Cabinets shall be disinfected prior to moving, service work or scraping.
HIV and HBV research laboratories shall meet the following criteria:
1. Each laboratory shall contain a facility for hand washing and an ANSI approved eye wash
which is readily available in the work area.
2. An autoclave for pretreatment of regulated waste shall be available.
Page 27 of 50
HIV and HBV production facilities shall meet the following criteria:
1. The work areas shall be separated from areas that are open to unrestricted traffic flow within
the building. Passage through two sets of doors shall be a basic requirement for entry into the
work area from access corridors or other contiguous areas. Physical separation of the high-
containment work area from access corridors or to other areas or activities may also be
provided by a double-doored clothes-change room (showers may be included), airlock or
other access facility that requires passing through two sets of doors before entering the work
2. The surfaces of doors, walls, floors and ceilings in the work area shall be water resistant so
that they can be easily cleaned. Penetrations in these areas shall be sealed or be capable of
being sealed to facilitate decontamination.
3. Each work area shall contain a sink for washing hands and an eye wash facility. The sink
shall be foot, elbow, or automatically operated and located near the exit door.
4. Access doors to the work area or containment module shall be self-closing.
5. An autoclave for decontamination of regulated waste shall be available within or as near as
possible to the work area.
6. A ducted exhaust-air ventilation system shall be provided. This system shall create
directional airflow that draws air into the work area through the entry area. The exhaust air
shall not be recirculated to any other area of the building, shall be discharged to the outside,
and shall be dispersed away from occupied areas and air intakes. The proper direction of the
airflow shall be verified (i.e., into the work area).
Additional training requirements are required for employees in HIV and HBV research
laboratories and production facilities are specified:
The employees shall also receive the following as part of initial training:
1. The employer shall ensure that the employees demonstrate proficiency in standard
microbiological practices and techniques and in the practices and operations specific to the
facility prior to being allowed to work with HIV or HBV.
2. The employer shall ensure that employees have prior experience in the handling of human
pathogens or tissue cultures prior to working with HIV or HBV.
3. The employer shall provide a training program to employees who have no prior experience in
handling human pathogens. Initial work activities shall not include the handling of infectious
agents. A progression of work activities shall be assigned as techniques are learned and
proficiency is developed. The employer shall ensure that employees participate in work
activities involving infectious agents only after proficiency has been demonstrated.
4. Training shall be documented and retained for a time period of not less than three years.
Review and Updating of Exposure Control Plan
This plan must be reviewed and updated at least annually and whenever necessary to reflect new
or modified tasks and procedures that affect occupational exposure and to reflect new or revised
employee positions with occupational exposure.
Page 28 of 50
Blood - human blood, human blood components, and products made from human blood.
Bloodborne Pathogens - pathogenic microorganisms that are present in human blood that can
cause disease in humans. These pathogens include, but are not limited to, hepatitis B
virus (HBV) and human immunodeficiency virus (HIV).
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 that has been soiled with blood or other potentially infectious
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
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.
Engineering Controls - controls (e.g. sharps disposal containers, self-sheathing needles) that
isolate or remove bloodborne pathogen hazards from the work place.
Exposure Incident - eye, mouth, mucous membrane, non-intact skin, or parenteral contact with
blood or other potentially infectious materials that result from the performance of an
Handwashing Facilities - facility providing an adequate supply of running potable water, soap,
and single use towels or hot air drying machines.
HBV - hepatitis B virus
HIV - human immunodeficiency virus
Licensed Health Care Professional - a person whose legally permitted scope of practice allows
him/her to independently perform the activities required in providing the hepatitis B
vaccination and post-exposure evaluation and follow-up.
Needleless Systems - a device that does not use needles for:
(1) The collection of bodily fluids or withdrawal of body fluids after initial venous or
arterial access is established; (2) The administration of medication or fluids; or (3) Any
other procedure involving the potential for occupational exposure to bloodborne
pathogens due to percutaneous injuries from contaminated sharps.
Occupational Exposure - reasonably anticipated skin, eye, mucous membrane, or parenteral
contact with blood or other potentially infectious materials that may result from the
performance of an employee's duties.
Other Potentially Infectious Materials (OPIM) - semen, vaginal secretions, cerebrospinal
fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
Page 29 of 50
saliva in dental procedures, any body fluid visibly contaminated with blood, and all
body fluids in situations where it is difficult or impossible to differentiate between body
fluids; any fixed tissues or organs other than intact skin from a human (living or dead)
and human immunodeficiency virus (HIV)-containing culture medium or other solutions
as well as blood, organs, or other tissues from experimental animals infected with HIV
Parenteral - piercing mucous membranes or the skin barrier through such events as needlestick,
human bites, cuts, and abrasions.
Personal Protective Equipment - specialized clothing or equipment worn by an employee for
protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or
blouses) not intended to function as protection against a bloodborne hazard are not
considered to be personal protective equipment.
Person-In-Charge (PIC) - any person who is responsible for, and supervises, activities of other
people who have the potential for an occupational exposure as defined above. This may
be a Supervisor, Principal Investigator, Department Chair, etc. Additionally, said person
is responsible, within the scope of their position, for carrying out and implementation of
university guidelines, policies and procedures.
Production Facility – means a facility engaged in industrial scale, large volume or high
concentration production of HIV or HBV.
Regulated 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 semi-liquid 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.
Research Laboratory – a laboratory producing or using research-laboratory-scale amounts of
HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV
but not in the same volume found in production facilities.
Sharps with engineered sharps injury protection – a non-needle sharp or needle device used
for withdrawing body fluids, access a vein or artery, or administering medications or
other fluids, with a built-in safety feature or mechanism that effectively reduces the risk
of an exposure incident.
Source Individual - individual, living or dead, whose blood or other potentially infectious
materials may be a source of occupational exposure to bloodborne pathogens or other
potentially infectious material(s).
Sterilize - the use of a physical or chemical procedure to destroy all microbial life including
highly resistant bacterial endospores.
Universal Precautions - an approach to infectious control in which all human blood and certain
human body fluids are treated as if infectious for HIV, HBV, and other bloodborne
Work Practice Controls - controls that reduce the likelihood of exposure to potential pathogens
by altering the manner in which a task is performed (e.g., prohibiting recapping of
needles by a two-handed technique).
Page 30 of 50
Job Positions at Risk of an Occupational Exposure
Animal Handlers/LAR Personnel Physical Plant (except office staff residing in U Hall)
Athletic Trainers - Maintenance
Athletic Coaches - HVAC
Disability Services, Personal Assistants - Environmental Services
EHS Personnel Physician
Laboratory Technician Police Officer
Laboratory Research Associate Research Faculty
Laboratory Supervisor Student Athletic Trainer
Life Guard Veterinarian
Nurses, Student Health Services
Tasks with a Risk of a Possible Exposure to Bloodborne Pathogens
Accident scene Manipulation of unfixed human tissue
Administering shots Manipulation of contaminated cultures
Autopsy Necropsy of infected animal carcasses
Cleaning bathrooms Public Disturbances
Cleaning up human blood Puncture wounds
Cutting with knife or scalpel Sonication of human blood or components
Drawing blood Handling used sharps
Emergency first aid and response
Handling infectious waste
Handling bathroom trash
Handling infected animals
Handling non-human primates (macaques)
Page 31 of 50
WRIGHT STATE UNIVERSITY
DEPARTMENT OF ENVIRONMENTAL HEALTH & SAFETY
OSHA'S BLOODBORNE PATHOGENS STANDARD
HEPATITIS B VACCINATION DECLINATION FORM
Today’s Date: _____________
Printed Name: ____________________________ Signature: ____________________________
Last Four Digits of Social Security No.: _________ Month/Day of Birth____________________
Department: ____________Supervisor/Lab Supervisor (print name):_______________________
Department Phone No._________________ Email address:______________________________
I am (check one): ____Faculty ____Staff ____Student Employee ____Student
____ I decline, at this time, to receive the Hepatitis B Vaccine Series.
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at
risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with
hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand
that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I
continue to have occupational exposure to blood or other potentially infectious materials and I want to be
vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
If you marked “I decline” you may stop HERE
____ I previously completed the Hepatitis B Vaccine Series.
A copy of past vaccination records must be submitted to EHS – Rm 129 Allyn Hall.
____ I consent to receive the Hepatitis B Vaccine Series.
____ I DO NOT have a history of allergic reactions to baker’s yeast, used for making bread.
____ I HAVE NOT had a reaction to previous hepatitis B vaccine.
____ I AM NOT moderately or severely ill at this time.
____ I have a history of hepatitis B:
THIS FORM MUST ACCOMPANY EACH PERSON TO EACH INJECTION, AND THEN MUST
BE RETURNED AFTER EACH INJECTION TO 129 ALLYN HALL or faxed to 937-775-3761.
STOP! For Office Use Only.
Signature: EH&S Approval:_____________________________________________________________
Signature: Health Care Provider; injection given:______________________________________
Disinfection & Sterilization Procedures
All blood and OPIM spills must be decontaminated with a freshly prepared 1:10 dilution of
household bleach, 2 ½ cups of bleach to a gallon of water.
Disinfection and cleaning
Surfaces contaminated with blood or OPIM should be cleaned using a freshly prepared 1:10
dilution of chlorine bleach solution that is prepared daily. The contaminated area should be
flooded with the bleach solution and then cleaned up using paper towels. Allow the solution to
remain in place for 20 minutes for disinfection. Safety goggles and gloves are to be worn during
the clean-up procedures. Chlorine bleach can corrode metal and metal items treated with chlorine
should be rinsed thoroughly. Thorough soap, water and a final rinse will remove chlorine
residue. Other high-level disinfectants (i.e. 2% glutaraldehyde) may be used after consultation
with the Institutional Biological Safety Officer and with the Department of Environmental
Health and Safety.
Routine cleaning of work surfaces, biosafety cabinets, and other laboratory equipment may be
cleaned with a freshly prepared 1:100 dilution of household bleach, ¼ cup of bleach to a gallon
of water. Other disinfectants may be used for routine cleaning and disinfection if they are an
EPA registered tuberculocide or sterilant, registered by the EPA effective against HIV/HBV or is
a FDA cleared sterilant/high level disinfectant. Any of these products are considered effective
when used according to the manufacturer’s instructions and provided the surfaces to be cleaned
have not been contaminated with high concentration or volume of agent material.
If you have questions about a specific item or about the efficacy of a specific disinfectant, please
call the Department of Environmental Health and Safety.
Objects to be sterilized should first be thoroughly cleaned to remove blood, tissue, food, and
other organic residue.
Steam sterilization is the best way to achieve inactivation of biological agents. An autoclave or
sterilizer can not be used to effectively decontaminate material for disposal as unregulated waste.
If the item may be damaged by heat, pressure, or moisture or if it otherwise not amenable to
steam sterilization, call the Department of Environmental Health and Safety for advice.
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INFECTIOUS WASTE MANAGEMENT GUIDE
TABLE OF CONTENTS
INTRODUCTION .................................................................................................... PAGE 1
SUMMARY OF REGULATIONS ........................................................................... PAGE 1
WRIGHT STATE UNIVERSITY INFECTIOUS WASTE STRATEGY ............... PAGE 5
PROCEDURES FOR WSU INFECTIOUS WASTE GENERATORS ................... PAGE 6
OEPA DEFINITIONS OF
INFECTIOUS WASTE ............................................................................................ APPENDIX I
WSU INFECTIOUS WASTE SPILL CONTAINMENT
AND CLEANUP PROCEDURES ............................................................................APPENDIX II
WRIGHT STATE UNIVERSITY SHARPS
MANAGEMENT POLICY……………………………………………………… .APPENDIX III
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On May 1, 1990, the Ohio Environmental Protection Agency (OEPA) amended Chapter
3745 of the Ohio Administrative Code (OAC). These and subsequent amendments
regulate the generation, management, and disposal of infectious waste.
For Wright State University (WSU) to comply with these regulations, individual
generators of infectious waste at WSU and WSU affiliated facilities will have to follow
the procedures outlined in this guide as a means of managing their infectious waste. This
guide should be reviewed periodically by all personnel responsible for areas where
infectious waste is generated. The guide MUST also be distributed to, and reviewed by,
all personnel working in areas where infectious waste is generated. The guide will be
updated as the OEPA revises the regulations or as WSU changes procedures.
The following appendices are included at the end of this guide to assist the individual
generators of infectious waste:
Appendix I - OEPA Definition of Infectious Waste
Appendix II - WSU Infectious Waste Spill Containment and Cleanup Procedures
II. SUMMARY OF REGULATIONS:
In addition to defining infectious waste, the amendments of OAC Chapter 3745 also
provide specific packaging, handling, treatment and transportation requirements, as well
as procedures for infectious waste spill containment and cleanup.
A. What is Infectious Waste?
Infectious waste is waste resulting from the work with infectious or zoonotic
agents. OEPA's definition of infectious waste, infectious agent, and zoonotic
agent can be found in Appendix I of this guide.
B. Infectious Waste Packaging and Handling Requirements:
All individual generators of infectious waste must segregate infectious
waste from other waste at the point of generation. Infectious waste, other than
sharps (i.e., hypodermic needles, syringes, scalpel blades, and glass articles that
have been broken) or liquids, shall be accumulated in red or other colored plastic
bags labeled with the international biohazard symbol. Bags containing infectious
waste that are being transported off the premises where generated shall be placed
inside a second sealed bag or fully enclosed, rigid, sturdy container. All sharp
infectious waste shall be accumulated only in containers specifically designed and
manufactured for the management and/or disposal of “sharps” and be labeled with
the international biohazard symbol and with the word “SHARPS”. All unused or
non-infectious discarded hypodermic needles, syringes, scalpel blades, and glass
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articles that have been broken shall be accumulated in rigid, puncture resistant,
leak resistant containers closed tightly to prevent loss of content and be labeled as
“SHARPS”. Containers consisting solely of unused or non-infectious sharps are
not required to be labeled with the international biohazard symbol. Liquid or
semiliquid infectious waste consisting of blood, blood products, body fluids, and
excreta shall be disposed of as described in paragraph C below. Liquid infectious
cultures can be chemically treated and disposed of as described in Section III, A.3
on page 6. No infectious waste shall be compacted or ground when packaged.
All packaged infectious waste shall be stored in a manner that maintains the
integrity of the packaging using refrigeration or freezing when necessary. All
storage areas must be limited to authorized personnel or labeled as an infectious
waste storage area.
C. Infectious Waste Treatment Requirements:
All infectious waste must be treated prior to disposal. Treatment can be
performed on the premises where the infectious waste is generated or the
infectious waste can be shipped off-site to a permitted infectious waste treatment
facility. Wherever the infectious waste is treated, it must be treated by methods
approved by the OEPA.
OEPA approved methods for the treatment of infectious waste includes
incineration, autoclaving, chemical treatment with sodium hypochlorite solution
(used for cultures only) and other methods specifically approved by the OEPA. In
order to comply with the infectious waste treatment regulations, a treatment
facility must meet operational and quality control requirements. For incineration
and autoclaving, this includes, but is not limited to:
- Specific design criteria
- Temperature and residence time requirements
- Temperature and pressure (for autoclaving) monitoring
- Treatment area drainage requirements
- Scheduled calibration and testing
- Loading requirements
- Personnel training
- Documentation and records retention requirements
- Contingency plans for alternate treatment
Chemical treatment utilizing sodium hypochlorite (bleach) is a method approved
for the treatment of cultures only.
Individual generators, who generate liquid or semiliquid infectious waste
consisting of blood, blood products, body fluids, and excreta may discharge this
material to a properly licensed sanitary sewer without prior treatment. This is the
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only type of infectious waste that can be disposed of without first treating it to
render it non-infectious. All other infectious waste must be properly treated
before being subjected to the general waste stream as ordinary solid waste.
D. Infectious Waste Transportation Requirements:
All infectious waste, even after it has been treated, which is transported off-site
for treatment or disposal must comply with the transportation and shipping paper
requirements of OAC Chapter 3745. For transporters who transport untreated
infectious waste, these regulations include requirements for registration, labeling,
packaging, vehicle design, refrigeration, holding time, disinfecting, spill
containment, and cleanup. However, transporters need only comply with the
shipping paper requirements if transporting treated infectious waste.
Generators of infectious waste must also comply with shipping paper
requirements. There are two different types of shipping papers. The generator
must assure that one of the two types accompanies every shipment of infectious
waste that is transported off the generator's premises. The OEPA has designed
treatment shipping papers which must accompany shipments of infectious waste
to an off-site treatment facility and disposal shipping papers which must
accompany treated infectious waste to an off-site disposal facility (i.e., landfill).
Both shipping papers consist of multi-copy carbonless paper that is designed to
track the waste from "cradle-to-grave" and assure the generator that the waste has
reached its intended destination.
E. Infectious Waste Spill Cleanup and Containment Requirements:
If a spill or accidental release of infectious waste occurs during the process of
generating, packaging, handling, treating or transporting infectious waste, the
person responsible for the spill/release must comply with spill cleanup,
containment, and reporting requirements. These requirements differ slightly for
generators, transporters, and treatment facilities.
Generators must develop and implement a written spill containment and cleanup
procedure that must be readily available to all persons likely to handle infectious
Transporters must also develop and implement a spill cleanup and containment
plan, as well as train all employees in the implementation of the plan.
Transporters must also carry spill containment and cleanup kits consisting of
specific cleanup material.
Infectious waste treatment facilities and generators who treat their own waste by
incineration or autoclaving must develop and implement a written spill cleanup
and containment plan and provide training to all individuals who handle
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infectious waste. A spill cleanup and containment kit consisting of specific
cleanup material must be kept in the vicinity of any storage, loading, unloading,
decontamination, and treatment areas.
THIS SUMMARY IS INTENDED AS AN OVERVIEW OF THE INFECTIOUS WASTE
REQUIREMENTS. THESE REGULATIONS APPLY TO GENERATORS OF FIFTY
POUNDS OR MORE OF INFECTIOUS WASTE PER MONTH. GENERATORS OF
LESS THAN FIFTY POUNDS PER MONTH ARE SUBJECT TO LESS STRINGENT
REQUIREMENTS. TO OBTAIN A SET OF THE INFECTIOUS WASTE
REGULATIONS, CONTACT THE DEPARTMENT OF ENVIRONMENTAL HEALTH
AND SAFETY AT EXT. 3788 OR THE OEPA AT (614) 644-2621.
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III. WRIGHT STATE UNIVERSITY INFECTIOUS WASTE STRATEGY:
The regulations implemented by the OEPA governing the generation, management, and
disposal of infectious waste create an impact on how WSU research, teaching, and health
professionals handle waste contaminated or potentially contaminated with infectious
agents. Depending on the time of year, WSU and WSU affiliated facilities generate
between 300 and 900 pounds of infectious waste per month. This makes WSU a large
quantity generator and subjects the university to the regulations for large quantity
generators, as summarized in Section II of this guide.
As a result of the regulation, a decision was made to transport WSU's infectious waste
off-site for treatment and disposal as opposed to treatment of infectious waste on-site
(other than chemical treatment of cultures). This decision leaves WSU with the task of
complying with the infectious waste generator requirements only, instead of both
generator and treatment facility requirements. The University Task Force on Toxins and
Infectious Material made the decision based on the costs and man-hours required to
comply with treatment facility requirements (i.e., autoclave room renovation, calibration
and testing, employee training, paperwork, etc.) versus the cost to transport and treat
infectious waste off-site.
As a result of this decision, WSU individual generators of infectious waste are not
permitted to autoclave or incinerate infectious waste and have it disposed of as ordinary
trash. Autoclaves can be used for disinfection and sterilization purposes (i.e., for
glassware, equipment) and for the treatment of waste not meeting the OEPA definition of
infectious waste. Waste that does not meet the OEPA definition of infectious waste but
requires autoclave treatment by another agency (i.e., National Institute of Health) shall be
autoclaved in bags not labeled with the international biohazard symbol. Infectious waste
will be accumulated in appropriate packages (supplied by the infectious waste contractor)
which will be picked up by Environmental Health and Safety personnel for eventual
transport off-site and treatment at a licensed facility prior to disposal.
Although infectious waste is not permitted to be treated via autoclaving or incineration
and disposed as ordinary solid waste at WSU, on-site chemical treatment of infectious
waste cultures (in liquid form only) using bleach is permitted. Also, untreated liquid or
semiliquid infectious waste consisting of blood, blood products, body fluids, and excreta
may be disposed of into the sanitary sewer system without prior treatment.
A. Procedures for WSU Infectious Waste Generators:
WSU personnel who generate infectious waste shall follow the following steps.
1. All WSU personnel who generate infectious waste must notify the
Department of Environmental Health and Safety (EHS). To determine if
you generate infectious waste, refer to the infectious waste definitions in
Appendix I of this guide. Any infectious waste meeting the definition of
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hazardous waste due to its chemical properties or which is also radioactive
must be managed differently than regular infectious waste. Any WSU
personnel who generates chemically hazardous or radioactive
infectious waste must contact EHS to determine proper treatment and
2. As a generator, you shall segregate infectious waste from other waste at
the point of generation.
3. If you generate cultures (in liquid form), which when intended for disposal
meet the definition of infectious waste, you can treat the cultures using
approved chemical treatment procedures. The approved chemical
treatment procedures are as follows:
a. Only cultures in liquid form can be chemically treated;
b. The approved chemical treatment solution shall contain, volume
per volume, at least fifteen percent sodium hypochlorite
(household grade bleach). The solution shall be at least fifteen
percent bleach not fifteen percent sodium hypochlorite which is the
active ingredient in bleach;
c. All cultures shall be submerged or otherwise in complete contact
with the chemical treatment solution for a minimum of twenty
d. Cultures of infectious agents that are recommended by the Centers
for Disease Control to be handled in accordance with biosafety
level 3 or 4 practices shall not be treated by these chemical
e. The chemical treatment solution shall be mixed immediately prior
to use and discarded after use; and
f. All waste cultures, which have been chemically treated, can be
released to the sanitary sewer.
4. Untreated liquid or semiliquid infectious waste consisting of blood, blood products, body
fluids, and excreta, may be disposed into the sanitary sewer system without prior
5. If you generate infectious waste other than liquid or semiliquid waste consisting of blood,
blood products, body fluids, excreta, or liquid cultures, EHS will supply you with a box
to accumulate your infectious waste. The individual generator must supply containers for
accumulating “sharps” waste (i.e., hypodermic needles and syringes, scalpel blades, used
or unused, and infectious waste glass articles that have broken).
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6. All "sharps" infectious waste must be accumulated in approved containers and must be
labeled with the international biohazard symbol or the words “Infectious Waste” and with
the words “SHARPS”. Refer to Appendix III Wright State University Sharps
Management Policy to determine the proper method for managing sharps waste.
7. All infectious waste, other than liquid waste, must be accumulated in boxes supplied by
EHS. These boxes are supplied by the infectious waste disposal contractor and meet all
specifications as required by the Ohio EPA. No other containers shall be used unless first
approved by EHS. When using the boxes supplied by EHS, the following restrictions
a. All waste must be bagged or properly containerized before being placed in a box.
b. No freestanding liquid shall be poured into a box and no containers of liquid shall be
placed in a box without prior approval from EHS.
c. Absolutely no chemically hazardous or radioactive waste, regardless of its infectious
nature, shall be disposed of in a box.
d. Do not fill a box greater than its maximum weight capacity. The maximum capacity of the
large box is 50 lbs. and the small box is 30 lbs.
e. A full box must have its interior liner bag taped closed and the box properly sealed before it
can be picked up.
8. Once a container of infectious waste becomes full, contact EHS at ext. 2215 or 3788, to
schedule a pickup. EHS will supply you with a new box. If you generate an infectious
waste, which you cannot keep in a nonputrescent state prior to a box becoming full,
notify EHS and immediate arrangements for a pickup will be made.
9. All labs and rooms that are accumulating infectious waste must be labeled with the
international biohazard symbol at all points of access. These labels will be supplied by
10. In the event of an accidental spill or release of infectious waste, the person or persons
responsible for the spill must instigate containment and cleanup. The WSU Infectious
Waste Spill Containment and Cleanup Procedure will be followed. These procedures are
provided in Appendix II of this guide. These procedures must be readily available to all
personnel involved with the generation and/or handling of infectious waste. All
personnel must periodically review and become familiar with the Spill Containment and
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All personnel who generate infectious waste shall follow these steps. By following these
procedures Wright State University can maintain compliance in a systematic manner with
the Ohio EPA infectious waste regulations. All personnel involved in the generation of
infectious waste shall become familiar with the procedures set forth in this guide. If
anyone has ideas that may enhance WSU's ability to comply with these regulations, please
contact EHS. Input from people who are directly regulated makes compliance much easier
and procedures more effective. For any questions, concerns, or input, the Department of
Environmental Health and Safety can be reached at ext. 3788.
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OHIO ENVIRONMENTAL PROTECTION AGENCY
DEFINITIONS OF INFECTIOUS WASTE
A. “Infectious Agents” means a type of microorganism, helminth, or virus that causes, or
significantly contributes to the cause of increased morbidity or mortality of human
B. “Zoonotic Agent” means a type of microorganism, helminth, or virus that causes disease
in vertebrate animals and that is transmissible to human beings and causes or
significantly contributes to the cause of increased morbidity or mortality of human
C. “Infectious Wastes” includes all of the following substances or categories of substances:
1. Cultures and stocks of infectious agents and associated biologicals, including,
without limitation, specimen cultures, cultures and stocks of infectious agents,
wastes from production of biologicals, and discarded live and attenuated vaccines;
2. Laboratory wastes that were, or are likely to have been, in contact with infectious
agents that may present a substantial threat to public health if improperly
3. Pathological wastes, including, without limitation, human and animal tissues,
organs, and body parts, and body fluids and excreta that are contaminated with or
are likely to be contaminated with infectious agents, removed or obtained during
surgery or autopsy or for diagnostic evaluation, provided that, with regard to
pathological wastes from animals, the animals have or are likely to have been
exposed to a zoonotic or infectious agent
4. Waste materials from the rooms of humans, or the enclosures of animals, that
have been isolated because of diagnosed communicable disease that are likely to
transmit infectious agents. Also included are waste materials from rooms of
patients who have been placed on blood and body fluid precautions under the
universal precaution system established by the "Center for Disease Control" in the
Public Health Service of the United States Department of Health and Human
Services, if specific wastes generated under the universal precautions system have
been identified as infectious wastes by rules referred to in section C.8. of this
5. Human and animal blood specimens and blood products that are being disposed
of, provided that with regard to blood specimens and blood products from
animals, the animals were or are likely to have been exposed to a zoonotic or
infectious agent. "Blood products" does not include patient care waste such as
bandages or disposable gowns that are lightly soiled with blood or other body
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fluids, unless such wastes are soiled to the extent that the generator of the waste
determines that they should be managed as infectious wastes;
6. Contaminated carcasses, body parts, and bedding of animals that were
intentionally exposed to infectious agents from zoonotic or human diseases during
research, production of biologicals, or testing of pharmaceuticals, and carcasses
and bedding of animals otherwise infected by zoonotic or infectious agents that
may present a substantial threat to public health if improperly managed;
7. Sharp wastes used in the treatment, diagnosis, or inoculation of human beings or
animals or that have, or are likely to have, come in contact with infectious agents
in medical, research, or industrial laboratories, including, without limitation,
hypodermic needles and syringes, scalpel blades, and glass articles that have been
broken. Such wastes are hereinafter in this rule referred to as "sharp infectious
waste" or "sharps";
8. Any other waste materials generated in the diagnosis, treatment, or immunization
of human beings or animals, in research pertaining thereto, or in the production or
testing of biologicals, that the Public Health Council created in Section 3701.33 of
the Ohio Revised Code (ORC), by rules adopted in accordance with Chapter 119
of the ORC, identifies as infectious wastes after determining that the wastes
present a substantial threat to human health when improperly managed because
they are contaminated with, or are likely to be contaminated with, infectious
9. Any other waste materials the generator designates as infectious wastes.
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WRIGHT STATE UNIVERSITY
INFECTIOUS WASTE CONTAINMENT AND CLEANUP PROCEDURES
A. PRIMARY CONTACTS FOR INFECTIOUS WASTE SPILLS:
INSTITUTIONAL BIOSAFETY OFFICER:
Kim Morris 104 HS 775-2623
INFECTIOUS WASTE CONTROL MANAGER:
Bill Palmer 129 Allyn Hall 775-3788
ENV. HEALTH AND SAFETY DEPT: 129 Allyn Hall 775-2215
WSU POLICE DEPT: 060 Allyn Hall 775-2111
B. LOCATION OF SPILL CONTAINMENT AND CLEANUP MATERIALS/KITS:
- Mathematics and Microbiology Building, hallway, Room 016 & 012
- Biological Sciences, Phase I, Room 117, under the sink
- Environmental Health and Safety, Room 141B Biological Sciences, Cabinet #24
- Student Health Services, 051T Student Union
- Disability Services, B072 Student Union
- Nutter Center, Athletic Training Area, Room 140
- Department of Human Biology, Room 150B, WSU Research Park
- Infectious Waste Storage Bldg., Parking Lot #20
- Cox Heart Institute, Room 223
Page 45 of 50
C. INFECTIOUS WASTE SPILL CONTAINMENT AND CLEANUP PROCEDURES:
In the event of an accidental spill or release of infectious waste at Wright State University or at a
Wright State University affiliated facility, the following procedures must be implemented by the
personnel responsible for the spill.
1. Immediately following the spill/release, secure the area so only authorized personnel may
enter. Remove and containerize any contaminated garments immediately. Contact one
of the primary contacts on the first page of this plan. At that time a determination will be
made as to what, if any, outside agencies or support groups shall be contacted. If the
spill/release occurs after 5:00 p.m. or on a Saturday, Sunday or holiday, contact Public
Safety, ext. 2111. Public Safety will contact appropriate Environmental Health and
2. Go to the nearest spill containment and cleanup kit and obtain all necessary containment,
cleanup and protective equipment needed to effectively handle the spill/release involved.
The location of the spill containment and cleanup kits are located on the first page of this
3. Further secure the area to authorized personnel if needed.
4. Each person involved in the cleanup shall wear protective equipment as needed. This
equipment is to be worn during the entire spill cleanup operation.
5. Wait 30 minutes before reentering the spill area to allow for settling of aerosols.
6. Spray spill area with disinfectant spray from the spill containment and cleanup kit or use
a bleach solution (minimum 15% bleach to water) if the spill is large. Begin at the
perimeter of the spill and work inward. Allow the disinfectant to remain in contact with
the spilled material for at least twenty minutes before proceeding.
7. Use the absorbent pads supplied from the spill containment and cleanup kit to absorb any
8. Place all used absorbent pads and other waste generated during the cleanup into a
biohazard bag supplied from the spill containment and cleanup kit. Absolutely no
freestanding liquid or containers of liquid shall be put in any biohazard bag. All
freestanding liquid shall be absorbed prior to placing it in the biohazard bag.
9. Use the chemical disinfectant supplied from the spill containment and cleanup kit to
disinfect the entire area again. Clean up the area as deemed appropriate (i.e., use of
absorbent pads). Any absorbent pads used during the disinfection of the area shall be
considered infectious waste and placed in the biohazard bags.
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10. Clean and disinfect all non-disposable items using the disinfectant supplied from the spill
containment and cleanup kit.
11. Remove protective equipment and manage disposable items as infectious waste (place in
12. Immediately following spill/release cleanup, all infectious waste generated from cleanup
operations must be stored and managed as specified in Wright State University's
"Infectious Waste Management Guide.”
13. Notify Environmental Health and Safety, ext 2215, if material from a spill containment
and cleanup kit was used to respond to the spill.
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WRIGHT STATE UNIVERSITY SHARPS MANAGEMENT POLICY
As a university that generates infectious waste, individuals on campus must be aware of recent
interpretations made by the EPA during inspections at WSU regarding the management of
sharps. The following procedures must be followed as interpreted by the EPA per the
requirements of Ohio Administrative Code 3745-27-34(B).
The EPA considers needles, razor/scalpel blades, lancets, broken glassware, pipettes, pipette tips,
and syringes (even without needles) to be sharps. All of these sharps must be accumulated for
disposal immediately into an approved sharps container. The type of container required depends
on the type of sharps and whether or not the sharps are considered infectious. The EPA separates
sharps into two categories. These are:
Maximum puncture potential sharps – These included needles, razor/scalpel blades, lancets,
and any other sharp deemed to pose a definite puncture potential.
Minimum puncture potential sharps – These include pipettes, pipette tips, syringes without
needles, and large broken glassware
Identify the type of sharps you generate and determine if they are infectious. Refer to Appendix
I of the Infectious Waste Management Guide to review the definition of infectious waste. Once
you have identified the type of sharp you generate and determined its infectious nature refer to
the category below and manage your sharps accordingly.
Maximum Puncture Potential Sharps that are Infectious:
An approved sharps container is a puncture and leak resistant container specifically designed and
manufactured for the accumulation of sharps and labeled with the words “Infectious Waste” or
with the international biohazard symbol (i.e. a red sharps container). This type of sharps
container, when full, shall be put in an infectious waste box supplied by EHS that also must
marked as containing sharps and will be managed by EHS.
Maximum Puncture Potential Sharps that are not Infectious:
An approved sharps container is a puncture and leak resistant container that can be specifically
designed and manufactured for the accumulation of sharps or could be a can or plastic container
with a secure fitting lid that can be closed when full. In any case, these containers must not be
labeled with the biohazard label or any other marking that would indicate it is infectious. The
container must be marked with the word “SHARPS and when full can be put into a non-
contaminated broken glass box provided by Environmental Services (formally Custodial
Services). You must then mark the box as containing “SHARPS”. The box, when full, can be
managed as regular solid waste by Environmental Services personnel.
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Minimum Puncture Potential Sharps that are Infectious:
An approved sharps container is an infectious waste box supplied by EHS. These types of sharps
must be accumulated immediately into the box after use. The infectious waste box must then be
marked as containing sharps and will be managed by EHS.
Minimum Puncture Potential Sharps that are not Infectious:
An approved sharps container is a broken glass box provided by Environmental Services. This
box must be labeled as “SHARPS”. This box, when full, can be managed as regular solid waste
by Environmental Services personnel.
IMPORTANT: The EPA does not allow the accumulation of sharps; including pipettes and
pipette tips or other minimum puncture potential sharps, in bags or open containers on a lab
bench. All sharps, regardless of their puncture potential, must be accumulated for disposal
immediately into an approved sharps container. Although this procedure may, in part, appear
overly protective and burdensome it must be followed in order for the university to avoid EPA
violations. The EPA has issued notice of violations to the university in the past for failure to
follow this requirement.
Please contact EHS at 2215 if you have any questions regarding these procedures.
Page 49 of 50
Additional Information and Documents of Interest
CDC Office of Health and Safety – Biosafety
Biosafety in the laboratory and publication Biosafety in Microbiological and Biomedical
Laboratories (BMBL), 4th edition
CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention
NIOSH Safer Medical Device Implementation in Health Care Facilities
NIOSH recommends that health care facilities use safer medical devices to protect workers from
needlestick and other sharps injuries
NIOSH Infectious Diseases HIV/AIDS, Hepatitis B Virus, and Hepatitis C Virus
Nursing World – Work Place Issues Occupational Health and Safety
HIV, Hepatitis B, Hepatitis C: Bloodborne Diseases
OSHA Bloodborne Pathogen Standard (29CFR1910.1030)
The text of the OSHA Standard for bloodborne pathogens
PERRP: State of OHIO Bureau of Occupational Health and Safety Needlestick Injury Report
Form (in PDF format) – Adobe Reader needed
Note: Both pages of form are required to be completed and submitted to the Department of
Environmental Health and Safety in the event of an injury involving a contaminated sharp
PERRP: Needlestick Prevention Web Site Links
Wright State University Department of Environmental Health and Safety web site
Forms to report Accident/Injuries, Accept/Decline Hepatitis B Vaccination and other needs
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