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Environmental Health and Safety

Environmental Health and Safety

Bloodborne Pathogens


View Video:

This 24 minute video explains how workers can protect themselves against occupational exposure to bloodborne pathogens, such as Hepatitis B Virus (HBV) and the Human Immunodeficiency Virus (HIV). This program is targeted primarily to health care workers and related professionals. OSHA, (1992).

As It Should Be Done- viewable on YouTube


New Training Opportunity!

Biosafety Training and Certificates are now available on the CITI (Collaborative Institutional Training Initiative) website. The CITI Program is a subscription service providing research ethics education to all members of the research community. To participate fully, learners must be affiliated with a CITI participating organization. Access to the CITI training is provided by the FGCU Office of Research and Sponsored Programs. For additional information regarding registering for this training, please contact Sandra Terranova at



Exposure Control Plan (ECP) for the Protection of Employees Against Bloodborne Pathogens


The University has developed this Exposure Control Plan to eliminate or minimize the occupational exposure to human blood or other potentially infectious materials since any exposure could result in the transmission of Bloodborne Pathogens, which could lead to disease or death.

Authority: Bloodborne Pathogens Final Standard:  29 CFR 1910.1030


This plan applies to all University employees (faculty, staff, OPS staff, OPS student, and volunteers) who, as a condition of their employment, can be expected to come in contact with blood or other infectious materials. Examples of these employees within the University may include laboratory workers handling human blood or blood products, employees with CPR/First Aid duties as a condition of their employment, and individuals who handle bio-hazardous or medical wastes.


Blood - Refers to human blood, human blood components, and products made from human blood.

Bloodborne Pathogens - 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, and human immunodeficiency virus (HIV).

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

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

Contaminated Sharps - 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 - 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.

Engineering Controls - Engineering controls are those controls (e.g. sharps disposal containers, self-sheathing needles, and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.

Exposure Incident - 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 - a facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines.

Licensed Healthcare Professional - a person whose legally permitted scope of practice allows him or her to independently perform the activities for the Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.

HBV - Acronym for Hepatitis B Virus.

HCV - Acronym for Hepatitis C Virus.

HIV - Acronym for Human Immunodeficiency Virus.

Needleless System - a device that does not use needles for: (A) the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (B) the administration of medication or fluids; or (C) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Occupational Exposure - Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

OSHA - Occupational Safety and Health Administration

Other Potentially Infectious Materials (OPIM)- Materials other than human blood are potentially infectious for bloodborne pathogens. These include 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, 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, culture medium or other solutions; and 4) blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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

Personal Protective Equipment - 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.

Production Facility - a facility engaged in industrial-scale, large-volume or high concentration production of HIV or HBV.

Regulated Waste - 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.

Research Laboratory - a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

Sharps with Engineered Sharps Injury Protections - Non-needle sharps or needle devices used for withdrawing body fluids, accessing a vein or artery, or administrating medications or other fluids, with a built-in safety or mechanism that effectively reduces the risk of an exposure incident.

Source Individual - any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.

Standard - OSHA's Bloodborne Pathogen Standard, 29 CFR§1910.1030

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

Universal Precautions - 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.

Work Practice Controls - Those practices that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles).


 Department Chairpersons or Directors have the responsibility to ensure that individual departments, units and divisions are in compliance with the Standard. Departmental supervisors, designated supervisors, or the Principal Investigators have the responsibility to ensure that the requirements and procedures outlined in the Exposure Control Plan that are appropriate to the individual work areas are carried out. Employees are responsible for reporting exposures to their supervisors and complying with all components of the ECP.

EH&S will routinely inspect areas where covered employees work to provide assurance that activities are conducted in compliance with this ECP and the Standard.

General Implementation:

Each department with employees covered by the Standard must comply with OSHA regulations and establish a compliance program to include employee training, record keeping of required forms, and compliance with the Exposure Control Plan. Department Chairs, Principal Investigators, or other lead authorities will have responsibility of ensuring compliance with all items in this procedure.

Exposure Control Plan:

Each department, unit or laboratory having employees with occupational exposure shall establish its own specific written Exposure Control Plan (ECP) designed to eliminate or minimize employee exposure in their specific work area. The ECP shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures and changes in technology that eliminate or reduce exposure to bloodborne pathogens. An employer, who is required to establish an ECP, shall solicit input from non-managerial employees who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the ECP.

Exposure Determination:

All covered departments, laboratories, and clinics must conduct an exposure determination for each position (individual employee) and identify those positions, which may have exposure to potentially infectious human material. This exposure determination must be done without regard to the use of personal protective equipment (PPE). Records will be kept of the names of affected employees, their job titles, and their duties and procedures that may expose them to blood and OPIM.

Hand Washing Facilities:

Departments must provide all covered employees with readily accessible hand washing facilities. If this is not possible due to the nature and location of the activity being conducted, hand sanitizers must be provided. When antiseptic solution is used, hands shall be washed with soap and running water as soon as feasible. Supervisors will ensure that employees are trained to wash their hands immediately after removing gloves and following procedures where exposure to potentially infectious materials could have occurred.

Personal Protective Equipment (PPE):

Personal protective equipment must not be used as a substitute for proper engineering and work practice controls. Departments must provide, at no cost to the employee, personal protective equipment when appropriate. This equipment must be readily available and accessible to users, and must include, but not be limited to, the following:

Disposable gloves shall be worn to protect hands from contact with blood or OPIM. The gloves shall be replaced when contaminated, torn or punctured. Persons allergic to latex shall be offered alternatives such as latex free or nitrile gloves. Non-disposable utility gloves can also be used when appropriate (these may be decontaminated for reuse as long as the integrity of the glove is not compromised).

Protective clothing (gowns, laboratory coats, aprons, etc.) must be appropriate to the task being performed and the degree of exposure anticipated. In situations when gross contamination can reasonably be anticipated, surgical caps and shoe covers must be provided and used. When other than disposable protective clothing is provided; cleaning and laundering must be performed according to the section on Laundry and must be provided by the department at no cost to the employee.

Face protection sufficient to shield the eyes, nose, and mouth from splashes, sprays, splatters, or droplets of potentially infectious materials, must be worn when contamination can be reasonably anticipated.

Repair or replacement of the items listed above needed to maintain their effectiveness must be paid for by the department.

Safer Medical Devices:

Safer medical devices must be available to employees such as needleless systems or sharps with engineered sharps injury protection. Employers must document annually the consideration and implementation of appropriate commercially available medical devices designed to eliminate or minimize occupational exposure. Employers must solicit input on these devices from the employees using them in the workplace.

Sharps Injury Log:

The departments or units under this standard shall establish and maintain a sharps injury log for the recording of parenteral injuries from contaminated sharps (see Attachment E). The information in the sharps injury log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The sharps injury log shall contain, at a minimum: the type and brand of device involved in the incident, department or work area where the exposure incident occurred, an explanation of how the incident occurred, and recommendations to prevent the injury from recurring.


All covered departments must promptly provide to affected employees an initial training program specific to the worksite. New employees will be trained at the time of their employment and prior to their working with regulated materials. Training must be provided at no cost to the employee and during work hours. All training will be appropriate in content and vocabulary to the educational level, literacy and language of the employee.

The training shall cover and explain the regulatory contents of the Standard, epidemiology and symptoms of BBP disease, modes of disease transmission, appropriate engineering controls, safe work practices and personal protective equipment, HBV immunization, emergency and post exposure procedures, and hazard communication. The participants must have the opportunity for interactive questions and answers with the person conducting the training session. The department will ensure the employee’s participation in a training session at least annually and within one year of their previous training.

All personnel involved and trained must sign the “Exposure Control Plan In-service Training Acknowledgement” found in Attachment A.

Laboratory workers shall receive additional training as it relates to their specific duties.

Training Records: Training records are maintained for each employee by their supervisor. Training records shall be maintained for three years from the date on which the training occurred.

Medical Programs:

Hepatitis B Vaccinations: Employees in positions with the potential for contact with human blood or other infectious materials shall receive Hepatitis B Vaccination (and boosters, if required or recommended by the physician) made available at no cost, within ten working days of assignment, via a University contracted licensed physician/health care professional. If an employee wishes to decline the vaccine, they must sign a “Mandatory Waiver for Declination of Hepatitis B Vaccination” found in Attachment B; however, the employee may request the vaccine at any time during the term of his assignment.

Post Exposure Evaluation and Follow-up: Any employee that incurs an exposure incident should report it to their immediate supervisor and obtain immediate medical attention.

The appropriate physician/health care professional will offer employees that have had an exposure a confidential post-exposure evaluation and follow-up. This evaluation will include documentation of the route of exposure, and the circumstances under which the exposure incurred; identification and documentation of the source individual, if applicable, unless the identification is unfeasible or prohibited by state or local law. Testing and follow-up consultation will be conducted as recommended by the physician. Employees must report the exposure incident to the Department of Human Resources within 24 hours, and complete an “Exposure Incident Investigation Form” found in Attachment D.

Medical Records: The University shall maintain copies of any medical records generated by this plan, as specified in the Standard, for the term of employment plus 30 years. Medical records shall be confidential and made available to the following people: the employee, anyone with consent of the employee, and upon request of OSHA, NIOSH, or State Department of Labor and Employment Security, Division of Safety.

Hazard Communication: Warning labels, including the orange or orange-red biohazard symbol will be apparent on all containers of regulated waste, refrigerators, freezers, and other containers used to store or transport blood or potentially infectious materials. Warning signs should be posted on doors to areas containing such materials. Labels required for contaminated equipment must also indicate which portions of the equipment remain contaminated.


Each department must adopt the use of Universal Precautions when handling soiled contaminated laundry. When doing this, the use of alternatively labeled or color-coded containers will suffice as long as all employees recognize the containers as requiring compliance with Universal Precautions.

Laundry that is contaminated must be disposed of as biohazardous waste or handled as little as possible with a minimum of agitation. This laundry must be bagged or containerized at the location where it was used and must not be sorted or rinsed in the location of use.

Departments must provide employees with appropriate secondary containment for the handling of laundry that is wet and that presents a reasonable likelihood of soak-through of, or leakage from, the primary bag or container. These secondary containers must be properly marked and prevent soak through and/or leakage to the environment.

When a department's contaminated laundry is transported off site; the department must ascertain compliance with all applicable federal, state, and municipal regulations, including labeling.

Biohazardous/Biomedical Waste:

Biomedical Waste is defined as any solid or liquid waste which may present a threat of infection to humans, including non-liquid tissue, body parts, blood, blood products, and body fluids from humans and other primates which contain human disease-causing agents; and discarded sharps. The following are also included:

1. Used, absorbent materials saturated with blood, blood products, body fluids, or excretions or secretions contaminated with visible blood; and absorbent materials saturated with blood or blood products that have dried.

2. Non-absorbent, disposable devices that have been contaminated with blood, body fluids or, secretions or excretions visibly contaminated with blood, but have not been treated by an approved method.

3. Pathological and microbiological wastes containing blood or other potentially infectious materials.

The State of Florida has established minimum sanitary practices relating to the segregation, handling, labeling, storage, treatment and disposal of biomedical waste in Chapter 64E-16 of the Florida Administrative Code (FAC). These practices have been developed to minimize exposure of employees, patients, and the public to disease-causing agents.

As a result of this, all disposal of biomedical waste must follow the FGCU Management and Disposal of Biohazardous Waste procedure. This procedure includes the proper use of red biomedical waste bags, autoclaving, sharps containers and record keeping. ANYONE who handles biological wastes on campus must complete and document training to this procedure and Regulation. Contact EH&S for additional information.

Spill Procedures:

All departments that work with blood or other potentially infectious materials must have an appropriate spill kit or materials available at all times. The spill kit contents should include disinfectant such as 10% bleach, PPE, dust pan and forceps for picking up contaminated sharps, paper towels and biohazard bags.

Employees should adhere to the following procedures when dealing with spills of potentially infectious materials.

♦ Isolate the area and warn others nearby.

♦ Notify the supervisor.

♦ Do not attempt to clean a spill unless appropriately trained and equipped with an adequate spill kit.

♦ Put on proper PPE and remove glass or sharps with forceps or dust pan.

♦ Put paper towels on spill and apply disinfectant carefully to avoid splashes.

♦ Allow adequate contact time for disinfectant to be effective.

♦ Dispose of spill and clean up materials in accordance with the University's policy on Biomedical Waste.

If a spill or accident results in an exposure incident involving infectious materials, the employee must immediately report the accident to their supervisor and medical provider and follow post exposure procedures.



CPR / First Aid:Employees who are anticipated to provide infrequent CPR/First Aid duties as a secondary condition of their employment will not be offered the Hepatitis Vaccine. However, if they perform a CPR/First Aid duty and are exposed, they will be offered the vaccine within 24 hours of the exposure. Any employees who are expected to perform First Aid in the normal course of their duties (e.g. first responders, law enforcement, and athletic trainers) will be offered the vaccine.

Records of Employees Working with Biohazards:

All records required to be maintained by this procedure shall be confidential and made available to the following people: the employee, anyone with consent of the employee, and upon request of designated representatives of the Florida State Department of Labor and Employment Security, Division of Safety; the Assistant Secretary of Labor for Occupational Safety and Health, or the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services.


This Exposure Control Plan will be reviewed annually, and updated as necessary to remain current with legislative changes.


Attachment A - In-Service Training Acknowledgement

Attachment B - Mandatory Waiver for Declination of Hepatitis B Vaccination

Attachment C - Biosafety Checklist

Attachment D - Exposure Incident Investigation Form

Attachment E - Sharps Injury Log

Additional Information:

Biosafety in Microbiological and Biomedical Laboratories -Centers for Disease Control

Also available separately: Appendix A – Primary Containment for Biohazards: Selection, Installation and Use of Biological Safety Cabinets


Rev. 7/2014 R. Holtzclaw