Bloodborne Pathogens (BBP) Exposure Control Program

1. For Laboratory Workers At UNC Chapel Hill Bloodborne Pathogens (BBP)Exposure Control Program In accordance with Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard29 CFR 1910.1030

2. In case of emergency… Knowing the right steps to take after an exposure incident is critical to reducing the likelihood of acquiring a bloodborne pathogen. Immediately after any exposure incident: • Wash the exposed area with soap and water; if the exposure involves the eyes, you should flush with tap water • Immediately report the incident to your supervisor and/or immediately call the University Employee Occupational Health (UEOHC) at 6-9119. Emergency Contact Numbers UEOHC Clinic: 966-9119 Emergency: 9-911 Questions regarding this training: 962-5507 Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

3. INTRODUCTION Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

4. BBP Training: Why should we do it? • It’s the law • It’s UNC’s responsibility • Knowing this information can protect your health and the health of others Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

5. It’s the law It’s UNC’s responsibility Knowing this information can protect your health and the health of others On March 6, 1992, OSHA created the Bloodborne Pathogen (BBP) Standard to make sure all employers strive to keep their workers safe from bloodborne pathogens. OSHA considers the Senior Scientist or Principal Investigator (PI) of each laboratory to be an employer. You work under the guidance of your PI for some benefit; be it knowledge, experience, or monetary compensation. Most hazardous laboratory tasks are covered under the OSHA Laboratory Standard and, at UNC, these are tracked in your lab’s Laboratory Safety Plan. Some laboratory tasks are more likely to come into contact with bloodborne pathogens. OSHA regulates potential bloodborne pathogen exposure separately from the Laboratory Standard. The OSHA Standard requires annual training and a vaccination or declination for Hepatitis B virus. BBP Training: Why should we do it? The complete OSHA Bloodborne Pathogens Standard is available at the OSHA website. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

6. It’s the law It’s UNC’s responsibility Knowing this information can protect your health and the health of others Employers demonstrate to OSHA that they are following the Bloodborne Pathogens Standard by implementing an Exposure Control Plan. At UNC, every Principal Investigator adopts the UNC Laboratory Exposure Control Plan. The UNC Laboratory Exposure Control Plan lists the steps UNC is taking to keep lab workers safe. It is the plan to control every lab worker’s exposure to bloodborne pathogens. Annual training on the Exposure Control Plan is one requirement of the OSHA BBP Standard. The other requirement is a vaccination/declination for Hepatitis B virus. As a lab worker, this training fulfills your training requirement. The complete UNC Laboratory Exposure Control Plan is available on the EHS website. BBP Training: Why should we do it? Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

7. It’s the law It’s UNC’s responsibility Knowing this information can protect your health and the health of others For lab workers, the potential for exposure to some bloodborne pathogens may exist during certain procedures, using particular devices, or when encountering spilled human material such as cell lines, blood , or body fluids, or improperly handling waste from your laboratory. Bloodborne pathogens and material potentially containing bloodborne pathogens are handled at Biosafety Level 2 (BSL-2). The OSHA Standard requires the use of the biohazard symbol to allow for communication of potential biological hazards. BBP training: Why should we do it? Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

8. EXPOSURE DETERMINATION IN THE UNC LABORATORY Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

9. Each Principal Investigator is responsible for ensuring the completion of the exposure determination for each employee who works with blood and/or Other Potentially Infectious Material (OPIM) including human cell lines. This should be completed upon orientation and “no later than 10 days after the date of employment” (OSHA). The exposure determination is documented via: The Laboratory Safety Plan Schedule A (updated annually); The employee Lab Worker Registration Form; and Followed-up during laboratory safety audits conducted by UNC EHS. Exposure Determination This determination must made without regard to use of PPE. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

10. I work in a lab, how do I determine“Occupational Exposure”? The OSHA definition of Occupational Exposure is 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 job duties. Parenteral contact is: piercing mucous membranes or the skin by needlesticks, human bites, cuts and abrasions. …for definitions f blood or OPIM other potentially infectious materials), read on Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

11. Blood: Human blood, human blood components, products made from human blood …so if you work with this material in a lab setting, you need to be enrolled in the Bloodborne Pathogens program. For the purpose of making an Exposure Determination, OSHA defines blood as: Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

12. Other Potentially Infectious Material For the purpose of making an Exposure Determination, OSHA defines OPIM as: • This includes: • Certain human body fluids • Any unfixed tissue or organ except intact skin from human (living or dead) • Human cell lines Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

13. OPIM: Other Potentially Infectious Material • Certain human body fluids include: • Semen • Vaginal secretions • Cerebrospinal fluid • Synovial fluid • Pleural fluid • Pericardial fluid • Peritoneal fluid • Amniotic fluid • Saliva in dental procedures • Any body fluid visibly contaminated with blood • All body fluids when it is difficult to differentiate between body fluids Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

14. OSHA's position has always been that workers handling human cell cultures (primary or characterized) fall under the Bloodborne Pathogen (BBP) Standard unless the cells have been tested and proven to be free of bloodborne pathogens. Because it is difficult to have cells tested for all bloodborne pathogens and ensure that they are never contaminated with bloodborne pathogens during research, UNC has taken the position that work with ALL human cell lines (including established lines) fall under the requirements of the BBP standard. A HeLa Cell Line named after Heinratta Lacks, one of the earliest human cell lines Human Cell Lines • OSHA’s interpretation of the BBP Standard that includes human cell lines is available here: Applicability of 1910.1030 to established human cell lines (06/21/1994) Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

15. GENERAL RISKS AND TRANSMISSION Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

16. OSHA defines bloodborne pathogens as: Pathogenic microorganisms that are present in human blood that can cause disease in humans. The risks and transmission of the following bloodborne pathogens will be discussed in this training: hepatitis B virus (HBV) hepatitis C virus human immunodeficiency virus (HIV) What are Bloodborne Pathogens? Many diseases are linked to bloodborne pathogens, but few bloodborne pathogens are frequently responsible for infections in the workplace. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

17. Non-A, non-B hepatitis Treponema pallidum (syphilis) Plasmodium spp. (malaria) Brucella spp. Leptospira interrogans Arboviruses Borreliae Creutzfeldt-Jakob disease agent Hemorrhagic fever viruses Other Bloodborne Pathogens Include: Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

18. Occupational transmission of HIV among health care workers. As of December 2001, occupational exposure to HIV has resulted in 57 documented cases of HIV among healthcare personnel in the United States. (Source: CDC 2003) Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

19. Laboratory Acquired HIV Two workers in different laboratories producing large quantities of highly concentrated HIV were documented to have laboratory-acquired HIV infections. One worker's infection was presumed to have been caused by "undetected skin contact with virus culture supernatant". The most probable cause for this infection was inapparent parenteral exposure. Gloves of questionable integrity, skin cuts and abrasions, and one episode of a dermatitis-like condition represented portals for possible exposure and routes of infection. The other worker's infection followed "an injury with a potentially contaminated needle". The most probable cause for the second worker's infection was parenteral inoculation. This worker recalled incurring an injury with a blunt cannula approximately 6 months before the first seropositive sample. Source: MMWR 37(S-4);19-22, Publication date: 04/01/1988 Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

20. The clinical symptoms of HIV infection ranges from those who have no symptoms to those with severe immunodeficiency or Acquired Immune Deficiency Syndrome (AIDS). Initial infection can be followed by an acute flu-like illness with non-specific symptoms such as fever, swollen lymph nodes, rash, malaise, sore throat, and headache. Other symptoms can include anorexia, chronic diarrhea, weight loss, and fatigue. Opportunistic infections and malignant diseases without a known cause for immune deficiency can also be indicative. Clinical Manifestations of HIV Infection Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

21. HIV Infection Without treatment, the natural history of HIV infection can vary considerably from person to person. The risk for disease progression increases with the duration of infection. Approximately 20-25% of HIV-infected adults will develop AIDS within 6 years after infection and 50% within 10 years. When an HIV-infected person develops certain diseases or conditions, they are then classified as having AIDS. Three of the most common clinical conditions are P. carinnii pneumonia, HIV wasting syndrome and candidiasis of the esophagus. Wasting Syndrome Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

22. Hepatitis B in the U.S. Annually, there are 10,000 new cases of Hepatitis B virus (HBV) reported in the U.S., with an estimated one to two million carriers of HBV. The prevalence of serologic markers for present or past Hepatitis B infection is approximately 5%. Studies have found a prevalence of Hepatitis B to be approximately 2% in the general U.S. population. (Source: www.cdc.gov) Viral hepatitis infects the liver Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

23. Estimated number of occupational Hepatitis B infections among U.S. health care workers, 1983–1999 (Source: CDC [2002a].) In the mid-1980s, health care facilities began adopting “universal precautions” against exposure to body fluids. These were followed in 1992 with the OSHA BBP Standard. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

24. Clinical Manifestations of Hepatitis B Virus Infection • 67% to 75% of infected persons have no symptoms or mild flu-like illness • 25% to 33% have a more severe clinical course: • Extreme fatigue, anorexia, nausea, abdominal and joint pain, rash, fever • Symptoms last for 3-10 days. This is followed by onset of jaundice or dark urine. • Severe acute liver failure with Hepatic encephalopathy (brain dysfunction directly due to liver dysfunction) can occur within 8 weeks of the onset of jaundice. Hepatitis B virus Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

25. Hepatitis B Vaccination Employees who have reasonably anticipated exposure to blood or OPIM will be offered the Hepatitis B vaccination free of charge through the University Employee Occupational Health Clinic (UEOHC) located at 145 N. Medical Drive. This vaccination must be made available within 10 working days of initial assignment or the Hepatitis B declination form must be signed. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

26. General Hepatitis B Vaccination Information Recombinant vaccines for HBV were licensed in the US in 1986. Given as a series of three injections, the vaccine produces a high antibody titer in over 90% of the population. The vaccine is safe and well tolerated by recipients. In about 1 out of 4 adults, soreness where the shot was given, lasting a day or twowas noted and mild to moderate fever was noted in 1 out of 100 adults. Employees with life threatening allergies to baker’s yeast should not receive the Hepatitis B vaccination. For more information about the Hepatitis B vaccination series, view the CDC fact sheet. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

27. Go on, do it now. Hepatitis B Vaccination Requirement Do you still need to schedule or decline the Hepatitis B vaccine? This requirement needs to be met within 10 working days after your exposure determination is made. The vaccine is offered by UNC at no cost to you. To obtain the Hepatitis B vaccination, complete these steps: • Fill out the Hepatitis B vaccination consent form available here. • If you don't have a medical record number, call 966-2555 to get one. • Schedule your appointment with the University Employee Occupational Health Clinic at 966-9119. To Decline the Hepatitis B vaccination: Complete this form and follow the directions on the form to submit it to the University Employee Occupational Health Clinic. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

28. Clinical Manifestations of Hepatitis C Virus Infection Hepatitis C is the most common chronic bloodborne infection in the US and is the leading indication for liver transplantation. • 25-30% of infections are asymptomatic • 55-85% of infected persons develop long-term infection • 70% of infected persons develop chronic liver disease • 5-20% of infected persons develop cirrhosis over a period of 20 to 30 years • 1-5% of infected persons die from the consequences of long term infection (liver cancer or cirrhosis) Symptoms include jaundice, loss of appetite, fatigue, intermittent nausea, abdominal pain and vomiting. There is no vaccine for Hepatitis C. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

29. Transmission In the lab setting, bloodborne pathogens are transmitted by: • Percutaneous exposure such as needlesticks, cuts with sharp objects contaminated with blood/OPIM • Direct contact of blood/OPIM with non-intact skin. • Mucous membrane exposure such as splashes of blood/OPIM to the eyes, nose and mouth. HIV and HBV can also be transmitted from mother to unborn child. If you are pregnant or intend to become pregnant, please contact EHS at 962-5507 for information about the UNC conceptus protection policy. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

30. Health Care Worker BBP Exposures Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

31. Up to 800,000 percutaneous injuries may occur annually among all U.S. health care workers (both hospital-based workers and those in other health care settings). After percutaneous injury with a contaminated sharp instrument, the average risk of infection is 0.3% for HIV and ranges from 6% to 30% for hepatitis B. Distribution of 10,378 reported percutaneous injuries among hospital workers by medical device associated with the injury, 1995-2000 (Source: CDC 2002) Percutaneous Injuries Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

32. Laboratory Associated Infections A study conducted by Pike in 1979 found that only a small proportion of all lab acquired infections (not just BBP) were associated with an identifiable accident. This study was updated in 1999 (Harding and Byers) and they also found a small percentage of lab acquired infections were linked to a specific accident. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

33. PREVENTING INCIDENTS AT UNC Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

34. Now that we’ve discussed how to respond in the event of a potential exposure, let’s look at how to protect ourselves and others from exposure. PREVENTING INCIDENTS AT UNC • Make sure you know what’s expected to keep your lab safe according to the OSHA BBP Standard: • To prevent exposures to lab workers and • To protect infrequent visitors to the lab (such as UNC Facilities Services workers, etc.) against exposures Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

35. Universal Precautions • Universal Precautions is an approach to infection control to prevent contact with blood or "other potentially infectious materials". These laboratorians practice Universal Precautions by safely handling all human blood and OPIM research material as if they are infected with HIV, HBV, and other bloodborne pathogens. • Universal Precautions is a simple approach toward protecting yourself in the laboratory environment. • With Universal Precautions, you wear PPE when you anticipate contact with any and all human blood, body fluids, or OPIM. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

36. Biosafety Level 2 (BSL-2) • To implement proper Universal Precautions under the OSHA BBP Standard at UNC, the lab worker is required to have basic knowledge of BSL-2 practices as described by the CDC/NIH. • Unlike the Bloodborne Pathogens training that is required annually, the BSL-2 training is a one-time requirement. BSL-2 training is available online. • Training history can be reviewed online to determine if you’ve met the requirement. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

37. Bloodborne Pathogens Spills Spills may occur when containers of blood or other potentially infectious materials (OPIM) are dropped in the clinic or laboratory. Employees designated to participate in emergency and decontamination procedures are exposed to blood or OPIM; they are to be thoroughly familiar with proper cleaning and decontamination procedures so that the contamination is contained and exposure to other people is minimized. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

38. Response to a BBP Spill • Evacuate laboratory and alert people in the immediate spill area • Remove any contaminated clothing and wash exposed skin with disinfectant • Notify PI and EHS (962-5507) • Wait 30 minutes before reentering. During this time the aerosol will be removed from the laboratory by the exhaust air ventilation system. • Re-enter wearing PPE --Lab coat with long sleeves, disposable gloves and shoe covers, eye/face protection • Clean-up • Use mechanical means to provide barrier from broken glass • Cover with paper towels or other absorbent materials • Pour appropriate disinfectant (i.e. diluted bleach) around and in spill area. Avoid splashing. • Allow 20 minutes contact time. • Use paper towels to wipe up spill working from the edges into the center • Place materials used to clean up spill, including PPE, in orange biohazard bag • Wash hands • Tape “X” on autoclave symbol with autoclave tape • Autoclave materials • Wash hands 1:10 dilution of household bleach 20 minute contact time Disinfect Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

39. Remember Your Sharps Precautions During a Spill Contaminated broken glassware is cleaned up by mechanical means (e.g. tongs, forceps, pieces of cardboard). Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

40. Biohazard Waste Disposal North Carolina Medical Waste Rules describes biological waste as: Blood and body fluids in individual containers in volumes greater than 20 ml 20 ml liquid ~ ½ shot glass Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

41. Biohazard Waste Researchers are responsible for properly treating Biohazard waste and sharps generated in their labs. Waste is to be treated according to procedures outlined in the UNC Biological Waste Disposal Policy. Most researchers treat their waste in an autoclave. Autoclaving is the most dependable procedure for the destruction of all forms of germs including bloodborne pathogens. For more information, Autoclave Usage and Safety trainingis available online. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

42. Biohazard Labels Biohazard labels are used to alert others of the potential presence of biohazardous materials such as human blood, body fluids, and OPIM. These labels are fluorescent orange or red/orange with contrasting letters and have the universal biohazard symbol. BIOHAZARD Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

43. Biohazard Labels At UNC, biohazard labels are used on: • Containers of biohazard waste • Refrigerators and freezers used to store human specimens • Containers used to store, transport and ship human specimens • Any equipment that could be potentially contaminated with human blood, OPIM, and other material that could allow bloodborne pathogens to live or to grow. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

44. Engineering and Work Practice Controls To eliminate or minimize employee exposure The BBP Standard requires the implementation of engineering and work practice controls. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

45. Engineering and Work Practice Controls Engineering controls are equipment or devices used to control exposures and at UNC include sharps disposal containers, safer needle devices, and biological safety cabinets. Work Practice Controls specifically reduce the likelihood of exposure by altering the manner in which a task is performed. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

46. Disposal of Biohazard Waste: SHARPS Because percutaneous exposure (through the skin) is a primary route of transmission at BSL-2, extreme caution should be taken with contaminated needles or sharp instruments. • Needles/contaminated sharps: • Must never be bent, recapped or removed unless there is no alternative • May only be recapped using a mechanical device or one handed technique • Must never be sheared or broken

47. Needles & Sharps Precautions Contaminated sharps must be placed in red, hard walled plastic containers labeled with the biohazard symbol as shown. When the container is no more than 2/3 full, place autoclave indicator tape over the biohazard symbol in an “X” pattern as shown. Containers must be placed in biohazard bag prior to autoclaving.

48. When possible, safer needle devices should be used in the laboratory. Examples of safer devices, including interactive animations, can be found on the OSHA website at the Safer Needles Section. Safer Needle Devices Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

49. Biological Safety Cabinets Biological Safety Cabinets are used in laboratories when conducting procedures with a potential for creating aerosols or splashes of blood/OPIM. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.

50. Work Practice Controls Minimize Splashes. Your technique is important. Germs can spread more readily when we cause splashing, spraying, spattering, and airborne droplets of blood or other potentially infectious materials. Hand washing. Hands are to be washed immediately or as soon as feasible after removal of gloves or other personal protective equipment. Do not use sinks in food preparation areas. If hand washing facilities are not immediately available use antiseptic hand cleanser and/or disposable wipes. Questions?? Call 962-5507 between 8 a.m. & 5 p.m.