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Bloodborne Pathogens Exposure Control Plan

Download a copy of the Bloodborne Pathogens Exposure Control Plan (PDF)


Boise State University is committed to minimizing individuals’ potential occupational exposure to bloodborne pathogens (BBP) through the use of engineering controls, administrative controls and as necessary, personal protective equipment (PPE). Bodily fluids will be referred to in this plan as OPIM, other potentially infectious materials. The Exposure Control Plan is written to eliminate or minimize exposure for all employees who may have the potential for occupational exposure to BBP. The plan complies with all applicable federal and state laws regarding blood- borne pathogens.

Exposure Determination

This program applies to occupations on campus that have been identified as having a potential occupational exposure to BBP and OPIM. Occupations that could be at risk for blood-borne pathogens may include but is not limited to:

  • Campus Security
  • Childcare Services
  • Janitorial/Custodial Staff
  • Athletic Trainers
  • Health Care Workers in Student Health
  • Research and Academic Laboratory Workers Handling Human Blood, Tissues, Cell Cultures and OPIM

Based on each groups’ exposure and job type they will be trained in the use of universal precautions to include the use of gloves, one-way masks for CPR, eye protection and the use of biohazard disposal containers for contaminated materials. For those employees where the risk of occupational exposure is reasonably anticipated, the identified members will be provided the opportunity to be immunized for the Hepatitis B virus. Individuals working in childcare will be offered the Twinrix Hepatitis A, Hepatitis B combination vaccine. In the event of an occupational exposure employees will be given the opportunity for a post exposure evaluation for Hepatitis B and/or HIV.

Universal Precautions

Because of the unknown origin of blood and OPIM, we must consider these materials as infectious. When working with or around blood or OPIM always protect yourself first. Personal Protective Equipment; (PPE) will be provided for you by the University. This may include gloves, gowns, lab coats, face shields, masks, eye protection, and pocket masks for CPR. PPE will be of the appropriate size and type and will always be made available. PPE will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through or to reach work clothes, street clothes, skin, eyes, mouth or mucous membranes under normal conditions of use and duration.

Disposable gloves are not to be washed or decontaminated. Replace them as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Utility gloves can be decontaminated if the integrity of the glove is not compromised. Spray them with a 1 to 10 part solution of household bleach and water, and allow to air dry.

In the event of a potential exposure you must remove your contaminated PPE and wash the effected area with soap and running water as soon as practical. Flush eyes and other mucous membranes with water if they have come in contact with potentially infectious materials.

If you are wearing gloves and come into contact with BBP or OPIM, remove your gloves and wash your hands as described above.

Remove all PPE before leaving the area. Place in a designated area for storage, washing or disposal and wash your hands thoroughly. This will decrease the opportunity for cross contamination into other areas of the campus.

Contaminated Sharps

Sharps are objects that can penetrate a worker’s skin, such as needles, scalpels, broken glass, capillary tubes and the exposed ends of dental wires. If blood or OPIM are present or may be present on the sharp it is considered contaminated. The suitable PPE must be worn and the sharp must be disposed of appropriately.

When possible, use sharps that have self-shielding or retractable needles.

Contaminated needles and other contaminated sharps should not be bent, recapped or removed. Shearing or breaking of contaminated needles is prohibited.

Sharps need to be collected separately from other wastes. Containers for bio-hazardous sharps must be red, puncture resistant and labeled as “Bio-Hazardous”. The sides and bottoms of the containers must be leak proof and designed to keep people from being able to reach in where sharps have been placed. If a sharps container is found to be leaking, it must be double bagged, removed from service, and disposed by following campus bio-hazardous disposal procedures.

Never touch broken glassware or sharps with your bare hands. Instead, they shall be cleaned up using a brush and dustpan, tongs or forceps.

The Bloodborne Pathogens Standard only applies to occupational exposure to blood and OPIM. Sharps generated by employees for personal medical issues are not managed by the University. Individuals generating their own sharps waste for personal medical needs are encouraged to provide their own rigid, sealable container for sharp waste disposal.

Labeling and Disposal

Warning labels shall be affixed to containers of bio-hazardous waste, refrigerators and freezers containing blood or OPIM, and other containers used to store or transport blood or OPIM.

In the event a bio-hazard label is not available, red/orange bags or red/orange containers may be substituted as long as they are labeled “Bio-Hazardous”.

Bio-hazardous waste is either taken offsite by a vendor or decontaminated by a method such as autoclaving in accordance with applicable Federal & State regulations to effectively destroy BBP. The costs for bio-hazardous waste containers and disposal will be charged to the Environmental Health and Safety department except for Auxiliaries, which will be billed separately.

Small amounts of medical waste (ie. a few bandages or a single gauze pad) can be thrown in a wastebasket, but more than a handful should be handled and disposed of in the red biohazard containers. If blood is present in such quantities that it drips, or if after drying, it is capable of flaking off and becoming airborne, then the blood is classified as medical waste and it must be collected in a red/orange biohazard container.

Once waste has been collected store the waste in your designated bio-hazardous waste area until it can be picked up by the vendor. In the event that you generate waste but do not have a regularly scheduled pick up, please contact the EH&S office and they will help you schedule the removal.

Best Practices

All procedures involving blood or OPIM shall be performed to minimize splashing, spraying, spattering or generation of droplets.

Mouth pipetting of any materials is strictly prohibited.

If laundry is contaminated it requires minimal handling with appropriate PPE. If there is a likelihood of leakage the materials should be double bagged to prevent leaking and exposure. Laundry should be bagged at the site in a color coded bag, and/or labeled as “Bio-Hazardous”. Contact the laundry service to ensure the facility is aware of the contamination and ensure the bags are appropriately labeled. Laundering and disposal of PPE will be at no cost to the employee.

Specimens must be kept in containers with leak proof sides and bottoms during collection, handling, processing, storage and shipping. Containers must be labeled as “Bio-Hazardous” and color coded. If the specimen could puncture the primary container then you need a secondary container that is puncture resistant and leak proof, labeled and color coded.

If the outside of the primary container becomes contaminated, it must be placed in a secondary leak proof container that is then labeled “Bio-Hazardous” and color coded.

Equipment which becomes contaminated must be decontaminated. If it is not feasible to decontaminate, the equipment must be labeled with red/orange bio-hazardous stickers indicating which portions remain contaminated. In this event all individuals working with the equipment must be trained on this hazard and increased risk and what precautions must be taken. Once the equipment has been decontaminated the label can be removed.

All worksites need to be maintained, clean and sanitary including labs and clinics conducting blood work, childcare, and athletics. In the event of a spill of blood or OPIM all equipment and working surfaces must be cleaned and decontaminated. A solution of 1 part bleach to 10 parts water should be used to decontaminate the area.

All bins, pails, cans and receptacles intended for reuse which have a reasonable likelihood for becoming contaminated shall be inspected and decontaminated on a regularly scheduled basis. They should be cleaned immediately if there is open visible contamination.

All PPE will be repaired or replaced by the University to ensure its effectiveness.

In labs or work areas where there is a potential for contamination, food and drink shall not be kept in refrigerators, freezers, on shelves, countertops and bench tops where potential infectious materials are present. Eating, drinking and application of cosmetics, lip balm or handling of contact lenses should not be completed in areas where there is a reasonable likelihood of occupational exposure.

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

Containment Equipment

Biological safety cabinets and other safety protective devices and clothing shall be used for all activities with other potentially infectious materials that pose a threat of exposure to droplets, splashes, spills or aerosols.

Biological safety cabinets shall be certified when installed or moved and annually thereafter.

Annual Training

All Boise State employees who have the potential to have an occupational exposure to BBP will participate in a training program which will be provided at no cost to the employee and conducted during working hours. Training shall be provided at the time of initial assignment to tasks where potential occupational exposure may take place and at least annually thereafter. Additional training will occur for individuals when changes such as modifications of tasks or procedures or institution of new tasks or procedures affect the employee’s potential occupational exposure. The training will comply with the recommendations set forth in the Idaho Division of Building Safety General Health and Safety Standards 330.

Hepatitis B Vaccination

Hepatitis B or the Twinrix A/B Vaccination will be made available to all employees or student employees who have the potential for exposure, or post exposure. Anyone with an exposure will have an opportunity for a post exposure evaluation and follow up with medical personnel through St. Luke’s Occupational Health at 703 Americana Blvd Suite 130. St. Luke’s is the University’s medical provider for all workers compensation claims. The vaccination series will be offered after BBP training and within 10 days of initial assignment unless the person has already received the vaccination and antibody testing reveals they are immune, or the vaccine is contraindicated.

Student employees participating in SHIP (Student Health Insurance Program) may be vaccinated at University Health Services at no cost to them or the University. Both the Hepatitis B and the Twinrix A/B vaccinations are covered 100% when completed at Health Services.

Employees of the University that participate in the PPO plan can receive either Hepatitis B, or the Twinrix A/B immunization service on campus through University Health Services in the Norco building. Through the PPO plan the costs are not subject to the copay or deductible and are paid in full. These vaccinations may also be conducted with individuals’ personal physicians; however a record of the vaccination will need to be given to the department manager.

If an employee has already participated in the vaccination series they will need to provide a copy of the vaccination record to their manager. If they believe they have participated, but they have no record, they may have their blood drawn and have their titers checked to see if they have any antibodies to HBV. The cost for this service is not the responsibility of the University. If the titer comes back negative, and no record of the vaccination can be found, the individual can either begin the series of the vaccination or request a booster of vaccine which will provide some level of protection from the virus, both of which will be paid for by the University.

Individuals can decline the vaccination but participate later if desired.

Post Exposure Evaluation and Follow Up

Following a report of exposure Boise State University will make available a confidential medical evaluation with St Luke’s’ Occupational Health Clinic. St Luke’s will comply with the recommendations set forth in the Idaho Division of Building Safety General Health and Safety Standards 330. Payment for these appointments and a post exposure prophylaxis if medically indicated will be the responsibility of Boise State University.

Boise State University shall obtain and provide the employee with a copy of the evaluating health care professional’s written opinion within fifteen (15) days of the completion of the evaluation.

Updated Plan

The Blood-borne Pathogens program and Exposure Control Plan will be reviewed annually to ensure its contents are compliant with the Idaho Division of Building Safety General Health and Safety Standards 330 and OSHA 1901.1030.