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Title: Bloodborne Pathogens
Subject: Health and Safety 
Policy No: HS: 2013:03 
Applies: University-wide 
Issuing Authority: Vice President, Health Sciences
Responsible Officer: Vice President, Health Sciences(signature)
Adopted: 10/15/13
Last Revision: 1/29/15

Last Reviewed: 1/29/15


The purpose of this policy is to establish procedures that will ensure compliance with the Occupational Safety and Health Administration's (OSHA) "Bloodborne Pathogens Standard" (29 CFR 1910.1030) as promulgated by the New Jersey Public Employees Occupational Safety and Health Act (PEOSHA).


Under the direction of the Deans, Associate Deans and Department Chairs shall ensure compliance and implement this policy. The Director of Environmental and Occupational Health and Safety Services (EOHSS) shall assist with implementation of this policy by providing guidance and technical assistance to SOM and patient care facilities.


This Bloodborne Pathogens policy applies to the following Potentially Infectious Materials:

  1. Human body fluids: blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, 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).
  3. HIV or HBV-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. (Bloodborne pathogens as they relate to the use of animal blood may also be covered by the policies of the University's research animal care facilities).


  1. Bloodborne pathogens shall refer to pathogenic micro-organisms that are present in human blood and can cause disease in humans. These pathogens shall include, but not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
  2. Engineering Controls shall mean controls, which by design, isolate or remove the bloodborne pathogen hazard from the workplace (e.g. sharps disposal containers, self-sheathing needles).
  3. Occupational Exposure shall be used to refer to reasonably anticipated or inadvertent 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.


A. Requirements:

The primary focus of this policy is to establish procedures, in accordance with OSHA's "Bloodborne Pathogens Standard" (29 CFR 1910.1030), that will protect RowanSOM staff and employees from the hazards related to occupational exposures to bloodborne pathogens and other potentially infectious materials. As such, this policy will supplement, not supersede, the existing RowanSOM policy on HIV, HBV and HCV developed to provide a safe work and learning environment for RowanSOM staff, students, faculty, and house staff.

  1. RowanSOM and its patient care facilities shall be responsible for developing standard operating procedures which will establish compliance with this policy. For the purposes of this policy, these standard operating procedures shall be known as an "exposure control plan".
  2. This policy shall be reviewed on an annual basis, or more frequently as new information arises.

B. Procedures:

  1. Exposure Control Plan:
    1. RowanSOM and its patient care facilities shall ensure that a written "Exposure Control Plan" is developed and implemented. This plan will function as a standard operating procedure; describing the procedures and/or programs established by that specific school or unit to eliminate or minimize employee exposure to bloodborne pathogens and other potentially infectious materials. In some cases, departmental "exposure control plans" may have to be developed. This would especially be the case for those departments whose risk of exposure is moderate, high and/or unique. In those cases where departmental "exposure control plans" are developed, it is recommended that they be modeled after the school/facility plan.
    2. The Exposure Control Plan shall minimally consist of the following components:
    3. An Exposure Determination for those titles within RowanSOM/facility:
      1. including a list of all job titles in which all employees have occupational exposure (as defined in this policy).
      2. including a list of all job titles in which some employees in that title have occupational exposure. For these titles, a list of all tasks and procedures (or groups of closely related tasks and procedures) in which occupational exposure occurs shall also be included.
    4. Descriptions or copies of specific programs, policies, or procedures implemented at each school or patient care facility to address the requirements in this policy.
    5. RowanSOM and its patient care facilities shall ensure that the Exposure Control Plan is accessible to its employees for examination.
    6. The Exposure Control Plan shall be reviewed and updated, by RowanSOM representatives (e.g., school/unit safety committee) at least annually and, whenever tasks, procedures, or titles are modified such that risk of exposure to bloodborne pathogens change.
  2. Universal Precautions:
    As required by the existing RowanSOM Policy on HIV, HBV, and HCV patient care facility and all employees shall comply with the Universal Precautions Guidelines as established by the Centers for Disease Control and the New Jersey Department of Health Infection Control Standards for Hospitals (NJAC 8:43G-14.1(b) 2). 
  3. Engineering Controls:
    1. RowanSOM will be responsible for reviewing and implementing available engineering controls. Engineering Controls refer to controls, which by design, isolate or remove bloodborne pathogen hazard from the workplace (e.g. sharps disposal containers, self-sheathing needles). In those cases where engineering controls have been implemented to the extent feasible and occupational exposure risk remains, other methods of controlling or minimizing occupational exposure, including personal protective equipment shall also be used.
    2. Engineering controls shall be maintained and evaluated periodically to ensure their continued effectiveness.
  4. Work Practices and Hygiene:
    RowanSOM shall establish general work practices that will eliminate or minimize employee exposures. These may include, but not limited to:
    1. Hand washing techniques and requirements;
    2. Procedures for handling and disposal of contaminated needles and sharps;
    3. Lists of prohibited activities. (For example, eating, drinking, and handling contact lenses in those work areas where there is potential for exposure, or storage of food in locations where blood or other potentially infectious material are present.);
    4. Procedures to minimize splashing, spraying, spattering, generation of droplets, etc. during tasks which involve blood or other potentially infectious materials; and
    5. Procedures for decontamination of contaminated equipment before servicing, shipping or disposal.
  5. Personal Protective Equipment:
    1. RowanSOM shall identify the specific procedures and/or tasks where personal protective equipment is required to prevent exposure to bloodborne pathogens. Specific descriptions of the personal protective equipment required for each task or procedure shall be included in the school's or patient care facility's Exposure Control Plan. For example, employees who transport specimens from clinics or patient care areas to laboratories may be required to wear gloves and laboratory coats. This requirement should be specified in the facility's Plan.
    2. Each school/unit shall be responsible for providing personal protective equipment identified as essential to job performance at no cost to the employee. Personal protective equipment may include, but not limited to, gloves, gowns, laboratory coats, face shields and eye protection, mouthpieces, and resuscitation bags.
    3. Each school/unit shall ensure that personal protective equipment is accessible and available in sufficient quantities and appropriate sizes.
    4. Each school/unit shall be responsible for cleaning, laundering, replacing and disposing of personal protective equipment as necessary.
  6. Housekeeping:
    1. RowanSOM shall ensure that an appropriate written schedule for cleaning and decontaminating different work areas and surfaces, based upon the location within the facility, type of surface to be cleaned, types of contamination present, and tasks or procedures being performed in the area, is established and implemented in each of their departments.
    2. RowanSOM shall ensure that all equipment and environmental and working surfaces are cleaned and decontaminated appropriately after contact with blood or other potentially infectious materials.
    3. RowanSOM shall ensure that regulated waste is maintained, labeled, and disposed of in accordance with the University Regulated Medical Waste policy.
  7. Hepatitis B Vaccination and Post-Exposure Evaluation:
    1. As required by the RowanSOM Policy on HIV, HBV and HCV, all house staff, faculty and staff who have direct patient contact, (as defined in the RowanSOM Policy on HIV, HBV and HCV), or who have contact with potentially infectious body fluids or laboratory materials must be immunized against hepatitis B or be able to demonstrate immunity. In accordance with the standard, each school/unit shall be responsible for establishing procedures such that all employees who have occupational exposure can obtain hepatitis B vaccinations at no cost to them. The vaccination shall be made available after the employee has received training in accordance with this policy (see Section 9 of this policy) and, within 10 working days of assignment to duty, unless immunity has been established or the vaccine is contraindicated for medical reasons.
    2. Confidential medical evaluation and follow-up shall be made immediately available to employees after an exposure incident is reported.
  8. Labels and Signs:
    1. Warning labels in accordance with the PEOSH/OSHA Bloodborne Pathogens standard shall be affixed to containers or regulated waste, refrigerators and freezers containing blood or other potentially infectious materials Exhibit A.
    2. PEOSH/OSHA bloodborne pathogens labels/signs must also be posted at the entrances to work areas conducting HBV and HIV research.
  9. Training:
    1. Each school/unit shall ensure that all employees with occupational exposure participate in a training program on Bloodborne Pathogens with the following frequency:
      1. At initial assignment;
      2. Annually;
      3. When changes that affect the employee's occupational exposure occur.
    2. Training shall include as a minimum:
      1. An explanation of the contents of the PEOSH/OSHA Bloodborne Pathogens Standard and information on how a copy of the standard may be obtained if requested;
      2. A general explanation of the epidemiology and symptoms of bloodborne diseases;
      3. An explanation of the modes of disease transmission;
      4. A review of RowanSOM's Exposure Control Plan and the steps that the employee can take to obtain a copy of it;
      5. An explanation of the appropriate methods that can be used to recognize and evaluate tasks and activities with potential exposure;
      6. An explanation of the use and limitations of the different methods of control including, but not limited to, engineering controls, work practices and personal protective equipment;
      7. Information on the types, proper use, location, removal, handling and disposal of personal protective equipment and the basis for selection of the different types of equipment;
      8. Information on the appropriate actions and procedures to follow if an exposure occurs;
      9. Information on the hepatitis B vaccine including efficacy, safety, and that the vaccine will be free of charge;
      10. An explanation of the signs and labels required by the standard;
      11. An opportunity for interactive questions and answers; and
      12. Additional training for employees in HIV and HBV research laboratories which is specific to the practices and operations of the laboratory.
  10. Recordkeeping:
    1. RowanSOM shall ensure that medical records for each employee with occupational exposure are maintained for the duration of employment and 30 years thereafter. Each school/unit shall ensure confidentiality of employee medical records. The medical records shall include:
      1. Hepatitis B vaccination status; including the dates of vaccination.
      2. A copy of all results of post-exposure medical evaluations.
      3. Copies of any information provided to the physician(s) performing medical evaluations related to this policy and the PEOSH/OSHA bloodborne pathogens standard.
    2. Training records shall be maintained by each school and patient care unit and EOHSS. The records shall include training dates, contents of training, names and qualifications of instructors, and names and titles of the employees attending the training. These training records shall be maintained a minimum of 3 years.
  11. HIV and HBV Research:

Each school/unit engaged in the culture, production, concentration, experimentation and manipulation of HIV and HBV shall comply with the requirements outlined for HIV and HBV research laboratories in PEOSH/OSHA's "Bloodborne Pathogens Standard" (29 CFR 1910.1030, paragraph (e)). These requirements, including mandates for hand and eye washing facilities as well as autoclaves for decontamination of regulated waste, shall be adhered to in addition to the requirements already outlined in this policy.


A. Attachment 1, Occupational Exposure to Bloodborne Pathogens


Occupational Exposure to Bloodborne Pathogens 

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