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Circular 92-04


DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
Public Health Service
Rockville, Maryland 20857

Refer to: OHP/OEHE

INDIAN HEALTH SERVICE CIRCULAR NO. 92-04

Effective Date:  05/15/1992

BLOODBORNE PATHOGEN EXPOSURE POLICY

  1. PURPOSE.  To establish responsibilities and procedures for protecting patients and personnel from bloodborne pathogens, e.g., human immunodeficiency virus, hepatitis B virus or other pathogens transmitted through contact with blood and body fluids.

  2. OBJECTIVES.

    1. To prevent the transmission of bloodborne pathogens from infected patients or visitors to healthcare workers.

    2. To protect Indian Health Service (IHS) patients and visitors to IHS healthcare facilities from being infected by bloodborne pathogens.

    3. To comply with Occupational Health and Safety Administration (OSHA) regulations at Title 29 of the Code of Federal Regulations, Subsection 1910.1030 (29 CFR, 1910.1030).

  3. SCOPE.  This circular applies to all IHS employees, including those assigned to Public Law (P.L) 93-638 facilities.  The law and implementing regulations apply to Indian Self-Determination Act, P.L. 93-638 and to Title V urban program contractors as employers.  Tribal contractors are strongly encouraged to adopt this circular.

  4. DEFINITIONS.

    Blood -- means human-blood, human blood components, and blood products made from human blood.

    Bloodborne Pathogens -- means 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).

    Body Substance Isolation -- is an infection control system where all body substances are considered to be potentially infectious.  It is equivalent to Universal Precautions.

    Clinical Laboratory -- means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

    Contaminated -- means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

    Contaminated Laundry -- means laundry or linen which has been soiled with blood or other potentially infectious materials or may contain sharps.

    Contaminated Sharps -- means any contaminated object that can penetrate the skin including, but not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

    Decontamination -- is a physical or chemical process to remove, inactivate, or destroy pathogens on a surface or item so that they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use or disposal.

    Engineering Controls -- means controls (e.g., sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.

    Exposure Incident -- means 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.

    Handwashing Facility -- means a facility providing an adequate supply of tempered running potable water, soap and single use towels or hot air drying machines.

    HBV -- means hepatitis B virus.

    Healthcare Professional -- means a physician or other licensed healthcare provider authorized to accomplish the evaluation procedures described in this policy, e.g., a registered nurse could be authorized to perform the required evaluation.

    HIV --- means human immunodeficiency virus Type-1.  Unless it is stated otherwise, all reference to HIV means HIV-1.

    IHS Facility -- means any IHS healthcare facility.  All contract facilities operated by a tribal organization under P.L. 93-638, “Indian Self-Determination and Education Assistance Act” or Urban Indian Health Centers are encouraged to adopt this IHS policy or shall develop equivalent policies which meet the minimum requirements of 29 CFR, 1910.1030.

    Occupational Exposure -- means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

    Other Potentially Infectious Materials -- means:

    1. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, urine (because of cytomegalovirus) any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;

    2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and

    3. The HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions.

    Parenteral -- means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

    Personal Protective Equipment -- is specialized clothing or equipment worn by an employee for protection against a hazard.  General work clothes (e.g. uniforms, pants, skirts, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

    Regulated Waste -- means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

    Source Individual -- means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.  Examples include, but are not limited to hospital and clinic patients, trauma victims, clients of drug and alcohol treatment facilities, and human remains.

    Sterilize -- means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

    Universal Precautions -- is an approach to infection control.  According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.  In the IHS, Body Substance Isolation may be used in place of Universal Precautions.

    Work Practice Controls -- means controls that reduce the likelihood of exposure blood or body fluids by eliminating a task or altering the manner in which a task is performed (e.g., prohibiting recapping of needles by two-handed technique).

  5. RESPONSIBILITIES.

    1. Headquarters Technical Consultant on Bloodborne Pathogens.  The Associate Director, Office of Health Programs (OHP), or designee, shall be the IHS technical consultant for the control of exposure to bloodborne pathogens.

    2. Area Technical Consultant on Bloodborne Pathogens.  The Area Chief Medical Officer (CMO) or designee, shall be the technical consultant for the service unit or P.L. 93-638 Program.  He/She shall act as consultant for the implementation of exposure control plans and other aspects of this policy.

    3. The Service Unit or P.L. 93-638 Program Director.  He/she shall assume responsibility for the implementation of the requirements of 29 CFR 1910.1030 at the local level.

  6. EXPOSURE CONTROL PLAN.  All IHS facilities and those operated by a tribal organization under P.L. 93-638 and urban Indian health centers shall have an Exposure Control Plan in accordance with 29 CFR, Subsection 1910.1030 (c).  See Appendix B for an example of a healthcare facility Exposure Control Plan.

    The Exposure Control Plan shall identify job classifications and tasks in which occupational exposure may occur.  Each IHS facility shall have departmental policies and procedures that cover tasks in which an occupational exposure may occur.  The procedures shall enumerate the correct steps to follow while performing such tasks to minimize any occupational exposure and to prevent contaminating other equipment or surfaces.

    1. Methods of compliance shall be based on Body Substance Isolation or Universal Precautions to prevent contact with blood or other potentially infectious materials.  Engineering and work practice controls shall be used to eliminate or minimize employee exposure.  Where a potential occupational exposure remains after applying controls, then personal protective equipment shall be used.

      1. Handwashing facilities shall be readily accessible to employees.  All personnel shall wash their hands and other skin with soap and water, or flush mucous membranes with water immediately or as soon as possible following contact of such body areas with blood or other potentially infectious materials.

      2. Contaminated needles and other contaminated sharps shall not be bent, cut, recapped or removed except as specified in Appendix B.

      3. Contaminated sharps shall be placed in appropriate puncture resistant, leak-proof containers, as specified in Appendix B, until properly reprocessed or disposed. Contaminated sharps containers shall be easily accessible to employees.

      4. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is reasonable likelihood of occupational exposure.

      5. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where blood or other potentially infectious materials are present.

        Specimens shall not be placed where medications are prepared or stored.

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

    2. Personal Protective Equipment (PPE).

      1. When a potential occupational exposure exists, the IHS facility administration shall provide, at no cost to the employee, appropriate PPE.

      2. Employees shall use appropriate PPE when the potential exists for occupational exposure.

      3. Appropriate PPE, as specified in Appendix B, shall be readily accessible at the worksite or issued to employees and shall be worn by employees.

      4. The IHS facility shall clean, launder, and dispose of PPE at no cost to the employee.

      5. The IHS facility shall repair or replace PPE as needed to maintain its effectiveness, at no cost to the employee.

      6. If a PPE is penetrated by blood or other potentially infectious materials the equipment shall be removed as soon as possible.

      7. All PPE shall be removed prior to leaving the work area.

      8. When PPE is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

    3. Housekeeping, Laundry and Instrument Reprocessing.

      1. IHS facilities shall be maintained in a clean and sanitary condition.

      2. Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.

        All new hospital construction and renovation shall be designed and equipped to isolate or eliminate hazards associated with reprocessing of contaminated instruments.

      3. Disposable contaminated sharps shall be discarded immediately in containers that are closable, puncture resistant, leak proof on sides and bottom and labeled or color coded.

      4. Other regulated waste shall be placed in containers which are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transportation or shipping.  The waste must be labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

        Note:  Disposal of all regulated waste shall be in accordance with applicable Federal or State regulations.

      5. Contaminated laundry shall be handled as little as possible to eliminate airborne contamination. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use.

      6. Laundry facilities shall be designed and operated to minimize occupational exposure and to ensure destruction or removal of all pathogenic agents. Refer to the IHS Health Facility Planning Manual and the Indian Health Manual Part 5, Chapter 10, Housekeeping, for additional information.

    4. Hepatitis B Vaccination and Post Exposure Evaluation and Follow-up.

      1. General.  Hepatitis B vaccination series shall be offered within 10 working days to all employees who have occupational exposure, and post-exposure evaluation and follow-up for employees who have had an exposure incident, at no cost to the employee.

        All employees who are offered and decline to accept hepatitis B vaccination shall sign a statement indicating their refusal.  A copy of the required statement is located in Appendix A.

        If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the hepatitis B vaccination shall be made available at that time.

        If a routine booster dose of hepatitis B vaccine is recommended by the United States Public Health Service at a future date, such booster doses shall be made available.

      2. Post-exposure Evaluation and Follow-up.  All incidents involving occupational exposure shall be reported, investigated, and documented in accordance with the Indian Health Manual, Part 1, Chapter 9, Occupational Health and Safety Program Management.  Following a report of an exposure incident, a confidential medical evaluation and follow-up, shall be made immediately available to the exposed employee.

      3. Healthcare Professional’s Written Opinion.  The employee shall be provided with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.  The healthcare professional’s written opinion for Hepatitis B vaccination shall be limited to whether vaccination is indicated for an employee, and if the employee has received such vaccination.

        The healthcare professional’s opinion for post-exposure evaluation and follow up is described in Appendix B.

    5. Communication of hazards to employees. Labels and signs.

        1. Biohazard labels shall be affixed to containers of regulated waste, refrigerators, and freezers containing blood or other potentially infectious materials; and other containers used to store, transport or ship blood or other potentially infectious materials.

        2. The Universal Biohazard Symbol shall be used.  The symbol is fluorescent orange or orange-red.  The background may be any color that provides sufficient contrast to be clearly defined.

        3. Red bags or containers may be substituted for labels.  However, regulated wastes must be handled in accordance with rules and regulations of the organization having jurisdiction.

        4. Blood products that have been released for transfusion or other clinical use are exempted from these labeling requirements.

      1. Information and Training.

        1. Training shall be provided at the time of assignment to tasks where occupational exposure may occur, and it shall be repeated annually.  It shall be tailored to the educational and language level of the employee, and offered during the normal work shift.  The training must be interactive and cover the information described in Appendix B.

        2. Employees who have received training on bloodborne pathogens in the year preceding the effective date of this policy shall only receive training in provisions of the policy that were not covered.

        3. Additional training shall be provided to employees when any changes of tasks or procedures affect the employee’s occupational exposure.

        4. The person conducting the training shall be knowledgeable in the subject matter.

        5. The use of a test to assess employee comprehension of subject matter is recommended.
    6. Recordkeeping.

      1. Medical Records.  Medical records shall be maintained in accordance with 29 CFR, 1910.20.  These records shall be kept confidential, be maintained for at least the duration of employment plus 30 years.

      2. Training Records.  Training records shall be maintained for 3 years and shall include the information described in Appendix B.

      3. Availability.  All employee records shall be made available to the Assistant Secretary of Labor for the OSHA and the Director of the National Institute for Occupational Safety and Health (NIOSH) upon request.

        All employee records shall be made available to the employee in accordance with 29 CFR, 1910.20.

      4. Transfer of Records.  If the IHS facility is permanently closed or there is no successor employer to receive and retain the records for the prescribed period, the Director of the NIOSH shall be contacted for final disposition.

    7. Exposure Control Plan Update.  The facility Exposure Control Plan shall be reviewed on an annual basis and revised as necessary.

  7. SUPERSESSION.  This is a new circular.  It modifies and supplements the Indian Health Manual, Part 1, Chapter 12, IHS Employee Immunization Program, D. Procedures, 2.  Additional Important Protection for Employees. b. Hepatitis B.

/Robert Marsland for/
Everett R. Rhoades, M.D.
Assistant Surgeon General
Director


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