[Major revision–posted 1/10/25 (replaces 7/5/22 edition)]
[PDF Version]

Texas Tech University Double T

Operating Policy and Procedure

OP 60.24: Bloodborne Pathogen Protection Program

DATE: January 10, 2025

PURPOSE: The purpose of this Operating Policy/Procedure (OP) is to protect individuals from anticipated exposure to bloodborne pathogens, which include Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV). The purpose of this plan is to provide safe work practices to prevent exposure of Texas Tech University employees and contractors whose job descriptions necessitate performing tasks that would result in occupational exposure to bodily fluids or other potentially infectious materials (OPIM) as defined in 29 CFR 1910.1030.

REVIEW: This OP will be reviewed every two years after publication by the Assistant Vice President for Environmental Health & Safety (EHS) with substantive revisions forwarded through the Associate Vice President for Research to the Vice President for Research & Innovation and the Provost and Senior Vice President.

POLICY/PROCEDURE

1. References

Title 29 Code of Federal Regulations § 1910.1030 (29CFR1910.1030) and Centers for Disease Control Biosafety in Microbiological and Biomedical Laboratories

2. Introduction

Exposure to blood and other bodily fluids can lead to numerous clinical diseases. Hepatitis B Virus (HBV) and the Human Immunodeficiency Virus (HIV) are examples of pathogens that can be transmitted via blood and other bodily fluids. These agents are referred to as bloodborne pathogens; because they can cause serious illness or death, operational guidelines must be followed to protect workers against exposures. This program includes the use of “universal precautions” for all human blood and other potentially infectious materials (OPIM).

3. Scope and Application

The Bloodborne Pathogen Exposure Control Plan (ECP) covers all Texas Tech University employees and contractors who could be “reasonably anticipated” to be exposed to human materials, such as bodily fluids, while conducting their job duties. The ECP details procedures for identifying occupational exposures to bloodborne pathogens, work practice controls such as personal protection and technology that eliminates or reduces exposure, housekeeping requirements, training, and medical surveillance.

The requirements of this program apply to all Texas Tech University employees, contract workers, and employees of firms working at locations where Texas Tech University has management control. However, the program does not address employees willingly responding to emergencies by choice (e.g., giving CPR involving blood and other bodily fluids). In addition, this program does not address employees whose immune systems are currently and/or previously impaired because of HIV or from other causes.

4. Terms and Definitions

Most of the terms and definitions in this program are taken from 29CFR1910.1030, “Occupational Exposure to Bloodborne Pathogens,” 1996.

a. “Blood” means human blood, human blood components, and products made from human blood.

b. “Bloodborne pathogens” means pathogenic microorganisms that are present in human blood that can cause disease in humans. These pathogens include, but are not limited to, HBV and HIV.

c. “Bloodborne Pathogen Exposure Control Plan” (ECP) means the Texas Tech University written program to prevent employee exposure to bloodborne pathogens in the workplace.

d. “Contaminated” means the presence or the reasonably anticipated presence of blood or OPIM on an item or surface.

e. “Decontamination” means 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.

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

g. “Exposure incident” means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that result from the performance of an employee’s duties.

h. “FDA” means Food and Drug Administration.

i. “Handwashing facilities” means a facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines.

j. “HBV” means Hepatitis B Virus.

k. “HIV” means Human Immunodeficiency Virus.

l. “Laboratory” means a workplace where diagnostic or other screening procedures are performed on blood or OPIM.

m. “Occupational exposure” means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee’s duties.

n. “Other potentially infectious materials” (OPIM) include human and non-human primate 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 bodily fluids in situations where it is difficult or impossible to differentiate between bodily fluids; any unfixed tissue or organ (other than intact skin) from a human; and HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing organisms, culture medium, or other solutions, and blood, organs, or other tissues from experimental procedures.

o. “Personal protective equipment” (PPE) is 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.

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

q. “Sharps” means any object that can penetrate the skin including, but not limited to, hypodermic needles, scalped blades, microtome blades, razor blades, lancets, dental scalers, broken glass, pipettes, capillary tubes, and exposed ends of dental wires.

r. “Universal precautions” is an approach to infection control. According to the concept of universal precautions, all human blood and OPIM are presumed to be infectious and treated as such.

s. “Work practice controls” means controls that reduce the likelihood of exposure by altering the way a task is performed (e.g., prohibiting recapping of needles by two-handed technique).

5. Responsibilities

a. The primary responsibilities of department heads and chairs are to:

(1) Be familiar with this program and its contents and objectives;

(2) Support the program and oversee its implementation;

(3) Implement proper administrative and engineering controls in the work area; and

(4) Develop a department procedure for any activity involving potentially infectious material.

b. Responsibilities of managers and supervisors are to:

(1) Be familiar with this program and its contents and objectives;

(2) Know where blood or OPIM are used, produced, stored, or handled in any manner in the department;

(3) Identify employees and non-TTU workers who may be at risk of exposure and implement this program. Risk is determined by reviewing each task related to fulfilling an employee’s job description that could result in exposure. Managers are expected to consult with EHS if there is a question regarding risk of exposure;

(4) Review and update the exposure information annually or more often, if necessary, to accommodate changes in tasks;

(5) Ensure employees and non-TTU workers are trained before beginning specific tasks involving blood or OPIM;

(6) Identify and develop safety procedures when work activities involve risk of exposure to blood and OPIM. Procedures for spills, waste disposal, decontamination, and accident response procedures must be developed by each department;

(7) Determine which employees are at risk of occupational exposure and require them to enroll in the Occupational Health Program, if necessary;

(8) Provide the correct personal protective equipment at no cost to employees who work with blood or bloodborne pathogens; and

(9) Monitor the work area for changing tasks and make corrections as needed.

c. Texas Tech University employees and non-TTU workers will:

(1) Be familiar with this program;

(2) Conduct each task in accordance with their training and standard operating procedure (SOP);

(3) Follow established university procedures;

(4) Complete the required university and duty-specific training before starting work;

(5) Participate in the Occupational Health Program as required;*

(6) Use PPE, work practice controls, and engineering controls as required; and

(7) Report to their manager or supervisor any deficiencies or exposures.

d. Environmental Health & Safety is responsible for:

(1) Developing and implementing the ECP;

(2) Giving guidance on how to package waste contaminated with blood or OPIM;

(3) Providing bloodborne pathogen awareness training to all Category A and B TTU personnel;

(4) Making training available online;

(5) Conducting work-site surveys and informing departments of results;

(6) Approving the department's SOP;

(7) Advising employees of the proper PPE;

(8) Administering the Occupational Health Program for university employees; and

(9) Providing required labels and signage.

6. Employee Exposure Determination

Employees, and non-TTU workers performing the same tasks, in Categories A and B below are considered reasonably anticipated to be exposed to blood or OPIM.

a. Category A – Moderate to High Risk Exposure

(1) Research and clinic technicians and laboratory personnel who work with bloodborne pathogens, human blood, or OPIM;

(2) Law enforcement officers;

(3) Athletic trainers; and

(4) Employees required to handle, clean up, and dispose of blood or OPIM.

b. Category B – Low to Moderate Risk Exposure

(1) Employees who may encounter raw sewage in their work;

(2) Childcare assistants; and

(3) Employees responsible for laundry cleaning.

c. Category C – No Risk to Low Risk Exposure

(1) Office staff;

(2) Employees who may solidify and clean up vomit in work areas; and

(3) Employees whose job description defines no task related to exposure.

d. Category D – Unclassified Risk Exposure

(1) This exposure will be determined by EHS on a case-by-case basis.

7. Employee Protection

a. If the determination is made that an individual is in the Category A or B exposure group or otherwise potentially subject to exposure, the department must follow the ECP.

b. Engineering controls will be used as a primary method to reduce work exposure (e.g., disposable bags, sharps containers, and self-sheathing needles).

c. Departments must provide, at no cost to the employee, and require employees to use equipment such as gloves, gowns, masks, and eye protection, as well as repair or replace those items when necessary.

d. Departments must launder, repair, and replace PPE items as necessary.

8. Workplace Practices

a. Individuals shall wash their skin immediately after removing gloves and after accidental contact with OPIM.

b. All PPE must be properly removed upon leaving the immediate work area.

c. All biohazardous materials (e.g., gloves, contaminated PPE) shall be segregated from other waste into biohazardous waste containers.

d. Used needles and other sharps shall not be bent, broken, recapped, or resheathed by hand.

e. Unsheathing sharps shall be done by a one-handed technique or bracing with a two-handed technique.

f. Eating, drinking, smoking, applying cosmetics, and handling contact lenses are prohibited in work areas where the potential for exposure exists.

g. Food and drinks shall not be stored in the same refrigerators or cabinets where blood or OPIM are stored.

9. Housekeeping

a. Work surfaces potentially contaminated with human blood or OPIM shall be decontaminated before beginning work and at the end of each day with an appropriate disinfectant.

b. Equipment shall be checked routinely and decontaminated before servicing or shipping.

c. All containers intended for reuse shall be inspected, cleaned, and disinfected on a regular schedule.

d. Broken glassware shall not be picked up by hand. Forceps or tongs should be used.

e. Specimens of blood shall be placed in a closeable, leak-proof container and labeled with the biohazard emblem and principal investigator or supervisor contact information for storage and transport.

10. Sharps

a. Sharps must be disposed of in an FDA-approved container. These containers are puncture-resistant, leak-resistant, and cannot be opened without great difficulty. The sharps container must always be kept in the immediate work area so transporting a sharp is not required.

b. Sharps containers must be red in color with biohazard labels.

c. Sharps containers are not to be filled beyond the fill line indicated on the container.

11. Training

a. All Category A and B employees and non-TTU workers who may be at risk of exposure will receive Bloodborne Pathogen Awareness training prior to potential exposure.

b. Individuals in Category A and B exposure groups will receive additional training as outlined below. Training will be provided annually and include the following:

(1) Information about the Bloodborne Pathogens standard;

(2) A general explanation of bloodborne pathogens;

(3) Modes of transmission;

(4) Methods for identifying tasks that may involve exposure to blood and OPIM;

(5) Practices that will prevent exposure, including engineering controls, work practices, and PPE;

(6) Information on the Hepatitis B vaccine;

(7) Response to emergencies involving blood or OPIM;

(8) How to handle exposures;

(9) Post-exposure evaluation and counseling for employees; and

(10) Signs, labels, and color-coding.

b. Training records must be maintained by the department for three years. They must include:

(1) Date and location of training;

(2) Contents of the training;

(3) Trainer's name; and

(4) Names and job titles of trainees.

c. Training shall be recorded and maintained by EHS.

12. Labeling and Signage

a. Biohazard warning labels shall be affixed to containers of infectious waste, refrigerators and freezers containing blood, and all other containers used to transport blood and OPIM.

b. These labels shall be orange or red with the word “BIOHAZARD” and the universal biohazard symbol in a contrasting color.

c. All infectious waste going for disposal shall be in closeable, leak-proof containers that are color-coded and labeled.

d. Disposal of all potentially infectious waste shall be in accordance with applicable federal, state, and local regulations.

e. Signs shall be posted at the entrance to work areas as specified in paragraph 1910.1030(e)(1), HIV and HBV Research Laboratory and Production Facilities, and will include special requirements for entering the area and the name and contact information of the principal investigator or other responsible person.

f. These signs shall be orange or red (or predominantly so) with lettering and symbols in a contrasting color.

13. Recordkeeping

a. Confidential health records shall be maintained for the length of employment plus 30 years.

b. Health records must include the employee’s name, social security number, Hepatitis B vaccination records, records of any exposure incidents, copies of all physical examinations, and a copy of the physician’s written opinion about past exposures.

c. Medical records must be made available to the employee and to anyone with written consent from the employee. These records are not available to the employer.

14. Medical Surveillance

a. Employees who have been identified as having an exposure to blood must have made available to them a Hepatitis B vaccination within 10 working days. This will include all individuals identified in Category A or B exposure groups. The boosters will be furnished to the employee at no cost. If there are boosters to be administered, they must be made available to the employee.†

b. Employees who have had an exposure must receive a follow-up evaluation at no cost to the employee. They must also file an incident report with the Office of Risk Management.‡

c. Employees must sign an Occupational Health Program Enrollment Form if they are determined to be in Category A or B exposure groups and be offered medical consultation to include a Hepatitis B vaccination prior to potential exposure.

15. References and Resources

a. 29 CFR 1910.1030 Bloodborne Pathogens

b. 29 CFR 1910.1020(e) Recordkeeping

* Only applies to TTU employees who are in Category A or B exposure group (section 6)

† Note that non-TTU employees must receive similar care from their employer.

‡ Note that non-TTU employees must receive similar care from their employer.

Operating Policies & Procedures

Address

Texas Tech Downtown Center Room 218
Email
officialpublications@ttu.edu

Operating Policies & Procedures

Operating Policy and Procedure

OP Categories

Contact TTU

News

Events

Operating Policies & Procedures

Address

Email