Infectious Disease Control Program
A. What is the purpose of the program?
The center for Disease Control and the Tennessee Occupational Safety and Health Administration have determined that employees in any occupation where they are directly exposed to body fluids are considered to be at substantial risk of occupational exposure to HIV (human immunodeficiency virus) and/or HBV (hepatitis B virus). The following program establishes UTC's rules to protect the employees from occupational exposure to such bloodborne diseases.
B. Who does the program apply to?
This program applies to all employees who have contact with human blood or body fluids while performing their duties at UTC. Everyone in the following job titles are specifically included:
- Athletic Trainer
- Children's Center Employees
- Campus Police
- Arena Security
- School of Nursing faculty
- Student Health Services
Some of the employees in the following job classifications may have occupational exposure to human blood or body fluids depending upon their specific duties:
- Physical Plant Plumbers
- Housing Maintenance Staff
- Housekeeping Staff
In job functions where occupational exposure may occur, it will be the responsibility of the department head to identify the particular tasks which would subject the employee to potential exposure.
Employees in job classifications not listed but who may experience exposure shall be identified by their departments.
Although not covered under CFR 1910.1030 (Bloodborne Pathogens), visitors and students of the University are protected by specific rights. Where potential exposure may exist, students and visitors will be made aware of this exposure. HBV vaccinations will be made available to students and visitors at their own expense.
C. What materials does the program apply to?
The program applies to contact with human blood and other potentially infectious materials including semen, vaginal secretions, cerebrospinal fluid, synovial fluid, amniotic fluid, saliva in dental procedures and any body fluid visibly contaminated with blood.
The program does not apply to feces, nasal secretions, sputum, sweat, tears, urine, vomitus or saliva unless they contain visible human blood.
D. What are the procedures to be followed?
- Universal Precautions
Universal precautions shall be followed at all times. That means that all body fluids are assumed to be infected with HBV and/or HIV, and all employees exposed to direct contact with body fluids must be protected as though such body fluids are known to be infected.
- Personal Protective Equipment
Personal Protective Equipment shall be worn during all contact with body fluids. Bloodborne pathogens can enter the body of a worker through a needle stick injury, through contact of non-intact (i.e. chapped or cut) skin with infected blood or through a splash of infected blood to the eye, nose or mouth of the employee. The personal protective equipment listed below must be worn to prevent entry of infectious material into the body.
- Disposable latex or vinyl gloves shall be worn during patient / blood contact. Gloves shall be discarded and hands washed immediately after each patient contact
- Small, medium, and large gloves are available. Employees shall wear the correct size of gloves.
- Nurses shall use fluid-resistant disposable gowns when splashes to the clothing with body fluids may occur such as when drawing human blood or when treating a patient with profuse bleeding.
- Masks and eye protection shall be worn when splashes to the face may occur such as when drawing human blood or when treating a patient with profuse bleeding.
- An EPA approved hospital disinfectant shall be used to decontaminate spills of human blood or body fluids. UTC shall use either a 1:10 dilution of bleach or approved disinfectant.
- A human blood spill shall be wiped up first, then the surface decontaminated with Clorox or approved disinfectant.
- Surfaces where procedures involving human blood or body fluids have been conducted, such as table tops or bench tops, shall be cleaned and disinfected after each procedure and at the end of the shift.
- Waste Disposal
- Needles shall never be recapped, purposely bent or broken, removed from disposable syringes or in any way manipulated by hand.
- All sharps shall be placed in puncture-resistant containers after use.
- All waste materials including sharps contaminated with human blood or body fluids shall be placed in containers or bags labeled with the word BIOHAZARD (or the biological hazard symbol).
- Disposable infectious waste shall be picked up by Stericycle Industries on an as-needed basis. DO NOT place infectious waste in regular trash. When you need disposal service, contact the Department of Safety & Risk Management at ext. 5209.
- Reusable Equipment
- All linen contaminated with human blood or body fluids shall be transported in bags labeled with the word BIOHAZARD.
- Soiled linen shall be bagged at the location where it is used and shall not be rinsed or handled before bagging.
- If leaking of the bag is possible, a second bag shall be used as reinforcement.
- Hepatitis B Vaccination
- All employees in the job titles listed in Section B shall be offered hepatitis B vaccinations.
- Vaccinations shall be given at Workforce Corperate Health.
- Vaccinations shall be given free of charge.
- Vaccinations are optional but are encouraged as the best means of protection against hepatitis B.
- Follow-up Procedure
- Follow-up procedures shall be initiated by the Department of Safety and Risk Management when any of the following incidents occur:
- If an employee has a needle stick or a cut with a sharp instrument used on a patient.
- A splash of human blood or body fluids to the eyes, nose or mouth.
- Contact of human blood or body fluids to workers chapped or abraded skin.
- Documentation of the following:
- Route of exposure
- The identity of the source patient
- The circumstances of the exposure, i.e. how it happened
- Collection and testing of the source patient's blood for HIV and HBV if possible
- Collection and testing of the affected worker's blood for HIV and HBV immediately
- Medical evaluation of the employee by a physician at the University's current workers compensation medical provider
- If the initial HIV test is negative, further testing for HIV six weeks, 12 weeks, and six months post exposure.
- If the worker has not been vaccinated against HBV or the antibody response is not adequate, post exposure prophylaxis including treatment with immune globulins and the hepatitis B vaccine shall be provided under the direction of a physician.
- Information and Training
Employees in the job titles listed in Section B shall receive training, which includes the following:
- A copy of the current regulations from TOSHA
- A general explanation of the epidemiology and symptoms of HIV and HBV
- An explanation of the modes of transmission of HIV and HBV.
- An explanation of the infection control program at UTC.
- An explanation of how to determine if a task will fall under this program.
- An explanation of the importance of universal precautions and other work practices to reduce worker exposure.
- An explanation of the availability, proper use, and disposal of personal protective equipment including the specific circumstances under which PPE is to be worn.
- An explanation of the follow-up procedure to follow if actual contact with human blood or body fluids occurs.
- An explanation of the labels and signs used.
- An explanation of the proper clean up of human blood spills.
- An explanation of proper disposal of contaminated items
- An explanation of the sterilization procedures for reusable equipments.
- An explanation of the risks and benefits of vaccination for HBV, and how to obtain same.
The accomplishment of this training will be the responsibility of the departments listed in Section B. The Department of Safety and Risk Management can assist with this training by supplying training assistance and training aids.
- Record Keeping
Records of exposure including route of exposure, identity of human blood source, and circumstances of exposure shall be maintained in the office of the Department of Safety & Risk Management. Additionally, records of all follow-up procedures will be kept in the office of the Department of Safety & Risk Management. All exposure records will be maintained for 30 years.
Records of both vaccination and the declination of vaccination for hepatitis B will be maintained in the office of the Department of Safety & Risk Management as well as the employee's department.
TOSHA requires that new employees in any department under Section B of this plan be trained and offered Hepatitis B vaccinations within 10 working days of their employment date (see Section D, Paragraph 9). Existing employees are required to be re-trained annually. A record of each training session shall be kept for three years by the Department of Safety and Risk Management as well as the department for which they are employed. The record shall include the following information:
- The dates of the training session.
- A summary of the contents of the session.
- The names and qualifications of the trainers.
- The names and job titles of all persons being trained.
Sharps Injury Prevention Plan
- To control employee needle stick/sharps injuries.
- To comply with OSHA, state regulations, requirements for a sharps safety program.
- To monitor sharps injury data and establish trend information.
- To establish an evaluation and implementation program for needle safety devices.
Sharps Injury Data Management
Data will be collected on all employees sustaining sharps injuries where there is any potential for exposure to bloodborne pathogens such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV), or other identified bloodborne pathogens.
Source of Sharps Injury Data
Reporting of sharps injuries and other blood/body fluid exposures is done as outlined in this plan.
It is the responsibility of the employee to immediately report any sharps injury to their supervisor.
It is the responsibility of the employee's department head to assure that the employee receives appropriate medical attention and that the incident is reported to the Office of Safety & Risk Management.
Data collection and Analysis
The data to be collected for employee sharps injuries includes:
- Employee Name
- Location of Injury
- Time and Date of Injury
- Activity at the time of injury
- Type and brand of device
- Purpose of device
- Use of PPE when injury occurred
- Notation of signs of visible blood on device
- Specific circumstances associated with injury
- Identification of source (if known) and source status related to bloodborne diseases
- Medical evaluation data is to be maintained for a period of 30 years by the medical provider.
- Identify sharps devices (including traditional devices, safety, needle less, etc.)
- Identify work locations with the greatest number of injuries and the devices causing the greatest number of injuries
- Select alternative devices to replace those identified with sharps injuries. Conduct staff education. Implement the use if safety devices that are found to be acceptable
Once a device has been evaluated and determined to be appropriate for use the product will be made available for use by all employees as applicable.
The educational program content will consist of information on safety features of the device and appropriate device usage. Staff education may be provided through:
- lectures with demonstrations/return demonstrations
- one on one preceptor training
- vendor assisted educational programs
- videos with live follow-up evaluation.
All records related to sharps injuries, including product evaluation, education and training on safety devices will be maintained for a period of three years as required by OSHA regulations (Federal Register vol. 56, No 235, p. 64181). Records will be kept in the files of the head of the department to which related employees are assigned.
Blood exposure data will be maintained for a period of 30 years beyond the date of last employment as required by the OSHA Bloodborne Pathogens Standard (Federal Register vol. 56, No 235, p.64181).
A record of each training session shall be kept by the Department of Safety and Risk Management as well as the department for which they are employed. The record shall include the following information:
- summary of program contents
- names and qualifications of persons conducting the training
- the names and job titles of persons attending the sessions.
- Acknowledgement of Training for Prevention of Bloodborne Disease Transmission
- Hepatitis B Vaccine Acceptance
- Hepatitis B Vaccine Declination