Emergency Operation Plan: Bloodborne Pathogens Exposure Control Plan (ECP)

Bloodborne pathogens such as HBV and HIV can present workplace risks when you have potential exposure to blood or other infectious materials. Understanding these requirements helps you reduce risk, respond appropriately to incidents and maintain a safe, compliant work environment.

1. Authority

In accordance with the Texas Health and Safety Code, Chapter 81, Subchapter H, and analogous to OSHA Bloodborne Pathogens Standard (29CFR 1910.1030) and enforced by the Texas Department of State Health Services (DSHS), East Texas A&M University has developed this Exposure Control Plan to eliminate or minimize occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other blood-borne pathogens.

2. Definitions

The following terms are defined as follows:

  • Blood: human blood, human blood components, and products made from human blood.
  • Bloodborne Pathogens: pathogenic microorganisms that are present in human blood and 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 workplace where diagnostic or other screening procedures are per- formed 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 sharps injury: Any sharps injury that occurs with a sharp used or encountered in a health care setting that is contaminated with human blood or body fluids.
  • 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.
  • Employee: An individual who works for a governmental unit or on premises owned or operated by a governmental unit whether or not he or she is directly compensated by the governmental unit.
  • Employs: Engages the services of employees.
  • Engineered sharps injury protection: A physical attribute that:
    • (A) is built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids and that effectively reduces the risk of an exposure incident by a mechanism, such as barrier creation, blunting, encapsulation, withdrawal, retraction, destruction, or another effective mechanism; or
    • (B) is built into any other type of needle device, into a non-needle sharp, or into a non-needle infusion safety securement device that effectively reduces the risk of an exposure incident.
  • Engineering Controls: means controls (e.g., sharps disposal containers, self-sheathing needles) that isolates or removes the bloodborne pathogens hazard from the work place.
  • Exposure incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.
  • Governmental unit: This state and any agency of the state, including a department, bureau, board, commission, or office and includes:
    • (A) a political subdivision of this state, including any municipality, county, or special district; or
    • (B) Any other institution of government, including an institution of higher education.
  • Hand washing Facilities: means a facility providing an adequate supply of running potable water, soap and single use towels or hot air-drying machines.
  • Licensed Healthcare Professional: is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post exposure Evaluation and Follow-up.
  • HBV: Hepatitis B virus.
  • HCV: Hepatitis C virus.
  • Health care professional: A person whose legally permitted scope of practice allows him or her to independently evaluate an employee of a governmental unit and determine the appropriate interventions after an exposure incident; this would include hepatitis B vaccination and post exposure evaluation and follow up.
  • HIV: Human immunodeficiency virus.
  • Needleless system: A device that does not use a needle and that is used:
    • (A) to withdraw body fluids after initial venous or arterial access is established;
    • (B) to administer medication or fluids; or
    • (C) for any other procedure involving the potential for an exposure incident.
  • Occupational exposure: A reasonably anticipated skin, eye, mucous membrane, or par- enteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
  • Other Potentially Infectious Materials (OPIM):
    • The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any bodily fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
    • Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
    • HIV containing cell or tissue cultures, organ cultures, and HIV or HBV containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
  • Parenteral: piercing mucous membranes or the skin barrier through such events as needle sticks, 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 hazard are not considered to be personal protective equipment.
  • Regulated Waste: liquid or semiliquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semiliquid 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.
  • Regulated waste/special waste from health care-related facilities: Solid waste which if improperly treated or handled may serve to transmit an infectious disease(s) and which is composed of the following:
    • (A) animal waste;
    • (B) bulk blood, bulk human blood products, or bulk human body fluids;
    • (C) microbiological waste;
    • (D) pathological waste; or
    • (E) sharps.
  • 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 volume found in production facilities.

3. Responsibilities and Implementation

Although the Department of Environmental Health and Safety (EHS) is charged with the overall responsibility to develop and implement the University’s exposure control plan, several other University departments will provide vital support in the effort to adequately protect University employees with potential occupational exposure and to achieve regulatory compliance with the Texas DSHS requirements.

Individual departments will be responsible for ensuring that the provisions of the University’s exposure control plan and the mandates of the Texas DSHS bloodborne pathogen standard are carried out.

The Texas A&M University System Risk Management department and the Department of Environmental Health and Safety have determined positions with potential occupational exposure. Training is available within TrainTraq, course number 2111525, for all employees.

4. Exposure Determination

The Texas Department of Health Bloodborne Pathogens Rule requires employers to perform an exposure determination for employees with potential occupational exposure to blood or other potentially infectious materials (OPIM). The exposure determination is made without regard to the use of personal protective equipment (PPE). This exposure determination is required to list all job classifications in which employees have potential for occupational exposure, regardless of frequency.

The departments in which University employees have potential for occupational exposure associated with the requirements of their normal employment are listed below:

  • Art
  • Athletics
  • Biological & Environmental Sciences
  • Campus Recreation
  • Chemistry
  • College of Agricultural & Natural Resources
  • Farm & Dairy
  • Environmental Health and Safety
  • Engineering & Technology
  • Facilities & Construction
  • Health & Human Performance
  • Nursing
  • Office of Research & Sponsored Programs
  • Physics & Astronomy
  • Residential Living & Learning
  • Sam Rayburn Student Center
  • Student Health Services
  • Theatre
  • Transportation
  • University Police
  • Additional Employees that are deemed Vulnerable and/or High Risk

5. Compliance Methodology

5.1 Control Methods / Universal Precautions

Standard methodology instructs employees that all blood, body fluids or other potentially infectious materials are to be considered infectious regardless of the perceived status of the source individual.

Engineering Controls: Important in eliminating or minimizing employee exposure to bloodborne pathogens, and reducing employee exposure in the workplace by either removing or isolating the hazard or isolating the worker from exposure. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.

Engineering control equipment includes:

  • sharps disposal containers
  • autoclave
  • disposable resuscitation equipment
  • disposable pipette bulbs
  • biological safety cabinet (a.k.a., bio-hood)
  • needleless systems
  • sharps with engineered sharps injury protection for employees

Additional engineering controls used throughout the facility include:

  • Hand washing facilities which are readily accessible to all employees who have exposure to blood or OPIM.
  • Antiseptic towelettes or waterless disinfectant when proper hand washing facilities are not available.

Work Practice Controls: When employees have an occupation exposure, standard practices shall be established by the department by which a task is performed.

  • Employees wash hands and any other potentially contaminated skin area immediately after glove removal. Employees wash hands as soon as possible with soap and water when waterless disinfectants have been used first.
  • Whenever an employee’s skin or mucous membranes have been exposed to blood or OPIM, the affected area is washed with soap and water or flushed with water as appropriate as soon as possible.
  • Contaminated needles and sharps are not bent, broken, recapped, removed, sheared or purposely broken. They are discarded immediately in a container that is closable, leak-proof, puncture resistant and biohazard labeled or color-coded.
  • Contaminated, reusable sharps are placed in a puncture-resistant, leak-proof container, properly labeled or color-coded, until they can be processed. The employee shall use the appropriate protective equipment to remove these reusable sharps for decontamination.
  • During use, containers for contaminated sharps are easily accessible to personnel; located as close as is feasible to the immediate area where sharps are being used or can be reasonably anticipated to be found; maintained upright throughout use; are not allowed to be overfilled; and replaced routinely.
  • Eating, drinking, applying cosmetics or lip balm, smoking or handling contact lenses is prohibited in working areas where occupational exposure may occur.
  • Mouth pipetting/suctioning is prohibited.
  • Food and drink are not kept in refrigerators, freezers, shelves, cabinets or on counter-tops or bench tops where blood or OPIM are present.
  • All procedures in which blood or OPIM are present are performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these materials.

5.2 Collection of Specimens

  • Specimens of blood or OPIM are placed in a container, which prevents leakage during the collection, handling, processing, storage, transport or shipping of the specimens.
  • The container used to collect specimens is labeled with a biohazard label or color-coded unless universal precautions are used throughout the procedure and the specimens and containers remain in the facility. If the specimen containers are sent to another facility, a biohazard or color-coded label is affixed to the outside of the container.
  • Specimens of blood and other potentially infectious body substances or fluids are usually collected within a clinic, doctor's office or laboratory setting. These specimens are appropriately labeled to indicate the contents and other pertinent information.
  • If outside contamination of the primary container occurs, the primary container is placed within a secondary container, which prevents leakage during the handling, processing, storage, transport or shipping of the specimen. The secondary container is labeled with a biohazard label or color-coded.
  • Any specimen that could puncture a primary container is placed within a secondary container that is puncture-proof.

5.3 Contaminated Equipment

  • At times it is inevitable that equipment will become contaminated with blood or OPIM.
    • Equipment is decontaminated prior to handling or servicing, unless the decontamination of the equipment is not feasible.
    • Contaminated equipment is labeled with a biohazard label.
  • If equipment cannot be decontaminated, DO NOT USE.

5.4 Personal Protective Equipment (PPE)

When occupational exposure remains after instituting engineering controls and work practice controls, personal protective equipment is used.

  • Personal protective equipment (PPE) is provided by the university without cost to the employee.
  • PPE is considered appropriate only if it is fluid resistant and does not permit blood or other OPIM to pass through or reach the employee's clothing, skin, eyes, mouth or other mucous membranes under normal conditions of use for the duration of time which the PPE is used.
  • Examples of PPE include:
    • Gloves
    • Gowns
    • Laboratory coats
    • Masks
    • Face shields
    • Eyewear with side shields
    • Mouthpieces
    • Resuscitation bags, pocket masks or other ventilation devices
    • Aprons
    • Shoe covers
  • All PPE is cleaned, laundered and disposed of by the university at no cost to the employees. All repairs and replacements are made by the university at no cost to the employees.
  • PPE shall be utilized whenever contact with blood or other OPIM may occur.
    • Gloves are worn whenever it is reasonably anticipated that hand exposure to blood, OPIM, non-intact skin or other mucus membranes may occur.
    • If the employee is allergic to certain kinds of gloves, hypoallergenic gloves or other alternatives will be provided.
    • Disposable gloves will not be re-used and will be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured or compromised.
    • Utility gloves can be decontaminated for re-use only if the gloves do not have any punctures, cracks or tears. They are discarded if they are cracked, peeling, torn, punctured, deteriorated, etc.
    • Masks in combination with eye protection devices are worn whenever splashes, spray, splatter or droplets of blood or OPIM may be generated and eye, nose or mouth contamination can reasonably be anticipated.
    • Appropriate protective body coverings such as gowns, aprons, caps and/or shoe covers are worn when gross contamination can be reasonably anticipated.
    • All garments that are penetrated by blood are removed immediately or as soon as feasible.
    • Personal protective equipment is removed before leaving the work area and after a garment becomes contaminated.
    • Used protective equipment is placed in appropriately designated areas or containers when being stored, washed, decontaminated or discarded.

5.5 Housekeeping Procedures

  • Supervisors must ensure that the work site is maintained in a clean and sanitary condition.
  • The Department must determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location with the facility, the type of surface to be cleaned, type of soil present and tasks or procedures being performed in the area.
  • All contaminated work surfaces are decontaminated after completion of procedures, immediately or as soon as feasible after any spill of blood or OPIM, and at the end of the work shift.
  • Protective coverings (e.g., plastic wrap, aluminum foil, etc.) used to cover equipment and work surfaces are removed and replaced as soon as feasible when they become contaminated or at the end of the work shift.
  • Bins, pails, cans and similar receptacles are inspected and decontaminated on a regularly scheduled basis.
  • Any broken glassware that may be contaminated is not picked up directly with the hands. A tool such as forceps is used to pick up the glass fragments for disposal.

5.6 Regulated Waste Disposal

  • All contaminated sharps are discarded as soon as feasible in sharps containers located as close to the point of use as feasible in each work area.
  • Regulated waste other than sharps is placed in appropriate containers that are closable, leak resistant, labeled with a biohazard label or color-coded and closed prior to removal. If outside contamination of the regulated waste container occurs, it is placed in a second container that is also closable, leak proof, labeled and closed prior to removal.
  • All regulated waste is properly disposed in accordance with state and federal requirements.

5.7 Laundry Procedures

  • Laundry contaminated with blood/bloody body fluids or OPIM is placed in a biohazard bag or color-coded laundry bag.
  • Contaminated laundry is decontaminated at the work site by autoclaving, washing with hot soapy water and bleach, or other acceptable method of treatment.

6. Hepatitis B Vaccination Program

  • All employees who have been identified as having potential occupational exposure to blood or OPIM are offered the hepatitis B vaccine (HBV) by the University at no cost to the employee.
  • The vaccination program is administered under the supervision of a licensed physician or licensed healthcare professional as a component of the Occupational Health Program.
  • The HBV is offered during bloodborne pathogen training and within 10 working days of their initial assignment where occupational exposure could occur unless the employee has previously received the complete HBV series, antibody testing has revealed that the employee is immune or that the vaccine is contraindicated for medical reasons.
  • Those employees who are occupationally at risk of having an exposure will receive the HBV at a healthcare facility contracted by the University or their primary care provider.
  • Vaccination is offered with post vaccination laboratory screening to assess immune status.
  • Employees who decline the HBV must sign a Declination of Vaccination Statement (Appendix A). Employees who later elect to receive the HBV may then have the vaccine provided at no cost.
  • Any necessary booster doses of the HBV are provided by the employer at no cost to the employee.

7. Post Exposure Evaluation and Follow-Up

  • If an employee suffers an occupational exposure, the employee must report the incident to their supervisor and submit a completed Incident Report to the Office of Human Resources within 24 hours of the incident.
  • The employee is offered a confidential medical evaluation and follow up that includes:
    • Documentation of the route(s) of exposure and the circumstances related to the incident.
    • Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law. After obtaining consent, unless law allows testing without consent, the blood of the source individual should be tested for HIV/HBV infectivity.
    • The results of testing of the source individual are made available to the exposed employee with the employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual.
    • The employee is offered the option of having their blood collected for testing of the employee's HIV/HBV serological status. The blood sample is preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status. If the employee decides prior to that time that the testing will be conducted, then testing is done as soon as feasible. (NOTE: In order for medical expenses associated with future development of disease resulting from this exposure to be compensable as a Worker's Compensation Insurance claim, the employee must have their blood tested within 10 days of the exposure to demonstrate absence of disease at the time of the exposure.)
    • The employee is offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service.
    • The employee is given appropriate counseling concerning infection status, results and interpretations of tests, and precautions to take during the period after the exposure incident. The employee is informed about what potential illnesses can develop and to seek early medical evaluation and subsequent treatment.
    • The unit head or supervisor of an employee with occupational exposure is designated to assure that the East Texas A&M University Exposure Control Plan is followed and maintain records required by the Plan.

8. Interaction with Healthcare Professionals

  • A written opinion is obtained from the healthcare professional when an East Texas A&M University employee is sent to obtain the HBV, or when an East Texas A&M University employee is evaluated after an exposure incident. In order for the healthcare professional to adequately evaluate the employee, the healthcare professional is provided with:
    • a copy of the East Texas A&M University Exposure Control Plan
    • a description of the exposed employee's duties as they relate to the exposure incident
    • documentation of the route(s) of exposure and circumstances under which the exposure occurred
    • results of the source individual's blood tests (if available)
    • medical records relevant to the appropriate treatment of the employee
  • Healthcare professionals should limit their written opinions to:
    • whether the HBV is indicated
    • whether the employee has received the vaccine
    • the evaluation following an exposure incident
    • whether the employee has been informed of the results of the evaluation
    • whether the employee has been told about any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment (all other findings or diagnosis shall remain confidential and shall not be included in the written report)
    • whether the healthcare professional's written opinion is provided to the employee within 15 days of completion of the evaluation

9. Use of Biohazard Labels

Biohazard warning labels and/or color-coding are used to identify any work area or object that has the potential to be exposed to blood or other infectious materials. Labels are placed on such objects as: sharps containers; specimen containers; contaminated equipment; regulated waste containers; contaminated laundry bags; refrigerators and freezers containing blood or OPIM; and containers used to store, transport, or ship blood or OPIM.

10. Training

  • Training for identified employees with the potential for occupational exposure will be assigned through TrainTraq.
  • Annual refresher training is provided within one year of the employee's previous training.
  • Training will include an explanation of the following:
    • Title 25 Health Services, Part 1 Texas Department of Health, Chapter 96 Bloodborne Pathogen Control;
    • OSHA Bloodborne Pathogen Final Rule;
    • epidemiology and symptomatology of bloodborne diseases;
    • modes of transmission of bloodborne pathogens;
    • how to recognize tasks and activities that may place employees at risk of exposure to blood or OPIM;
    • the East Texas A&M University Bloodborne Pathogens Exposure Control Plan;
    • the use and limitations of work practices, engineering controls, and personal protective equipment;
    • the types, selection, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;
    • the employee's responsibility to reduce the risk of exposure to bloodborne pathogens for oneself and for co-workers;
    • the Hepatitis B Vaccination Program;
    • procedures to follow in an emergency involving blood or OPIM;
    • procedures to follow if an exposure incident occurs to include U.S. Public Health Service; Post Exposure Prophylaxis Guidelines;
    • post exposure evaluation and follow up;
    • warning labels and signs, where applicable, and color-coding;
    • an opportunity to ask questions of the EHS office.
  • Additional training is given as new information is acquired or job duties change.

11. Recordkeeping

  • Employee medical records shall include:
    • the employee’s name and social security number or university identification number;
    • Hepatitis B vaccination status, including the dates of all the HBV vaccinations;
    • a copy of all results of examinations, medical testing and follow-up procedures related to an occupational exposure;
    • the employer's copy of the healthcare professional's written opinion;
    • a description of the employee's duties as they related to the exposure incident;
    • a description of the route of exposure and the circumstances under which exposure occurred;
    • results of the source individual's blood testing, if available.
  • Confidentiality of medical records is maintained.
  • Employee medical records are maintained at the Office of Human Resources in the employee's personnel file.
  • Employee medical records are maintained in accordance with the System Records Retention Schedule.
  • Training records are maintained by the employer in the employee's personnel files for at least three years from the date on which the training occurred. Training records include:
    • the dates of the training sessions;
    • the contents or a summary of the sessions;
    • name(s) and qualifications of the person(s) conducting the training if not TrainTraq;
    • names and job titles of those in attendance.

12. Contaminated Sharps Reporting

In accordance with the requirements of the Texas Bloodborne Pathogens Rule, injuries from contaminated sharps must be reported to the Texas Department of State Health Services (DSHS). A contaminated sharp includes, but is not limited to, a needle, scalpel, lancet, broken glass or broken capillary tube used or encountered in a healthcare setting that is contaminated with human blood or body fluids.

The Contaminated Sharps Injury Reporting Form located in Appendix B of this document must be completed within 24 hours of the incident. The Reporting Form must be submitted to Human Resources along with an Employee Incident Report. Provide copies of both reports to the Environmental Health & Safety Office. The EHS Department will submit a copy of the Contaminated Sharps Injury Reporting Form to the Texas Department of State Health Services. The responsible governmental agency for Health Service Region 11 (HSR11) is located at the Regional Sub-Office:

  • 5155 Flynn Parkway
  • Corpus Christi, Texas
  • Office: 361.888.7837
  • Fax: 361.883.9942

The injury must be reported to DSHS no later than ten working days after the end of the calendar month in which the contaminated sharps injury occurred.

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