Effective Date: Oct. 28, 2011
Amended: May 21, 2014
2.408 Bloodborne Pathogens, Exposure and Control
A. The agency follows standards set forth in the Occupational Safety and Health Administration regulation 29 CFR Part 1910.1030, pertaining to Occupational Exposure to Bloodborne pathogens.
B. The responsibility of maintaining a safe work place is shared by the employer and employee.
1. The agency will provide training and materials to enable employees to remain safe.
2. Employees will be conscientious and exercise good judgment by taking necessary steps to use equipment and training provided by the agency.
A. Body Fluids: Fluids that have been recognized by the Centers for Disease Control and Prevention (CDCP) as directly linked to the transmission of HIV, HBV, or to which universal precautions apply. These fluids are blood and blood products, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pericardial fluid, amniotic fluid, and saliva. Saliva is included because it is often difficult, if not impossible, to determine if blood is present in the saliva at time of exposure.
B. Contact: Contact without regard to use of any personal protective equipment (PPE) between an employee’s skin or mucous membranes and another person’s blood, bodily fluids, or tissues.
C. Exposure: A specific eye, mouth, other mucous membrane or non-intact skin contact with blood or other body fluids that results from performance of an employee’s duties.
D. Other Potentially Infectious Materials: They are semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, any body fluid that is contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.
E. 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.
F. Source: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients, clients in institutions for the developmentally disabled, trauma victims, clients of drug and alcohol treatment facilities, residents of hospices and nursing homes, human remains, and individuals who donate or sell blood or blood components.
G. Universal Precautions: Treating all blood and body fluids as if they are contaminated.
2.408.04 Exposure Determination
A. Blood, blood products, and other potentially infectious materials (as defined in the OSHA regulation for Bloodborne Pathogens; 29 CFR Part 1910.1030) will be considered infectious at all times.
B. Universal precautions will be observed by all agency employees.
1. Sworn employees must exercise universal precautions because they have opportunities to respond to, or have contact with, emergency medical incidents in which they treat or transport the ill or injured. Additionally, sworn employees may have contact with body fluids or parts at crime scenes, during arrest situations, or evidence and property retrieval.
2. Non-sworn personnel must exercise universal precautions because they may have cause to respond to crime scenes and handle evidence that may be contaminated with blood or body fluids.
2.408.06 Engineering Controls
A. The agency provides equipment and supplies that protect employees from bloodborne pathogen hazards. The Operations Captain is responsible for ensuring Personal Protection Equipment (PPE) and first aid kits are stocked and supplied with necessary equipment and supplies.
B. Sharps containers will be in all agency first aid kits. The containers are marked with biohazard symbols and have lids to prevent the spilling of sharps.
C. Disposable, latex or vinyl gloves are available to all employees. Heavy duty rubber gloves are also available for clean-up purposes.
D. Disposable resuscitation masks with one-way valves are issued to all police.
E. Disposable face and eye protection are in all first aid kits.
F. Anti-microbial, waterless hand cleaner are in first aid kits.
G. Disposable gowns and shoe covers are in all first aid kits.
H. Biohazard bags and ties are maintained in all first aid kits.
I. Disinfection kits are available to all employees for cleaning of agency issued equipment, excepting uniforms, clothing, firearms, and transport vehicle interiors.
J. Waste containers will be available in areas designated by the agency.
1. Waste containers will be marked with biohazard symbols and designed so as not to spill their contents.
2. Housekeeping will be contacted as needed to dispose of waste containers.
2.408.08 Personal Protection Equipment (PPE)
A. PPE kits contain:
1. Eye and face protection;
2. Heavy duty gloves;
3. Resuscitation mask;
4. Moist towelettes;
5. Hand towels;
6. Sharps container;
7. Biohazard bags and ties;
8. Latex/Vinyl gloves;
9. Biohazard stickers; and
10. Liquid impervious gown and shoe covers for use when dealing with large amounts of blood or body fluids.
B. PPE kits will be in:
1. Designated agency vehicles;
2. Communications Center;
3. The Officers room adjacent to Communications; and
4. The file room outside the Chief’s office.
C. PPE kits will be inspected regularly by the Operations Captain.
2.408.10 Use of PPE
A. PPE will be used at all times except when such use could compromise public safety or the delivery of emergency medical care. In those instances, the circumstances will be documented by the employee and investigated by on-duty supervisor to determine if changes should be made to prevent future occurrences.
B. Gloves will be worn by employees whenever hand contact with blood, body or other potentially infectious materials is anticipated.
C. Disposable gloves are to be replaced as soon as possible if they become contaminated, torn, punctured, or otherwise lose their ability to function as a barrier to exposure.
D. Disposable Gloves Will Not be Reused.
E. Utility (rubber) gloves used for cleaning may be reused if they are disinfected and do not lose their ability to function as a barrier to exposure.
F. Eye and face protection will be used whenever splashes or spray of blood or body fluids are reasonably anticipated.
G. Resuscitation masks with one way valves will always be used when performing mouth to mouth breathing.
1. The new "hands only" CPR method may alleviate the use of the resuscitation masks.
H. Employees will wear gowns and shoe covers when large amounts of blood or body fluids are present at crime or incident scenes.
I. Employees will remove and place all contaminated PPE inside biohazard bags prior to clearing calls. Bags will be placed in designated containers for disposal.
2.408.12 Work Practice Controls
A. Latex, vinyl, or rubber gloves will be worn when the likelihood of exposure to contamination is likely.
B. Employees are urged, and may be required, to cover all open wounds with "band-aids" prior to reporting for duty.
C. Employees will wash their hands as soon as possible after contacts, even if gloves were worn. Towelettes in first aid kits will be used until the employee can get to hand washing areas.
D. Mucus membranes are to be flushed with water immediately or as soon as possible after exposures.
E. Contaminated uniforms or clothing will be removed and the skin thoroughly cleaned.
F. Whenever possible, gloves should be changed between patients and removed before handling other equipment, i.e., radios, notepads, interiors of police vehicles, etc.
G. Recapping, bending or breaking of needles is prohibited. Needles are to be placed in approved sharps containers using a one handed technique.
H. Employees will use caution so as to minimize splashing, spraying and splattering or blood or other potentially infectious materials.
I. Employees will not use mouth suctioning of blood when dealing with snake or animal bites.
J. Eating, drinking, smoking, or the application of cosmetics and handling of contact lenses is prohibited in areas where potentially infectious wastes are present. Food will not be stored in refrigerators with blood or other infectious materials.
K. Prisoners with body fluids on their persons will be transported in separate vehicles from other prisoners.
L. Prisoners with known communicable diseases, who do not present immediate risks of contaminating others, will not be isolated from other prisoners.
M. When prisoner custody is relinquished to other agencies, arresting officers will notify receiving agencies that prisoners have communicable diseases. These notifications will be given only on a need to know basis.
N. Equipment that is contaminated must be placed out of service and decontaminated prior to reuse, servicing or shipping, i.e., duty weapon, uniform, vehicle.
O. If it is not feasible to clean contaminated equipment prior to shipping, or items are of evidentiary value, information regarding the contamination must be conveyed to representatives of other law enforcement agencies. Evidence containers will be marked with biohazard symbols.
P. Employees are prohibited from reaching into sharps containers as this increases the likelihood of accidental needle sticks.
2.408.14 Decontamination and Housekeeping
A. Physical Plant is responsible for conducting decontamination efforts in agency facilities and vehicles.
B. All used PPE and contaminated non-evidence items will be placed in biohazard bags for disposal. Employees may leave used PPE in biohazard bags at health care facilities or inside ambulances.
C. All evidence which may be contaminated will be submitted in biohazard bags or sharps containers and separate from other evidence.
D. Employees whose clothing is contaminated will remove the clothing as soon as possible and wash the skin area below contaminated sites.
1. Clothing will be placed in biohazard bags and turned over to the Operations Captain who will, in accordance with OSHA regulations, dispose of the contaminated uniform or have it cleaned and reissued.
2. For employees wearing personal clothing, their personal clothing will clean or dispose of the clothing at their own expense.
E. Employees will ensure any issued, contaminated equipment is cleaned as soon as possible using disinfection kits.
1. Rubber cleaning gloves are available and must be used for the cleaning.
2. Eye and face protection will be used when splashing is likely.
3. Equipment will be cleaned twice and thoroughly dried prior to reuse.
4. Interiors of transport vehicles will be cleaned as soon as possible.
5. Contaminated vehicles will be placed out of service. The Operations Captain will be notified to coordinate the decontamination activities.
F. All contaminated firearms will be unloaded, placed in biohazard bags, and turned over to the Firearms Sergeant.
1. Magazines and ammunition contained in contaminated weapons will similarly be submitted.
2. The Firearms Sergeant will issue temporary replacement weapons, magazines, and ammunition.
G. A disinfection kit, composed of a bucket, approved detergent germicidal disinfectant, rubber gloves, and paper towels, will be maintained with supplies of other, expendable EMS supplies. Gloves will be cleaned and the water bucket emptied after use. All used paper towels will be disposed of in biohazard containers.
H. Employees observing any measurable quantity of spilled blood or other body fluids within agency facilities will immediately isolate the affected area with signs or barrier tape and contact Physical Plant for clean-up. Minor spills can and should be cleaned by employees using the disinfection kit.
I. Broken glassware which may be contaminated will not be picked up directly with the hands. It will be picked up using mechanical means such as dust pans, brushes, tongs, or forceps.
J. Secondary biohazard bags will be used if the primary bag becomes contaminated or leaks. The second bag will be placed and secured over the first bag.
K. Needles needed as evidence will be packaged into a separate sharps containers for processing. Operations Captain will ensure all needle containers transported to the BPD lab are marked with biohazard symbols.
2.408.16 Hepatitis B Vaccination
A. The Hepatitis B vaccination series are offered, free of charge, to all officers and at-risk civilian employees of the agency.
B. Employees, after being thoroughly educated regarding HBV, may refuse vaccination by signing a waiver.
C. If at any time after refusing the HBV vaccination series, employees change their mind, the series may be requested through the Operations Captain.
D. Employees starting the HBV series are strongly encouraged to complete the series in order to receive the protections afforded by the series.
2.408.18 Information and Training
A. All sworn personnel and at-risk civilian personnel will participate in annual bloodborne pathogen training and annual retraining thereafter.
B. The Operations Captain, will develop training which will include, but is not limited to:
1. Explanation/applicability of OSHA/MOSH standards;
2. Epidemiology and symptoms of bloodborne diseases;
3. Methods of disease transmission;
4. Explanation of the exposure control plan policy;
5. How to recognize tasks that may involve exposure to bloodborne pathogens;
6. Methods of preventing exposures;
7. Limitations of prevention measures;
8. Engineering controls to minimize exposures;
9. Usage of PPE;
10. Hepatitis B vaccination series;
11. Exposures procedures and required decontamination;
12. Post exposure procedures;
13. Records to be maintained by the agency;
14. Signs and color codings used to identify potentially infectious items; and
15. A question and answer period.
C. The exposure control plan will be reviewed annually and updated whenever necessary to reflect new or modified tasks or procedures.
2.408.20 Management of Exposure Incidents
A. Employees will report all injuries, exposures, suspected exposures, or contacts to supervisory personnel.
1. The events and means will be documented in agency reports and Workers’ Compensation forms.
2. Supervisory personnel will:
a. complete all required documents and reports in a timely manner;
B. Exposed employees will, as soon as possible, report to the closest hospital for treatment of any exposure related injuries.
1. Current exposure related protocols recommend prophylaxis treatments be initiated less than two hours after exposures occur.
C. Employees should thoroughly flush exposed muscle areas, e.g., eyes and mouth, with water as soon as possible following exposure.
D. Wounds must be allowed to bleed freely at first, then cleaned thoroughly before applying bandages and dressing.
E. If possible, attempt to identify the source of potential infection.
1. Health Article 18-213 mandates that receiving hospitals notify law enforcement personnel if a patient they had contact with is subsequently diagnosed with a contagious disease or virus.
2. If officers are exposed in the field and source individuals are transported to hospitals by fire department personnel, officers will ensure that their names and ID numbers are included on the fire department run sheets.
3. If source individuals are transported by officers to hospitals, officers will have their names and ID numbers placed on emergency room paperwork.
4. Healthcare personnel will seek to get voluntary consent from individuals to be tested.
5. Receiving hospitals will make notification to the Office of the Chief within 48 hours of confirmation of the patients’ diagnoses. The Office of the Chief will forward the results of tests to the affected officers.
6. As soon as possible, affected employees should contact the Occupational Health Company contracted by the University to schedule follow-up evaluations.
7. Copies of test results conducted by the employees' physicians will be submitted to HR for inclusion in employees' medical records.
8. HR will render a written opinion on the exposure incident to the employee within 15 days of the evaluation.
2.408.22 Record Keeping
A. The Business Specialist, through the Operations Captain, will maintain records verifying training and annual retraining for a period of at least three years.
B. Business Specialist, through the Operations Captain, will also retain a separate set of employee records relating to each employees’ contacts or exposures, vaccinations, evaluations, and treatments at least 30 years following employees’ separation from the employ of the agency.
2.408.24 HIV Testing of Charged Individuals
A. Consistent with CP 11-112, within 10 days of a written request of a victim or victim’s representative to the State’s Attorney in the county where a prohibitive exposure occurred, the court shall order a test of a blood sample for HIV and any other identified causative agents of AIDS.
B. After conviction or a finding of a prohibited exposure, a finding of probable cause under § 11-110(3) of this subtitle, or a granting of probation before judgment under § 11-112 of this subtitle, the State's Attorney shall, within a set number of days days, notify the local health officer of the written request by the victim or victim's representative for testing.
C. On receipt of a court order for testing issued under § 11-110 (3) or § 11-112 of this subtitle, the local health officer or health officer’s designee from any governmental unit shall:
- collect the blood sample within 7 days from the person who is charged with, convicted of, or found to have committed a prohibited exposure:
a. test the blood sample; and
b. give pretest and post test counseling to the victim or victim’s representative and the person subject to testing in accordance with title 18, Subtitle 3, Part VI of the Health-General Article.
2. To victim or victim's represented and tested person:
a. After receiving the results of a test conducted under section 1. Of this section, the local health officer shall promptly send notice of the test results to:
i. The victim or the victim's representative and
ii. The person charged with, convicted of, or found to have committed a prohibited exposure.
3. The local health officer may not disclose positive test results to a victim or victim's representative or a person charged with, convicted of, or found to have committed a prohibited exposure without also giving, offering or arranging for appropriate counseling to:
a. the victim or victim’s representative and
4. To the victim or victim's representative of provisions of Part II. – The following shall notify a victim of prohibited exposure or the victim’s representative of the provision of part II of this subtitle.
D. Exposures between victims and persons charged must be:
2. Mucocutaneous contact with blood or bloody bodily fluids of offenders having splashed into the eyes, mouths, or noses of victims;
3. Blood or bloody body fluids of offenders having contacted already existing open wounds, sores, or chapped or non-intact skin of victims for at least five minutes; or
4. Intact skin contact with large amounts of blood or bodily fluids for at least 60 minutes.
E. Body fluids are fluids containing visible: blood, semen, vaginal secretions, cerebral spinal fluid, or synovial or amniotic fluids. Body fluids do not include saliva, stool, nasal secretions, sputum, tears, urine, or vomitus.
F. Victims are those directly victimized by offenses and includes:
1. Parents of minor victims;
2. Legal guardians of victims; and
3. Persons authorized to give substituted consent for victims.
2.408.26 See UB Policy on AIDS on next page, Appendix A
AIDS – UB
Approved by Provost's Council 12/5/90
Acquired Immune Deficiency Syndrome (AIDS) is a condition which destroys the human body's immune (defense) system and allows life-threatening infections to develop. It has no known cure or vaccine for prevention, and an individual can transmit the virus even in the absence of symptoms. Available medical knowledge indicates that transmission is primarily through sexual contact or through the sharing of intravenous drug paraphernalia. According to the Centers for Disease Control, contracting the disease in most situations encountered in an individual's daily activities is not known to occur.
For purposes of this policy, the following explanations and definitions apply:
AIDS-related complex (ARC) - A variety of chronic symptoms and physical findings that occur in some persons who are infected with the human immunodeficiency virus but that do not meet the Center for Disease Control definition of AIDS
HIV - Human immunodeficiency virus (the causative agent of AIDS)
HIV Antibody - A protein in the body produced in response to exposure to the human immunodeficiency virus (The "HIV antibody test" is a test for the presence of these proteins in the body.)
The University of Baltimore recognizes that in many cases it will not be necessary or appropriate to deny any individual access to academic, social, or employment opportunities because he/she has AIDS or is infected with HIV. The university also recognizes that in some cases it will be necessary and prudent to limit or deny such opportunities to protect the health of the HIV-infected individual or to avoid inappropriate risk of transmission of the HIV virus in the course of study or employment.
In all matters relating to persons who have AIDS or who are infected with HIV, the University of Baltimore will observe requirements of applicable federal and state laws.
Faculty members, employees, or students with any form of HIV infection will be permitted to continue their activities at the institution or unit without change to the extent that they are (1) permitted by their health status, including their risk of contraction of infectious diseases from others; and (2) consistent with the university's interest in preventing infection of others.
Confidentiality will be observed as to information about individuals who know or suspect that they have AIDS or HIV infection unless an exception is granted by the affected person, a report of infection is required by law, or a report of possible infection of others is required by law or infection control policy. However, such information will be shared among institution officials and the university's legal counsel on a need-to-know basis.
A program of education about AIDS and HIV prevention and transmission will be provided to students and employees by the University of Baltimore Health Service with the cooperation of various other departments on campus.
Departments within the university dealing with exposure to blood-borne pathogens will maintain a written procedure for handling infectious materials. All staff shall be informed and trained on the appropriate procedure for dealing with a potential hazard. All employees and students who handle human blood or other tissues are provided personal protective equipment necessary to perform their jobs with minimum risk of infection.
The University of Baltimore Health Service will maintain a current roster of agencies and organizations to which persons seeking further information about AIDS, including persons concerned that they may have AIDS or are infected with HIV, may be referred for counseling and other related services.