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									                    UNIVERSITY OF HAWAI‘I
                        John A. Burns School of Medicine at Kaka‘ako




        Biological Agents and Bloodborne Pathogens Standard
                       Exposure Control Plan


Original Plan Prepared by:                  The Bloodborne Pathogens Committee,
                                            Student Health Services
                                            University of Hawaii at Manoa
                                            March 1993

Reviewed/Updated:                           The UH Health Committee,
                                            University Health Services
                                            University of Hawaii
                                            February 2004

Modified by:                                Insert name
                                            Insert PI’s name
For:                                        Insert Department, Building, Lab number
Date:                                       Insert date

Approved:                                   (         Head of Department           )
                                            Title
                                            Signature

Annual Review Date:                 (1 year from origination)


1.      PURPOSE

The University of Hawaii's Biological Agents and Bloodborne Pathogens Exposure Control Plan (ECP)
has been developed in compliance with the State Department of Labor and Industrial Relations (DLIR),
Division of Occupational Safety and Health (HiOSH), "Biological Agents and Bloodborne Pathogens
Standard," Title 12, Subtitle 8, Chapter 205 HRS (Hawaii Revised Statutes) §396.4. This plan describes
how employee's, student's, volunteer's, occupational and instructional exposure to biological agents,
blood, or other potentially infectious materials can be eliminated or minimized.


                                        1
2.     SCOPE

All activities at the University will utilize this Plan when possible risk of occupational and/or
instructional exposure to potentially infectious materials; biological agents, and bloodborne pathogens
exist. These standards must be followed in order to meet Federal and State requirements' for worker -
student protection. Flexibility exists for University department supervisors to develop more stringent
guidelines as needed, i.e., working with other potential hazardous biological commodities, including
student instructional exposure. All infection control policies and procedures will be consistent with the
intent of this Plan.

The standard requires an annual review of the exposure control plan. In addition, whenever changes in
tasks, procedures, or employee positions affect or create new occupational exposure, the existing plan
must be reviewed and updated accordingly.


3.     RESPONSIBILITIES FOR COMPLIANCE

       A.      Departmental - The supervisor of the Department or Unit will be responsible for the
               integrated compliance of actions (such as engineering controls, work practice
               modifications, appropriate use of personal protective equipments, training and education,
               vaccination, prophylaxis, and exposure follow-up) to prevent or reduce the risk of
               employees' - students' exposure to biological agents, blood, and other potentially
               infectious materials. The supervisor will also be responsible for keeping UH
               Environmental Health and Safety Office - Biological Safety Program (EHSO-BSP)
               informed of any occupational-instructional exposure incident.

       B.      Supervisor - The supervisor will assure that all personnel (employees, students,
               volunteers) are aware of and are following this Plan. Supervisors will identify and direct
               specific departmental work-instructional practices that facilitate meeting the provisions of
               this Plan and immediately notify the administrator of any occupational - instructional
               exposure incident.

       C.      Employees – Employees, students, and volunteers will be responsible for complying with
               procedures established by their work supervisors in accordance with this Plan to prevent
               or minimize their risk. They are also responsible to promptly report any worksite -
               classroom exposure incident to their supervisor. Any refusal to practice this Plan is
               subject to disciplinary action by the appropriate administrator and violates the mandate of
               HiOSH.

4.     EXPOSURE DETERMINATION

       In the following job - student classification at the John A. Burns School of Medicine at
       Kaka‘ako, these employees/students may have contact with biological agents, blood and other
       potentially infectious materials (OPIM). They may be exposed to these materials regardless of
       whether they wear or use protective equipment. Full, part-time, per diem, temporary, and
       student employees as well as volunteers are included.




                                          2
A.   The following employees/students will have occupational or instructional exposure:

     1.     (Job Titles)
     2.
     3.
     4.
     5.
     6.
     7.
     8.
     9.
     10.



B.   The following employees - students may have occupational or instructional exposure:

     1.     (i.e., Students in Microbiology 135)
     2.
     3.
     4.
     5.
     6.
     7.
     8.
     9.
     10.

C.   The following tasks and procedures usually performed at the JABSOM at Kaka‘ako
     involves a potential risk of occupational - instructional exposure to biological agents,
     blood and other potentially infectious materials:

     1.     (Name of Tasks and Procedures - Tasks, procedures, or groups of closely related
            tasks/procedures in which occupational exposure occurs to some of those in the
            jobs listed in B above: (i.e., janitorial duties at UH Health Services)
     2.
     3.
     4.
     5.
     6.
     7.
     8.
     9.
     10.




                                3
5.   UNIVERSAL PRECAUTIONS or STANDARD PRECAUTIONS

     A.   Universal precautions will be used by all JABSOM at Kaka‘ako personnel to prevent
          contact with biological agents, blood or other potentially infectious materials. Materials
          will be considered potentially infectious when it is impossible to distinguish between
          these materials.

     B.   Universal precautions are an approach to infection control to reduce exposure to
          biological agents, bloodborne pathogens and other potentially infectious materials.
          Universal precautions apply to biological agents, blood and to other potentially infectious
          materials, i.e., body fluids containing visible blood, semen and vaginal secretions, human
          tissue, organs and the following fluids: cerebrospinal fluid, synovial fluid, pleural fluid,
          peritoneal fluid, pericardial fluid, amniotic fluid. PRECAUTIONS MUST BE
          UNIFORMLY USED WITH ALL PATIENT CONTACTS AND RESEARCH-
          CLINICAL-INSTRUCTIONAL MATERIALS.

          The standard covers animal blood only for those animals purposely infected with HIV or
          HBV. Although the standard does not apply to animal blood unless the animal has been
          purposely infected with HIV or HBV, persons handling animals or animal blood should
          follow general precautions as recommended by the Centers for Disease Control/National
          Institutes of Health Publication, Biosafety in Microbiological and Biomedical
          Laboratories (Publication No. 88-8395). However, animal blood, tissues, etc., may
          contain potential zoonotic diseases and must be treated as potentially infectious materials.
          Some plant pest maybe considered pathogenic, especially fungi.

          Standard precautions combine the important features of Universal (Blood and Body
          Fluid) Precautions (designed to reduce the risk of transmission of blood-borne pathogens)
          and Body Substance Isolation (BSI) (designed to reduce the risk of transmission of
          blood-borne pathogens from moist body substances). Standard Precautions are designed
          to reduce the risk of transmission of micro-organisms from both recognized and
          unrecognized sources of infection. Standard precautions apply to blood, all body fluids,
          other potentially infectious materials, secretions and excretions except sweat, regardless
          of whether they contain visible blood, non-intact skin and mucous membranes. BSI is an
          acceptable alternative to Universal Precautions, provided facilities utilizing BSI adhere to
          all other provisions of the standard.

     C.   Protective barriers' precautions, such as the use of gloves, gowns, respirators and
          protective eyewear (safety goggles) or face shields, reduce the risk of exposure to
          biological agents, blood, other fluids, and other potential infectious material to which
          universal precautions apply. Although universal precautions do not apply to feces, nasal
          secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood,
          other methods of infection control apply to these potential pathogenic sources of
          nosocomial, zoonotic, and community-acquired infections. Universal precautions should
          not replace procedures for routine infection control, such as hand washing and using
          personal protective equipment.

     D.   Fluid resistant gowns or aprons should be worn during procedures that is likely to
          generate splashes or aerosols of biological agents, blood or other potentially infectious
          materials. Gowns should be closed front or a coat with an overlapping front. Uniforms,

                                     4
          laboratory coats, scrubs, if used as a PPE, must not be used outside of the containment
          facility.

     E.   Practicing "universal precautions" consists of the following CDC recommendations:

          1.     Appropriate barrier precautions should be routinely used to prevent skin and
                 mucous membrane exposure when contact with biological agents, blood or other
                 potentially infectious materials of any clinical - research - instruction are
                 anticipated.

                         a.     Gloves should be worn: for touching biological agents, blood and
                                other potentially infectious materials, mucous membranes, or non-
                                intact skin of all clinical- research - instruction, for handling items
                                or surfaces soiled with biological agents, blood or other potentially
                                infectious materials, and for performing venipuncture and other
                                vascular access procedures. Gloves should be changed after
                                contact with each clinical - research - instructional materials and
                                hands must be washed.

                         b.     Masks and protective eyewear (safety goggles) and face shields
                                should be worn during procedures that are likely to generate
                                droplets, aerosols, splashes of potentially infectious materials that
                                may be exposed to the worker mucous membranes (mouth, nose,
                                eyes or open wounds).

          2.     Hands and other skin surfaces should be washed immediately and thoroughly if
                 contaminated with biological agents, blood or other potentially infectious
                 materials. Hands should be washed immediately after personal protective gloves
                 are removed.

          3.     All "touch and splash" surfaces must be carefully disinfected with an intermediate
                 or higher level EPA registered, hospital-grade disinfectant.

          4.     Contaminated and potentially contaminated waste must be properly
                 decontaminated and disposed. See the JABSOM Kaka‘ako’s Hazardous Material
                 and Hazardous Waste Management Program and the UH Biohzardous Waste
                 Disposal Guidelines for proper procedures.

6.   SPECIFIC ENGINEERING AND WORK PRACTICE

     A.   ENGINEERING CONTROLS

          1.     Red-colored sharp's disposal containers are puncture resistant and leak proof
                 (especially sides and bottom) and appropriately labeled. Sharp containers must be
                 maintained up-right during use. They will be located as close as possible to
                 where sharps are used. They shall be examined on a regular schedule and
                 replaced when the containers are 7/8 filled. They are not reusable containers.
                 These containers will be closed if they are moved to prevent spillage. In the event
                 that a sharp's container appears to be leaking, it should be placed inside another

                                     5
     closable, leak proof container with the appropriate color-coding or label. If
     sharps' containers are mounted on walls, the height must be between 52 and 56
     inches for correct ergonomically position. Red sharps containers are for only
     biological contaminated sharps.

2.   In addition to needles and syringes, regulated wastes includes used biological
     contaminated disposable gloves, blood contaminated items, or pathologic and
     microbiological wastes containing biological agents, blood or other potentially
     infectious materials (lancet, glass slide, covers slip, pipette tips, capillary tubes
     etc.).

3.   Regulated biological contaminated wastes requires special disposal. See the
     JABSOM Kaka‘ako’s Hazardous Material and Hazardous Waste Management
     Program and the UH Biohzardous Waste Disposal Guidelines for proper disposal
     procedures.

4.   Waste generated during the course of work with potentially infectious materials,
     other than sharps, will be immediately transferred upon generation into a red
     biohazard bag held within a closable, leak-proof secondary container with
     biohazard labeling or color-coding. Bags will be closable, constructed to contain
     all contents and prevent leakage during handling, storage, transport, or shipping.
     They will be closed prior to removal to prevent spillage or protrusion of contents
     at any time.

5.   Specimens of biological agents, blood or potentially infectious materials are kept
     in leak-proof containers during collection, handling, processing, storage,
     transport, or shipping. Any specimen that could puncture a primary container will
     be placed within a secondary container that is puncture resistant.

6.   The following items will have a biohazard label or be stored in a red bag or red
     container: regulated biological contaminated waste that has not been
     decontaminated, refrigerators, freezers, storage cabinets used to store biological
     agents, blood or other potentially infectious material, and equipment or containers
     used to store, move, or ship biological agents, blood or other potentially infectious
     materials.

7.   Soiled laundry will be kept in a closed laundry hamper that hold all contents
     without leakage during handling, storage, transport, and is color-coded or labeled.

8.   Equipment and instruments that may become contaminated will be inspected for
     biological agents, blood or other potentially infectious materials on a regular basis
     and decontaminated if necessary. If not decontaminated on a regular basis, must
     be appropriately labeled with the Universal Biohazard Symbol. The schedule and
     procedures are identified in the unit's policy manual. All equipment that is to be
     serviced must be decontaminated prior to repair or maintenance. If cannot be
     decontaminated, the service department must be notified.

9.   Section supervisors will be responsible for examining engineering controls used
     to eliminate or minimize exposure to these materials on an established, regular

                         6
      schedule, which is identified in unit's policy. They will ensure the effectiveness
      of these controls and updates as needed.

10.   Every effort must be made to control the isolates or remove the bloodborne
      pathogens hazards from the workplace, such devices include but not limited to:
      sharps disposal containers, shelf-sheathing needles, safer medical devices, sharps
      with engineered sharps injury protections, needleless systems and other newer
      engineering controls.

11.   Needleless systems are devices that do not use needles for the collection of body
      fluids or withdrawal of body fluids after initial venous or arterial access is
      established, for the administration of medications or fluids or other procedures
      involving the potential for occupational exposure to bloodborne pathogens due to
      precutaneious injuries from contaminated sharps. Examples of such devices or
      alternatives include needle-protected systems and "self-sheathing" needles.

      a.     Needle stick Safety and Prevention Act applies to all employers who have
             employees with reasonably anticipated occupational exposure to blood or
             other potentially infectious materials (OPIM) due to accidental sharps
             injuries in healthcare and other occupational settings. It mandated
             additional requirements for maintaining a sharps injury log and for the
             involvement of non-managerial healthcare workers in evaluating and
             choosing devices.

      b.     Engineering and work practice controls shall be used to eliminate or
             minimize employee exposure. Controls (e.g., sharps disposal containers,
             self-sheathing needles, safer medical devices, such as sharps with
             engineered sharps injury protections and needleless systems) that isolate
             or remove the bloodborne pathogens hazard from the workplace.

      c.     Each new engineering and work practice control must be evaluated. A
             key element in choosing a safer medical device, other than its
             appropriateness to the procedure and effectiveness, is its availability on
             the market. If there is no safer option for a particular medical device used
             where there is exposure to blood or OPIM, you are not required to use
             something other than the device that is normally used. During your annual
             review of devices, you must inquire about new or prospective safer
             options and document this fact in your written Exposure Control Plan.
             With increasing medical technology, more devices are becoming available
             for different procedures. If no engineering control is available, work
             practice controls shall be used and, if occupational exposure still remains,
             personal protective equipment must also be used. Non-managerial
             healthcare workers must be solicited in evaluating and choosing devices.

      d.     Also must maintain a log of occupational injuries and illnesses under 29
             CFR 1904, you must also establish and maintain a sharps injury log for
             recording percutaneous injuries from contaminated sharps. The Sharps
             Log must contain, at a minimum, information about the injury, the type
             and brand of device involved in the injury (if known), the department or

                         7
                  work area where the exposure occurred, and an explanation of how the
                  incident occurred. The log must be recorded and maintained in such a
                  manner so as to protect the confidentiality of the injured employee (e.g.,
                  removal of personal identifiers)

     12.   Other engineering controls such as biological safety cabinet, plastic shielding,
           etc., are to be used for appropriate containment of biological commodities to
           reduce exposure to biological agents, blood, and other potentially infectious
           materials.

     13.   Reusable sharps must be placed in containers that are puncture-resistant, leak
           proof on the sides and bottom, and properly labeled/color-coded until they are
           reprocessed. Contaminated reusable sharps must not be stored or reprocessed in a
           manner that would require the employee to reach by hand into sharp containers.



B.   WORK PRACTICE CONTROLS

     1.    Hand washing facilities are readily accessible in all laboratories at JABSOM
           Kaka‘ako. Hand washing should be done with soap and running water as soon as
           feasible after contamination, between clinical - research - instruction materials,
           and after removal of gloves or other personal protective equipment.

     2.    Handwashing guidelines are already described with Universal Precautions
           procedures. In the event of contact with biological agents, blood or other
           potentially infectious materials to the eyes, nose, mouth or open wound, these
           mucous membranes will be flushed with water immediately or as soon as feasible.

     3.    Contaminated needles and other contaminated sharps will not be bent, sheared, or
           purposely broken. Recapping is permitted if a procedure does not have a feasible
           alternative and the action is required by the specific medical procedure. If needle
           removal or recapping is necessary, removal or recapping must be done either by
           one-handed scooping (passive recapping) or through a removal device. [Specify
           any known need to recap or remove needles.] All straight needles systems have
           been converted over to newer safer needle technology systems.

     4.    Reusable sharps that are contaminated with biological agents, blood or other
           infectious materials are stored and processed in a way that does not require
           anyone to reach, by hand, into the containers where these sharps have been
           placed.

     5.    Mouth pipetting, or mouth suctioning of biological agents, blood or other
           potentially infectious materials, is prohibited.

     6.    All procedures involving biological agents, blood or other potentially infectious
           materials must be performed in such a manner as to minimize splashing, spraying,
           splattering and generation of droplets of these substances.



                              8
          7.     Eating, drinking, smoking, applying cosmetics or lip balm, or handling contact
                 lenses are prohibited in work areas where there is any risk of occupational
                 exposure.

          8.     Food and drink shall not be kept in refrigerators, freezes, shelves, and cabinets or
                 on counter-tops or bench tops where biological agents, blood or other potentially
                 infectious materials are present.

          9.     Warning labels containing the universal biohazard symbol and the word
                 "BIOHAZARD" will be used to warn employees who may have contact with
                 areas and containers of the potentially hazardous materials. Labels are not
                 required when red bags are used.

          10.    In an event of a biological agent or blood spill, lab specific contingency spill plan
                 must be initiated. General example of a plan:

                 a.      Flood spill with appropriate freshly made disinfectant, let sit for 20-30
                         minutes.

                 b.      Absorb the spill with towels or spill pillows.

                 c.      Place in autoclave bag.

                 d.      Autoclave and re-disinfect spill area.

7.   PERSONAL PROTECTIVE EQUIPMENT (PPE)

     A.   Personal protective equipment (PPE) will be used when appropriate to protect employees
          from potential occupational - instructional exposure incidents. PPE will be chosen based
          upon the type of anticipated exposure to biological agents, blood or other potentially
          infectious materials. The specific equipment for a situation will be determined by each
          section in which the potential for occupational - instructional exposure occurs and may
          include gowns, aprons, lab coats, disposable gloves, utility gloves, chin-length face
          shields, facemasks, respirators, eye protection (safety goggles), shoe covers, surgical
          caps, and mouthpieces or pocket masks. Note: Regular safety glasses will not provide
          protection if aerosols occurs.

     B.   Personal protective equipment will be considered appropriate only if it does not permit
          biological agents, blood or other potentially infectious material to pass through or reach
          the worker provider clothing, skin, eyes, mouth, or other mucous membranes under
          normal conditions of use and for the duration of time that the protective equipment will
          be used.

     C.   The financial responsibility for providing personal protective equipment (PPE) rests with
          the department. However, there is no obligation to provide general work clothes. All
          PPE will be cleaned, laundered, or properly disposed of by the department. All garments
          that are penetrated by biological agents, blood or other infectious materials shall be
          removed as soon as feasible and laundered or properly disposed. Contaminated clothing



                                     9
          will not be sent home with the worker for cleaning, unless person has been properly
          trained on proper transporting and laundering.

     D.   Appropriate sizes of personal protective are available for use. At a minimum, gloves will
          be used whenever there is a reasonable anticipation of hand contact with biological
          agents, blood or other potentially infectious materials. Hypoallergenic gloves,
          powderless gloves, glove liners, or other similar alternatives shall be readily accessible to
          those who are allergic to the gloves normally provided.

     E.   A worker may temporarily and briefly decline wearing personal protective equipment
          under rare and extraordinary circumstances of life-threatening situations when the use or
          protective equipment will pose an increased hazard to workers or prevent the delivery of
          care. When this judgment is made, the circumstances shall be investigated and
          documented by the section supervisor to determine whether changes can be institutes to
          prevent such occurrences in the future. Appropriate follow up action will occur.

     F.   Department personnel will discard any disposable equipment after use in the appropriate
          receptacle and properly decontaminated prior to disposal. Reusable PPE will be
          decontaminated and cleaned prior to storage in a designated area for future use. All PPE
          will be removed prior to leaving the work area.

     G.   PPE will be replaced as often as necessary. At a minimum this will occur after each use
          where the equipment becomes contaminated and cannot be decontaminated effectively,
          and when equipment becomes old and ineffective.

     H.   The PPE equipment checked below is provided at this unit: [Check those that are
          provided and list any additional items under "other"]

          _____ Gloves                   _____ Gowns                    _____Lab Coats

          _____Face Shields/Masks        _____ Eye Protection

          _____ Mouth Pieces             _____ Resuscitation Bags

          _____ Pocket Masks             _____Other Ventilation Devices

          _____ Utility Gloves           Other (specify) _____________________




8.   HOUSEKEEPING

     A.   JABSOM Kaka‘ako must be maintained in a clean and sanitary condition at all times.
          Each department section will implement an appropriate written schedule for the manner
          in which and the time when their areas are cleaned and disinfected. This schedule will
          also include an explanation of the cleaning and decontamination of equipment, which has
          been in contact with biological agents, blood or other potentially infectious materials.



                                    10
          [Indicate the cleaning schedule and measures in use by revising and/or adding to the
          examples listed in the table below:]


        SCHEDULE FOR CLEANING AND METHOD OF DECONTAMINATION

ITEM OR AREA METHOD OF DECONTAMINATION                                  SCHEDULE

Work Surfaces            Wash with 1:10 bleach solution.                After the
                                                                        completion of
                                                                        procedures or
                                                                        end of work
                                                                        shift that
                                                                        involved
                                                                        contamination.
                                                                        When surfaces
                                                                         become
                                                                        obviously
                                                                        contaminated.

Reusable         Wash with hot soap and water                           After each use
Resuscitation                                                           disinfect with
Mask                                                                    alcohol.


   B.     Work surfaces must be decontaminated, with a hospital-grade, tuberculocidal, fungicidal,
          and virucidal disinfectant that is registered with the EPA at the intermediate or higher
          level, after completion of procedures, immediately or as soon as feasible after any spill of
          biological agents, blood or other potentially infectious materials, as well as the end of the
          work shift if the surface may have become contaminated since the last cleaning.

          UNIT'S DISINFECTANT: ___________________________________
          MSDS or Product Insert (attached)


   C.     Reusable receptacles, such as bins, pails, and cans that have the likelihood for becoming
          contaminated, must be inspected and decontaminated with a hospital-grade disinfectant
          or autoclaved on a regular basis. When contamination is visible, receptacles should be
          cleaned and decontaminated as soon as feasible.

   D.     Any broken glassware or other sharps that may be contaminated will not be picked up
          directly with the hands. Tools that are used in the clean-up of broken glass (brush, dust
          pan, forceps, and/or tongs) must be decontaminated after use and the contaminated broker
          glass should be placed in a red sharp's container. Vacuum cleaners are not appropriate for
          use in the cleanup of biological hazardous or contaminated broken glass




                                    11
9.    LAUNDRY

      A.   Biologically contaminated laundry will be handled as little as possible. Sorting or rinsing
           of contaminated laundry will not be performed in patient care areas. Contaminated,
           soiled laundry will be place and transported in biohazard labeled or color coded red bags
           or containers.

      B.   Contaminated laundry, which is wet and presents the reasonable likelihood of soak-
           through or leakage from the bag or container, will be a stored and transported in double
           bags that prevent soak through and leakage of fluids to the exterior.

      C.   Protective gloves, and other appropriate personal protective equipment as required, will
           be used by anyone who has contact with contaminated laundry.

      D.   Laundry from JABSOM Kaka‘ako laboratories is commercially cleaned in a facility,
           which uses Universal Precautions in handling linen.

10.   HEPATITIS B VACCINE (OR OTHER APPROPRIATE VACCINE)

      A.   JABSOM Kaka‘ako will make the hepatitis B vaccine and vaccination series (or other
           appropriate vaccine) available at no cost to all employees who have been identified in this
           Plan as having occupational exposure. For instructional purposes, since students are not
           in an occupational setting, the cost maybe burdened by the students. The vaccine series
           will be explained at an employee or student training session held within 10 days of initial
           assignment of duties or starts of instruction that may result in potential occupational -
           instructional exposure to bloodborne pathogens. JABSOM Kaka‘ako will also make
           routine booster doses of the hepatitis B vaccine available if booster doses are
           recommended by the U.S. Public Health Service.

           Proof of Hepatitis B vaccination or other appropriate vaccine is a prerequisite for
           employees, students and volunteers entering the unit. Written proof of completion of
           vaccination series must be submitted to the administrator.

      B.   Personnel identified in the exposure determination will be asked to complete and sign a
           copy of Hepatitis B Immunization Form (or other vaccine immunization form) or a
           declination form. This form will be included in their confidential personnel record (and
           medical record if occupational exposure occurs).

      C.   The hepatitis B vaccination (or other appropriate vaccine) will continue to be available
           without cost to anyone who initially declines the vaccination if that individual is still
           covered by the HiOSH standard and requests the vaccine series at a later date.

      D.   The vaccination must be given at a reasonable time and place, be performed by or under
           the supervision of a licensed physician and provided according to the recommendations
           of the U.S. Public Health Service. All laboratory tests for antibody testing shall be
           conducted at no cost to the employee. Participation in pre-screening program shall not be
           a prerequisite for receiving Hepatitis B vaccination (or other vaccine).




                                     12
      E.   The CDC is the U.S. Public Health Service (USPHS) agency responsible for issuing
           guidelines and making recommendations regarding infectious agents. OSHA requires
           employers to follow the CDC guidelines current at the time of the evaluation or
           procedure. Copies of the current guidelines and other CDC documents can be obtained
           on CDC's web site, http://www.cdc.gov.

           The hepatitis B vaccination must be given in the standard dose and through the standard
           route of administration as recommended in the USPHS/CDC guidelines. The most
           current CDC guideline regarding Hepatitis B is Updated U.S. Public Health Service
           Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and
           Recommendations for Postexposure Prophylaxis published in Morbidity and Mortality
           Weekly Report Vol 50, No. RR-11, June 29, 2001.

           It states that employees who have ongoing contact with patients or blood and are at
           ongoing risk for percutaneous injuries are to be tested for antibody to Hepatitis B surface
           antigen, one to two months after the completion of the three-dose vaccination series.
           Employees who do not respond to the primary vaccination series must be revaccinated
           with a second three-dose vaccine series and retested, unless they are HbsAg-positive
           (infected). Non-responders must be medically evaluated.

11.   EXPOSURE INCIDENT REPORTING, EVALUATION AND FOLLOW-UP

      A.   Any exposure incident (e.g., needle stick, mucous membrane or open wound
           contamination) shall be promptly reported, investigated, and documented by the
           employee's - student's section supervisor and routed to the Department Chair, who is the
           facility exposure incident evaluator.

      B.   First Aid Incidents

           All first aid incidents involving exposure are reported to the employer before the end of
           the work shift during which the incident occurs.

           Reports of first aid incidents must include the names of all first aid providers and a
           description of the circumstances of the accident, including date and time, as well as a
           determination of whether an exposure incident, as defined in the standard, has occurred.

                 Exposure reports must be included on a list of such first aid incidents that is
                  readily available to all employees and provided to OSHA upon request.

                 First aid providers must receive training under the Bloodborne Pathogens
                  Standard that covers the specifics of the reporting procedures.

                 All first aid providers who render assistance in any situation involving the
                  presence of blood or other potentially infectious materials, regardless of whether
                  or not a specific exposure incident occurs, must have the vaccine made available
                  to them as soon as possible but in no event later than 24 hours after the exposure
                  incident. If an exposure incident as defined in the standard has taken place, other
                  post-exposure follow-up procedures must be initiated immediately, per the
                  requirements of the standard.

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C.   All precutaneious injuries from contaminated sharps must be logged on the sharp's injury
     log. Confidentiality of the injured employee - student must be insured. Included on the
     log must be the:

     1.     Type and brand of device involved in the incident,

     2.     Department or unit where the exposure incident occurred, and

     3.     Explanation of how the incident occurred. All records must be maintained for 30
            years.

D.   Post-exposure medical evaluation and follow-up will be made available immediately at
     no cost, to any employee who has experienced an occupational exposure incident. Post-
     exposure evaluations and management must be confidential and provided according to
     the U.S. Public Health Service recommendations. Student evaluation from an injury
     exposure is a unit's internal policy.

E.   The exposed employee will be offered blood collection and/or testing. This individual
     has the right to refuse either or both. However, if the exposed person gives consent for
     blood collection but not for HIV testing, the blood will be kept for 90 days, during which
     time the exposed person can choose to have the sample tested. In addition, laboratory
     tests performed in connection with an evaluation must be conducted at no charge to the
     exposed individual, including serological testing; i.e., HBV antibody titer and HCV
     antibody titer. Student blood collection and/or testing is a unit's internal policy.

F.   The exposed employee will have the choice of obtaining their medical evaluation with
     appropriate lab studies at the medical advisor of their choice, their personal physician's
     office, or a local emergency room. A physician with HIV expertise or consultant HIV
     physician will be promptly available for preliminary evaluation and counseling upon
     request. Then, the exposed individual can make an informed choice regarding post-
     exposure medical evaluation and treatment This exposed individual, additionally, will
     have counseling and evaluation of any related, reported illnesses. Student evaluation
     from an injury exposure is a unit's internal policy.


     UNIT'S MEDICAL ADVISOR: _____________________________________
     LOCATION: ____________________________________________________
     ADDRESS: _____________________________________________________
     TELEPHONE NO.: _______________________________________________


G.   The confidential medical evaluation should include at least the following:

     1.     Documentation of the route of exposure. And the circumstances under which the
            exposure incident occurred.

     2.     Identification and documentation of the exposure source, unless it can be
            established that identification is not feasible or prohibited by state or local law.

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           3.     Consent obtained from the exposure source and having the source individual's
                  blood tested as soon as possible for hepatitis (HBV), HIV or other appropriate
                  infectivity. If consent is not obtained, the head of the department must show that
                  legally required consent could not be obtained. The source person's blood need
                  not be tested if the source individual's HIV, HBV, etc., infection status is known.

           4.     Results of the source individual's testing shall be made available to the exposed
                  individual, and the exposed individual also be informed of the confidentiality laws
                  protecting these results.

      H.   The Administrator shall ensure that the healthcare provider receive the appropriate
           incident report.

      I.   The medical advisor shall obtain and provide the exposed employee with a copy
           professional's written opinion within 15 days. Student evaluation from an injury
           exposure is a unit's internal policy.

           1.     The healthcare professional's written opinion for vaccination shall be limited to
                  whether vaccination is indicated for the exposed individual, and if that individual
                  received such vaccination.

           2.     The healthcare professional's written follow-up shall be limited to the following:

                  a)      A statement that the exposed individual has been informed of the results of
                          the evaluation; and

                  b)      A statement that the exposed individual has been told about any medical
                          conditions resulting from exposure to biological agents, blood or other
                          potentially infectious materials which may require further evaluation or
                          treatment,

           3.     All other findings or diagnosis shall remain confidential and shall not be included
                  in the written report.

      J.   Post-exposure prophylaxis must be offer to the exposed employee - student (internal
           unit's policy) as recommended by the U.S. Public Health Services. These may include
           Hepatitis B immune globulin (HBIG), Hepatitis B Vaccine, and/or other prophylactic
           anti-viral treatment for HIV. The recommendations of the current CDC guidelines on
           post-exposure prophylaxis treatment for HIV should be followed in the event of HIV
           exposure. Student evaluation from an injury exposure is a unit's internal policy.

12.   LABELS AND SIGNS

      A.   Each section supervisor shall ensure for their work - instructional section that biohazard
           labels shall be affixed to entry doorway, containers, refrigerators, storage areas and
           freezers containing biological agents, blood materials, other potentially infectious
           materials, and other containers used to store, transport, or ship biological agents, blood,
           and other potentially infectious materials.

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      B.   The universal biohazard symbol shall be used. The label shall be fluorescent orange or
           orange-red color.

      C.   Red bags or red sharp containers may substitute for labels. However, regulated wastes
           must be handled in accordance with applicable rules and regulations of the State
           Department of Health and county's wastes regulations.

13.   INFORMATION AND TRAINING

      A.   The Department will be responsible for assuring that personnel receive training at the
           time of initial assignment (10 days within assignment) to tasks where occupational -
           instructional exposure may occur, and that training shall be updated every twelve month.

      B.   When modifications of tasks or procedures occur after the training, the supervisor shall
           provide for additional necessary training. When necessary, the training program will be
           modified to accommodate the educational or language level of the employee.

      C.   Training will be done at no cost to the employee - student and will be conducted during
           working - instructional hours or the employee - student will otherwise be compensated
           for the time in training, as per union contracts - student's rights. Student training should
           be part of their curriculum.

      D.   Only departmental personnel designated by the department will be provided with
           Biological Agents and Bloodborne Pathogens Exposure training. The person(s)
           conducting the training shall be knowledgeable in the subject manner.

      E.   Training records shall be maintained for three years from the date of training. These
           rosters will include the dates of the training sessions, an outline or summary describing
           the materials presented, the names and qualifications of persons conducting the training,
           and the names, signatures, and job titles of all persons attending the training sessions.

      F.   Training will be interactive and cover the following:

           1.     Explanation of the HiOSH standard's contents;

           2.     Discussion of the epidemiology and modes of transmission of biological agents
                  and bloodborne pathogens;

           3.     Explanation of Department's Biological Agents and Bloodbome Pathogen
                  Exposure Control Plan, location and availability of copies of this plan;

           4.     Recognition of tasks that may involve exposure;

           5.     Explanation of the use and limitations of methods to reduce exposure such as
                  engineering controls, work practices, and the use or personal protective
                  equipment;




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           6.     Information on the types, use, location, removal, handling, decontamination, and
                  disposal of PPE's;

           7.     An explanation of the basis of selection of PPE's;

           8.     Information on Hepatitis B vaccination (or other appropriate vaccination),
                  including efficacy, safety, methods of administration, benefits, and that it will be
                  offered free of charge;

           9.     Explanation of the procedures to follow in the event of an accidental exposure to
                  biological agents, blood or potentially infectious materials, including reporting,
                  evaluation, and follow-up;

           10.    Explanation of the signs, labels and color-coding systems.

           11.    New safer needle technologies.

      G.   Annual Bloodborne Pathogen Refresher training can be done on-line via Web Based
           Computer Training (WebCT). All questions or concerns are interactive to UH EHSO at
           biosafe@hawaii.edu or 956-3197.

14. RECORDKEEPING

      A.   Confidential medical records are kept for all employees and students with occupational or
           instructional exposure for the duration of employment or tenure plus 30 years.

      B.   The information in these files related to exposure will not be disclosed or reported
           without the involved individual's written consent except as required by law.

      C.   Medical records or laboratory studies obtained for exposures will be maintained by the
           practitioner or agency conducting the evaluation and/or providing care.

      D.   All employee - student, as records required by HiOSH Standard Chapter 205 and OSHA
           29 CFR 1910.20 will be provided upon request for examination and copying to the
           subject employee - student, to anyone with written consent of the individual, and to the
           authorized representatives of the Director of the State Department of Labor and Industrial
           Relations and U.S. OSHA, Assistant Secretary of Labor.

15.   PLAN REVISIONS, EVALUATION, AND REVIEW

      A.   The administrator and/or UH Medical Director will be responsible for annual review and
           revisions of the Plan, as well as evaluation of its effectiveness; including changes in
           technology that eliminate or reduce exposure to bloodborne pathogens, document
           annually consideration and implementation of appropriate commercially available and
           effective safer medical devices designed to eliminate or minimize occupational or
           instructional exposure.

      B.   This plan will also be revised whenever necessary to reflect new or modified tasks,
           procedures, exposures, rules that affect occupational - instructional exposure and to

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             reflect new or revised employee - student positions with occupational - instructional
             exposure, at the University Health Services, CDC and Public Health Services
             recommendation and State and Federal law changes.

      C.     Solicited input from non-managerial employees responsible for direct clinical,
             occupational, or instructional use who is potentially exposed to injuries from
             contaminated sharps in the identification, evaluation, and selection of effective
             engineering and work practice controls. All solicitation must be documented.

16.   SPECIFIC EXPOSURE CONTROL PLAN FORMS

      A.     Hepatitis B Immunization Form

      B.     Blood and Body Fluid Exposure Report

      C.     Needlestick and Sharp Object Injury Report

      D.     Post-Exposure Follow-Up

17.   FORMS DISTRIBUTION

      All forms must be distributed to the following:

      1. Worker's Compensation Forms to Unit's Personnel Officer

      2. Medical Records and Forms to Unit's Personnel Officer

             Hepatitis B Immunization Form
             Exposure Incident
             Post Exposure Incident,
             Blood and Body Fluid Contact)

      3. Needlestick/Sharp Injury Log to EHSO Biological Safety Program.

18.   APPENDIX

      A.     Table 1. Bloodborne Pathogens.

      B.     Exposure Source Evaluation Guidelines

      C.     Information Sheet for an Exposed Person About Hepatitis B, Hepatitis C, and HIV

      D.     Immediate Treatment of the Exposed Person

      E.     Protocol for Post-Exposure to Biological Agents, Blood, Body Fluids and Other
             Potentially Infectious Materials - Faculty and Staff.

      F.     Protocol for Post-Exposure to Biological Agents, Blood, Body Fluids and Other
             Potentially Infectious Materials - Students

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19.   REFERENCE

      1.   OSHA Bloodborne Pathogen Standard - 29 CFR 1910.1030
                http://www.osha-slc.gov/OshStd_data/1910_1030.html

      2.   OSHA-Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens
           - http://www.osha-slc.gov/OshDoc/Directive_data/CPL_2-2_69.html

      3.   Updated U.S. Public Health Service Guidelines for the Management of Occupational
           Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis
           Morbidity and Mortality Weekly Report (MMWR )- Recommendations and Reports,
           June 29, 2001/Vol. 50/No. RR-11
                  http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf




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