TE-8 FM70-90 Annex K.doc

TECHNICAL EXHIBIT 8

ANNEX K

BLOODBORNE PATHOGENS EXPOSURE CONTROL PROGRAM

1. INTRODUCTION: This annex provides the FLETC Bloodborne Pathogen Exposure Control Plan. The purpose of these guidelines is to minimize employee and student exposure to bloodborne pathogens. They provide minimum requirements for procedures to prevent contact with blood or other potentially infectious materials (OPIM), and address the requirements of the Occupational Safety and Health Administration (OSHA) standard 29 CFR Part 1910.1030.

2. SCOPE: This Program applies to all FLETC locations and training sites, and contains elements that apply to all FLETC staff, Partner Organization representatives and staff, students, guests, and contractor personnel.

3. REFERENCES:

a. 29 CFR Part 1910.1030, Bloodborne Pathogens.

b. 29 CFR Part 1904.8 Recording Criteria for Needlestick and Sharps Injuries.

4. FORMS:

a. FLETC Form FTC-SVC-25, Hepatitis B Vaccination Record

b. FLETC Form FTC-SVC-41, Hepatitis B Vaccine Declination

5. DEFINITIONS:

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 and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV), Hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

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

d. Contaminated Laundry means laundry which has been soiled with blood or other potentially infections materials or may contain sharps.

e. 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.

f. 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.

g. Exposure Incident means a specific eye, mouth, or other mucous membrane, non-intact skin, or perenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

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

i. 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.

j. Other Potentially Infectious Materials (OPIM) means any body fluid that is visibly contaminated with blood or where it is difficult or impossible to differentiate between body fluids including any unfixed tissue or organ (other than intact skin) from a human (living or dead).

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

l. Personal Protective Equipment is specialized clothing or equipment worn or used by an employee for protection against a hazard such as CPR face shield and gloves.

m. Prophylaxis means measures designed to protect health and promote life and prevent the spread of disease. In the case of bloodborne pathogens this is the Hepatitis B vaccine, and the post exposure antiretroviral drugs and protease inhibitors.

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

o. Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

6. RESPONSIBILITES:

a. The FLETC Safety Programs Branch shall:

(1) Inform personnel of their rights and responsibilities under this Program.

(2) Ensure records of bloodborne pathogen training, related medical evaluations, and Hepatitis B vaccination records are kept in accordance with the Occupational Health and Safety Bloodborne Pathogen standard.

(3) Evaluate the facilities and types of operations for potential exposure to bloodborne pathogens including exposure determination for job classifications and job tasks.

(4) Evaluate any exposure incident and ensure medical follow-up evaluation is made available according to the Bloodborne Pathogen standard.

b. Division Chiefs shall ensure that:

(1) Personnel are informed of their rights and responsibilities under this Program;

(2) The Job Hazard Assessment (JHA) for their Division identifies potential occupational exposures to bloodborne pathogens;

(3) Affected personnel receive proper training; and

(4) Any exposure incidents are investigated, and that medical follow-up evaluations are available.

c. Employees shall know:

(1) Their rights and responsibilities under this Program;

(2) The potential exposure to bloodborne pathogens in their job tasks/training scenarios;

(3) The required proper training; and

(4) That any exposure incidents are investigated, and that medical follow-up evaluations are available and completed according to the Bloodborne Pathogen standard.

7. PROCEDURES:

a. Exposure Determination.

(1) It is the FLETC policy to wear protective equipment, however, exposure potential shall be determined without considering the use of personal protective equipment.

(2) In coordination with the Safety Programs Branch, each Division shall complete a JHA that identifies the potential occupational exposure to bloodborne pathogens.

(3) Employees who respond as trained lay rescuers to emergencies are considered to have the potential for occupational exposure.

b. Engineering and Work Practice Controls.

(1) Personnel shall observe “universal precautions,” and treat all body fluids as potentially infectious materials.

(2) All trauma bags and automated external defibrillator response kits shall have bloodborne pathogen kits/supplies.

(3) The FLETC shall provide hand-washing facilities readily accessible to personnel.

(4) Where the installation of hand washing facilities is not feasible, appropriate antiseptic cleanser and clean paper or cloth towels shall be provided.

(5) All personnel shall wash their hands and any other potentially exposed skin with soap and running water as soon as possible after removing gloves or other personal protective equipment or after contact with potentially infectious materials.

(6) All personnel shall flush eyes or other mucous membranes with copious amounts of water as soon as possible after contact of these areas with potentially infectious materials.

(7) Eating, drinking, smoking, applying cosmetics (including lip balm), and handling contact lenses shall not be permitted in areas where there are potentially infectious materials.

(8) For emergency first aid situations involving multiple victims, the same equipment shall not be used on different victims unless it has been properly decontaminated, or if the victim’s medical condition would be seriously affected by a delay in treatment.

(9) The FLETC shall provide appropriate personal protective equipment including gloves, facemasks, eye protection, mouthpieces, etc., for protection against potentially infectious materials.

(10) Personal protective equipment shall not allow potentially infectious materials to pass through or reach an employee's clothes, skin, eyes, or mouth during normal use.

(11) Personnel shall use the appropriate personal protective equipment unless, in unusual circumstances, the person believes that using the protective equipment will prevent the administering of first aid or would pose an increased risk. Any incident where the use of protective equipment is declined shall be investigated and documented by the Safety Programs Branch.

(12) Single-use protective equipment, such as surgical-style gloves, shall be disposed of after each use, or as soon as possible after the equipment has become contaminated or damaged.

(13) Multi-use protective equipment, such as coveralls or utility gloves, shall be cleaned and decontaminated, or disposed of properly, when they become contaminated.

(14) All personal protective equipment shall be removed, decontaminated or disposed of properly, before leaving the area.

c. Decontamination Procedures.

(1) All equipment, working surfaces and non-working surfaces shall be decontaminated after contact with blood or other potentially infectious materials with an appropriate solution.

(2) Contaminated sharp objects shall not be picked up directly with unprotected hands, but by mechanical means, such as a brush and dustpan.

(3) Protective body clothing, such as an apron and masks, eye protection, or face shields, shall be worn whenever spray, splashes, or droplets of blood or OPIM may be generated during the process of decontamination.

(4) Only personnel directly involved with the decontamination efforts shall be allowed in the work area while cleaning is taking place.

(5) For minor injuries where personnel are able to return to work, the injured person shall clean up their own blood or OPIM.

(6) A professionally qualified contractor may be required to perform decontamination of any major incidents. The Safety Programs Branch shall make this determination.

d. Waste Disposal.

(1) All contaminated waste or clothing shall be disposed of in a properly labeled or color-coded receptacle. Labels or color-coding shall be fluorescent orange or orange-red and display the biohazard symbol in a contrasting color. Red biohazard bags and containers are also permissible.

(2) Contaminated sharp objects such as needles or broken glass shall be disposed of in a puncture-resistant container. The container shall also be leak-proof on the sides and bottom.

(3) Receptacles for other types of contaminated wastes shall be constructed to prevent leakage or breaking during storage or transport. Receptacles shall be able to be closed prior to storage or transport.

FLETC Manual 70-09 Annex K 2/2/2006 Page 90 of 165

(4) Contaminated clothing, equipment and other materials shall be handled as little as possible and with minimum agitation. Bags containing contaminated materials shall not be carried or handled from the bottom.

(5) All contaminated waste shall be disposed of in accordance with federal, state, and local regulations.

(6) If contaminated clothing is sent to another facility for cleaning, the FLETC will inform the facility that the clothing is contaminated with potentially infectious materials. The facility may be informed by the use of labels or another equally effective means.

e. Hepatitis B Vaccine.

(1) The Hepatitis B vaccine series shall be offered to all FLETC and Partner Organizations personnel who have a potential for occupational exposure to bloodborne pathogens after the required training has been completed, and within 10 working days of initial assignment.

(2) Conditions that do not require personnel to receive the Hepatitis B vaccine series are:

(a) The individual has previously received the Hepatitis B vaccine series;

(b) Antibody testing revealed immunity; or

(c) Vaccine contraindicated due to medical reasons.

(3) A Hepatitis B Vaccine declination form is mandatory when personnel with a potential occupational exposure to blood and OPIM decline the vaccine series; however, they may receive the vaccine series at a future date if desired.

f. Exposure Incidents.

(1) All exposure incidents shall be reported immediately to Health Services and a medical evaluation shall be offered.

(2) The Safety Programs Branch shall evaluate all exposure incidents.

(3) Exposure incident evaluation should include:

(a) Part(s) of the body contaminated;

(b) Quantity of potentially infectious material to which the person was exposed;

(c) Route of exposure;

(d) Pathogen, if known, to which the person was exposed;

(e) Identification of source individual (including name, social security number, and address) unless not feasible; and

(f) The site of the exposure incident shall be left undisturbed and appropriately secured until the Safety Programs Branch has completed the exposure evaluation.

(4) A copy of the Exposure Control Plan shall be easily accessible.

(5) Also, a copy of the Bloodborne Standard 29 CFR Part 1910.1030 shall be made available to personnel on request.

g. Bloodborne Pathogen Training.

(1) The Safety Programs Branch shall provide Bloodborne Pathogen training to all personnel with the potential for occupational exposure to blood or OPIM at the time of initial assignment.

(2) Annual training shall be provided within one (1) year of their previous training.

(3) Additional training shall be provided when changes such as new tasks or procedures affect exposure potential.

(4) The training should include, at a minimum:

(a) The symptoms and epidemiology of bloodborne diseases;

(b) The methods of transmitting bloodborne pathogens;

(c) The Bloodborne Pathogens Program;

(d) OSHA guidelines;

(e) Job hazards that involve potential exposure to bloodborne pathogens;

(f) The proper use or application of the engineering and work practice controls;

(g) The types, proper use and handling, location, removal, and decontamination or disposal of personal protective equipment;

(h) The proper criteria for selecting personal protective equipment;

(i) The Hepatitis B vaccine series including the effectiveness, safety, method of administration, and benefits of the vaccination;

(j) Post-exposure steps including both decontamination procedures and reporting requirements; and

(k) A question and answer period.

h. Recordkeeping.

(1) Medical records for occupational exposures shall be established and maintained in accordance with 29 CFR Part 1910.1020.

(2) Medical records shall be kept confidential.

(3) Training records shall include the date of training, contents of training, course instructor, list of names of personnel attending training.

(4) Training records shall be maintained for three (3) years from the date on which the training occurred.

(5) Personnel may request a copy of their records by written notice.

Solicitation LGL08R00010, Drivers Training Support Services