Bloodborne Pathogens

CSUN program for minimizing the risk of exposure to potentially infectious human blood or body fluids.

I. Purpose/Scope

The Bloodborne Pathogen Exposure Control Program has been developed to reduce the risk of occupational exposure to blood and other potentially infectious materials (OPIM) in accordance with the Cal/OSHA Bloodborne Pathogens Standard (Title 8, Code of California Regulations, Section 5193).

Purpose: California State University Northridge (CSUN or University) is committed to conducting work activities in a manner that promotes the safety and health of faculty, staff, students, and visitors and to complying with all applicable occupational health and safety regulations.
This plan sets forth procedures, control measures, and equipment designed to minimize risk from exposure to the Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), and other pathogens transmitted by contact with human blood.

Scope: This Bloodborne Pathogen Exposure Control Program (BBP Program) applies to all University employees who have potential occupational exposures with blood or potentially infectious materials during their normal job duties. See Section IV, Exposure Determination.

II. Definitions

Blood: human blood, human blood components, and products made from human blood.

Bloodborne Pathogen: Pathogenic microorganisms that are present in human blood and can cause disease in humans. The pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

Contaminated: The presence or the reasonably anticipated presence of blood or Other Potentially Infectious Materials on a surface or in or on an item.

Engineering Controls: Controls (e.g. sharps disposal containers, needleless systems and sharps with engineered sharps injury protection) that isolate or remove the bloodborne pathogen(s) hazard from the workplace.

Engineered Sharps Injury Protection: A physical attribute built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, which effectively reduces the risk of an exposure incident by a mechanism such as barrier creation, blunting, encapsulation, withdrawal or other effective mechanisms; or a physical attribute built into any other type of needle device, or into a non-needle sharp, which effectively reduces the risk of an exposure incident.

Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee’s duties.

Other Potentially Infectious Materials (OPIM):

(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 other body fluid that is visibly contaminated with blood such as saliva or vomitus, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids such as emergency response; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV: (A) Cell, tissue, or organ cultures from humans or experimental animals; (B) Blood, organs, or other tissues from experimental animals; or (C) Culture medium or other solutions.

Any unfixed tissue or organ (other than intact skin) from a human (living or dead);
Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV:
Cell, tissue, or organ cultures from humans or experimental animals;
Blood, organs, or other tissues from experimental animals; or
Culture medium or other solutions.

Parenteral Contact: Piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

Personal Protective Equipment: Specialized clothing or equipment worn or used 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.

Sharp: Any object used or encountered that can be reasonably anticipated to penetrate the skin or any other part of the body, and to result in an exposure incident, including, but not limited to, needle devices, scalpels, lancets, broken glass, broken capillary tubes, exposed ends of dental wires and dental knives, drills and burs.

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 HCV, and other bloodborne pathogens.

III. Administration

The CSUN Environment, Health, & Safety department (EH&S) is responsible for implementation of the BBP Program. Those employees who have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in the ECP.

A. Evaluation and Review

EH&S will review and update the campus Bloodborne Pathogen Exposure Control Program manual at least annually and whenever necessary as follows:

To reflect new or modified tasks and procedures which affect occupational exposure;
To reflect changes in technology that eliminate or reduce exposure to bloodborne
pathogens; and
To document consideration and implementation of appropriate commercially available needleless systems, needle devices, and sharps with engineered sharps injury protection;
To include new or revised employee positions with occupational exposure;
To review exposure incidents that occurred since the previous update; and
To review and respond to information indicating that the Exposure Control Plan is deficient in any area.

Faculty and staff supervisors, including principal investigators, are responsible for making sure their work or group-specific Exposure Control Plans (ECPs) are updated, and any changes are communicated to their employees promptly.

IV. Exposure Determination

Each Faculty or Staff Supervisor must evaluate all employee job functions to determine which of their workers may be “at risk” of occupational exposure to blood or Other Potentially Infectious Materials (OPIM). OPIM includes clothing, vomit, and saliva with visible blood as well as unfixed human tissue.

(8 CCR §5193 (c)(3)(A) requires that the following lists be maintained as part of the ECP:

A list of all job classifications in which all employees in those classifications have occupational exposure (Category I),
A list of job classifications in which some employees have occupational exposure (Category II),
A list of all tasks and procedures or groups of closely related task and procedures in which occupational exposure occurs and that are performed by employees in job classifications listed in accordance with the provisions of subsection (c)(3)(A)2 of this standard.

A. Limits on potential exposures on campus-owned property

At CSUN, outside of Student Health Services, the following prohibitions limit potential exposures to general personnel:

Faculty, staff, and student employees are not permitted to clean up (non-lab generated) spills of blood or other bodily fluids in hallways, bathrooms or other public areas.

EXCEPTION

Only trained campus custodial staff and athletics trainers or outside licensed contractors are permitted to clean up spills of this nature.

Highly infectious organisms, such as Biosafety Level 3 or 4, may not be brought onto CSUN property due to the lack of adequate facilities to handle this type of work.
For teaching and research purposes, authorization by the CSUN Biosafety Committee is required to use Biosafety Level 2 organisms, unfixed human tissue, human blood or OPIM.
Knowledgeable and trained lab personnel are responsible for cleaning up spills of human blood or OPIM, used or generated by research or academic laboratories, not custodial staff.
University personnel are not required to clean up human blood or OPIM as part of major crime scenes or trauma scenes.
No university personnel are required to provide first aid, medical aid or CPR as part of their job description or classification – except for the following specialized staff:
- trained medical providers, such as EMTs and nurses
- athletic trainers,
- uniformed police officers.

B. Category I Job Classifications: All employees have occupational exposure

Physician	Athletics Trainers	Uniformed Police Officer
Registered Nurse	Physician Assistant	Custodian
Nurse Practitioner	Medical Assistant	Designated First Aid Provider
Nursing Students/Interns	Clinical Assistant	Plumber
		Waste Management Laborer

C. Category II Job Classifications: Some employees have occupational exposure

Job Type or Title	Tasks and Procedures in These Jobs with Potential for Occupational Exposure
Academic Instruction
Instructional Support Technicians Instructional Faculty Lecturers Teaching Associates Graduate Teaching Assistants Student Assistants	Human Blood, Body Fluids Handle human blood products such as whole blood, plasma, serum, platelets, or white cells and OPIM Handle unfixed human tissue or organs. (Tissues and organs soaked in chemical preservatives such as alcohol or formaldehyde are “fixed”.) Work with HBV, HIV, HCV or other bloodborne pathogens or with preparations, such as liquid solutions or powders containing the HBV or HIV Handle blood, blood products, body fluids or unfixed tissues or organs of animals infected with the HBV, HCV, HIV or other bloodborne pathogens Work with OPIM (Other Potentially Infectious Materials) Work with people potentially infected with a disease communicable by contact with blood or OPIM. Sharp Objects Handle sharp instruments such as knives, needles, scalpels, or scissors which have been used by others working with human blood or other potentially infectious materials to include human organs, tissues or body fluids Handling filled sharps containers Spills Dispose of medical waste or soiled laundry (soaked with blood/OPIM, not dried) Clean up spills of human blood or OPIM
Research and Investigation
Research Faculty Post-Doctoral Candidates Research Assistants Independent Researchers	Human Blood, Body Fluids Handle human blood products such as whole blood, plasma, serum, platelets, or white cells and OPIM Handle unfixed human tissue or organs.(Tissues and organs soaked in chemical preservatives such as alcohol or formaldehyde are “fixed”.) Work with HBV, HIV, HCV or other bloodborne pathogens or with preparations, such as liquid solutions or powders containing the HBV or HIV Handle blood, blood products, body fluids or unfixed tissues or organs of animals infected with the HBV, HCV, HIV or other bloodborne pathogens Work with OPIM (Other Potentially Infectious Materials) Work with people potentially infected with a disease communicable by contact with blood or OPIM. Sharp Objects Handle sharp instruments such as knives, needles, scalpels, or scissors which have been used by others working with human blood or other potentially infectious materials to include human organs, tissues or body fluids Handling filled sharps containers Spills Dispose of medical waste or soiled laundry (soaked with blood/OPIM, not dried) Clean up spills of human blood or OPIM
Facilities/Maintenance
Equipment Technicians Equipment Maintenance Assistants	Doing maintenance, repair or cleaning on equipment contaminated with blood or OPIM, handle laundry soiled with blood or other OPIM.
Other Campus Services
EH&S Staff	Assisting with emergencies and cleanup where contact with human blood or OPIM is possible.
HAZWOPER Trained Staff	Cleaning up spills with a human blood or OPIM component as part of a chemical spill scenario. COSE HAZWOPER team may clean up spills of blood or OPIM in laboratory environments if lab personnel are unable to do so.

D. Biohazard Use Authorization and CSUN Intuitional Biosafety Program

To identify those with research-related occupational exposure, all research proposals involving biological materials are subject to review by university’s Intuitional Biosafety Committee (IBC), via a short Materials Survey which will help determine which projects will require submission of a protocol and a detailed review by the committee. For those projects that require a full protocol, RSP and EH&S will consult the lead faculty investigator as they complete and submit their protocol through the Hazard Safety module on the Cayuse platform.

The risk assessment and BUA approval process includes a review of currently available engineering controls and the selection and use of controls, as appropriate, to mitigate the risk of exposure to BBP. This determination is made without regard to the use of personal protective equipment (PPE). All employees with potential exposure to BBP must meet the same regulatory requirements regardless of job classification.

E. Special CSUN Programs

Certain programs at CSUN have requirements that may be more stringent than the general campus Bloodborne Pathogen Program.

Nursing Program

The Nursing Program requires all of its faculty and students to have BBP training and to complete the HBV series before working in a medical setting. Off-site work is under the control and Bloodborne Pathogen Program of that off-site facility. Contact 881.677.2401 for program details.

Note: Needlesticks and other exposure incidents must also be reported to XXXXXXX. This includes incidents that happened off-campus as part of an employee’s work assignment.

Radiologic Science Program

The RS Program requires all its faculty and students to have BBP training and to complete the HBV series before being allowed into the program. Documentation of training and vaccination must be provided to EH&S.

F. Student Health Center

Student Health Center (SHC) is a medical facility that provides services to CSUN students. All of medical services providers are expected to have the required training and immunizations and maintain these records for at least three years. SHS must comply with requirements related to medical providers in addition to the provisions of this BBP Program.

V. Exposure Control Plan Requirements

The California Occupational Safety and Health Administration (Cal- OSHA) Bloodborne Pathogens Standard (8 CCR, Title 8, Section 5193) requires the following for employees with a potential exposure to BBP:

Initial Bloodborne Pathogens Training (General(CSU Learn) and Work-specific)
Annual Bloodborne Pathogens Training (CSU Learn)
Hepatitis B Immunization offered free of charge to the employee and documentation of vaccination or declination
Implementation of engineering and work practice controls to reduce the risk of BBP exposure when possible
When appropriate, PPE must be made available free of charge to the employee
A Sharps Injury Log to document exposure incidents involving sharps

All employees with the potential for occupational exposure to BBP are required to read, understand and have the opportunity to comment on this plan. A review of the program is part of the initial and annual BBP training. A PDF copy of the Bloodborne Pathogen Manual is available at https://live-csu-northridge.pantheonsite.io/sites/default/files/2025-08/Bloodborne-Pathogens-Manual.pdf.

Each supervisor must ensure that a copy of the plan and specific ECP are accessible to employees. Employees may provide comments regarding the Exposure Control Plan to EH&S at 818.677.2401 or via email at ehs@csun.edu.

VI. Bloodborne Pathogens Training

All employees with the potential for occupational exposure to BBP must participate in a training program provided at no cost to the employee and offered during working hours.

At the time of initial assignment to tasks where occupational exposure may occur;
At least annually thereafter
Supervisors shall provide additional training when changes are made which may affect the employee’s occupational exposure, such as introduction of new engineering, administrative or work practice controls, modification of tasks or procedures, or institution of new tasks or procedures.
Material appropriate in content and vocabulary to the educational, literacy, and language levels of employees shall be used.

The training must contain a comprehensive discussion of the Bloodborne Pathogens Standard that includes, but is not limited to, epidemiology, symptoms, and transmission of BBP, and the specific ECP. Additional discussion points include procedures for use and limitations of PPE, availability of the Hepatitis B vaccination, exposure emergency procedures, post-exposure follow-up procedures, communication of hazards, and an opportunity to ask questions.

Bloodborne Pathogens training is available to campus personnel via CSU learn. Contact EH&S for help with accessing on-line training at ehs@csun.edu, or visit the EH&S website

Initial work-specific BBP training is performed by the Supervisor or EH&S staff and is documented with signatures and a quiz. Online training is documented in the Learning Management System (CSU Learn LMS). Training records are kept for a minimum of three years.

VII. Medical Surveillance

A. Hepatitis B Vaccination

The hepatitis B vaccine and vaccination series will be made available to all employees who may have occupational exposure.

Pre-exposure vaccine will be offered free of charge to employees after they have received training in BBP occupational exposure prevention and within 10 working days of initial assignment, unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, the vaccine is contraindicated for medical reasons or satisfy the “exception” defined below. Participation in a prescreening program is not a prerequisite for hepatitis B vaccination.

Employees who decline to take the vaccine will be required to sign a Cal/OSHA required waiver indicating their refusal (see XVIII. Forms Used). However, employees who refuse the initial vaccine may change their decision and receive the vaccine at any time as long as they are still considered to be at risk.
If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service, at a future date, such booster dose(s) shall be made available.

The Hepatitis B vaccine will be administered by the CSUN contracted occupational medicine provider, Student Health Services, or another approved medical provider.

The Enterprise Risk Management (ERM) department is the program administrator for Hepatitis B vaccinations and shall ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post-exposure follow-up, including prophylaxis are:

Made available at no cost to the employees;
Made available to the employee at a reasonable time and place;
Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed health care professional; and
Provided according to the recommendations of the U.S. Public Health Service

The Environment, Health, & Safety (EH&S) department oversees compliance with the Cal/OSHA Bloodborne Pathogen Exposure Standard vaccination requirements.

*Exception:

First aid providers are not required to be offered pre-exposure hepatitis B vaccine if:

The primary job assignment is not the rendering of first aid;
Any first aid rendered is only as a collateral duty responding solely to injuries resulting from workplace incidents, generally at a location where the incident occurred; and
This exception does not apply to designated first aid providers who render assistance on a regular basis. Examples: Emergency or public safety personnel who are expected to render first aid in the course of their work or first aid station workers.

B. Post-exposure Reporting

Any exposure incident must be reported immediately to the supervisor, and to EH&S. EH&S staff will investigate the circumstances of the exposure incident. The goal of the investigation is to identify and correct any problems in order to prevent recurrence of similar incidents.

All first aid incidents involving the presence of blood or OPIM should be reported to the supervisor as soon as possible before the end of work shift during which the first aid incident occurred. Use the Supervisor Accident/Incident Investigation Form whenever a state employee is injured. Use the Laboratory Accident/Incident Report Form whenever a student, or campus visitor is injured.
The report must include the names of all first aid providers who assisted, regardless of whether personal protective equipment was used and must describe the first aid incident, including time and date.
- The description must also include a determination of whether or not, in addition to the presence of blood or OPIM, an exposure incident occurred.
- This determination is necessary in order to ensure that the proper post-exposure evaluation, prophylaxis and follow-up procedures are made available immediately if there has been an exposure incident.

C. Post-exposure Evaluation and Follow-up

Following a report of an exposure incident, EH&S or the medical provider will make available to the exposed employee a confidential medical evaluation and follow-up, to include the following elements:

Post-exposure treatment when medically indicated by current recommendations of the U.S. Public Health Service.
Counseling and evaluation of reported illnesses.
Employees exposed to human blood or OPIM will be provided serologic testing, post-exposure prophylaxis as appropriate, and counseling.
Post-exposure follow-up is available to all employees who have had an exposure incident. The post-exposure follow-up is maintained in confidential medical records separate from personnel records.

The full hepatitis B vaccination series will be made available as soon as possible, but not later than 24 hours, to all unvaccinated first aid providers who have rendered assistance in any situation involving the presence of blood or OPIM regardless of whether a specific exposure incident has occurred.

D. Sharps Injury Log

Employees calling to report an exposure will be asked for certain information, including the type and brand of sharp used, if any, in order for the Occupational Health provider to record the information in the Sharps Injury Log. See Appendix B.
The information in the Sharps Injury Log shall be recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The Sharps Injury Log shall be maintained for five years from the date the exposure incident occurred.

VIII. Signs and Labels

Warning labels, including the international biohazard symbol, must be affixed to containers of biohazardous materials and medical wastes, refrigerators, and freezers containing blood or OPIM, and other containers used to store, transport, or ship blood or OPIM.

Lab or medical facility: Biohazard warning signs must be posted on the entrance of any restricted areas where certain biohazardous materials are used. The hazard warning sign must include the biohazard symbol, name of the agent(s) if applicable, special entry requirements and 24-hour contact information for two responsible individuals, one of whom should be the Principal Investigator (PI) or physician.

IX. Scientific Research or Academics: Additional Documentation

This section primarily involves research or academic activities associated with the College of Science & Math. However, other research programs, such as in the department of Kinesiology, that work with human blood, unfixed human tissue, or organisms (bacteria, spores, viruses, prions) that are pathogenic to humans are also subject to this section.

For research or classes involving human blood, OPIM, etc., detailed information regarding laboratory- specific biohazard issues must be provided to the university’s Intuitional Biosafety Committee (IBC). The Principal Investigator or Teaching Lab Coordinator must complete and submit their protocol through the Hazard Safety module on the Cayuse platform.

X. Management Controls

A. Training

Safe work practices are discussed during employee’s initial training and reviewed annually during refresher training.

B. Universal Precautions

The most effective way to prevent infection with bloodborne pathogens is to minimize the possibility of contact with contaminated materials. As mandated by the BBP Standard, Universal Precautions shall be practiced at all times to prevent contact with blood or OPIM by those persons designated to be "at-risk".

Universal Precautions apply to the handling of the following human materials:

Blood;
Tissues and organs (prior to fixation) body fluids containing visible blood;
OPIM fluids regardless of visible blood contamination, e.g., semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic, saliva in dental procedures

Unless they contain visible blood, the following body substances are unlikely to contain bloodborne human pathogens: » Feces » Nasal secretions » Sputum » Sweat » Tears » Urine » Vomit »Saliva »Breast Milk

XI. Engineering Controls

Engineering controls, used to reduce or eliminate potential exposures, shall be inspected by supervisors on a regular basis. Engineering controls will be replaced/ modified as necessary to maintain safe working conditions.

Engineering controls include but are not limited to:

Self-sheathing needles;
Biological safety cabinets (Class II);
Splashguards;
Sharps disposal containers;
Mechanical pipetting devices;
Contained centrifuge enclosures; and
Screw top centrifuge bottles or tubes.

A. Biological Safety Cabinets

Biological safety cabinets (Class II) used to prevent harmful exposure from biohazard agents or biohazardous materials must be certified when installed, annually, and whenever they are moved or undergo major servicing (HEPA filter replacement, motor repairs, etc.)

Records of tests performed must be retained for at least 5 years.
DCSs coordinates service with a contractor and maintains the certifications.

B. Engineered Sharps for Injury Protection

Engineered sharps for injury protection must be used for withdrawal of body fluids or any other procedure involving the potential for an exposure incident for which such a needle device is available.

Evaluate your use of syringes and needles and verify that you cannot use these types of sharps or needleless syringes because they either don’t work for your procedure or what you would need is unavailable for purchase.

XII. Work Practice Controls

Work practice controls are meant to reduce the likelihood of exposure through alteration of the manner in which a task is performed. Therefore, supervisors will be responsible for documenting and instituting work practices or laboratory procedures that will minimize potential exposure and will be responsible also for evaluating these on a regular basis to ensure their effectiveness. Appropriate work practices will be reviewed with each employee, and the employee will be expected to follow the designated work practice controls.

All procedures involving blood or OPIM shall be performed in a manner that minimizes splashing, spraying, spattering, and generation of droplets of these substances.

A. Employee Personal Actions

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure;
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or OPIM are present;
Mouth pipetting/suctioning of blood or OPIM is prohibited.

B. Hand washing

Hand washing facilities must be readily accessible to employees
When provision of hand washing facilities is not feasible, either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes must be provided. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as possible.
Employeesmustwashtheirhandsimmediatelyorassoonasfeasibleafterremovalof gloves or other personal protective equipment
Employees shall wash their hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or OPIM

C. Handling of Disposable Needles and Other Sharp Instruments

Contaminated needles and other contaminated sharps shall not be bent, recapped or removed. Shearing or breaking of contaminated needles is prohibited
If the supervisor can demonstrate that no alternative is feasible or that such action is required by a specific research procedure, then bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique. Campus Biosafety Committee approval is required for science teaching or research labs.

D. Handling of Reusable Sharp Instruments (e.g., lancets, scalpels, etc.)

Reusable sharps are not permitted without prior approval from the Campus Biosafety Committee. If approval is granted, the following requirements will apply.

Contaminated reusable sharps shall be placed in appropriate containers immediately or as soon as possible after use until properly reprocessed. These containers shall be puncture resistant, properly labeled “Biohazard”, leak proof on the sides and bottom
Reusable sharps that are contaminated with blood or OPIM shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed

E. Handling Specimens of Blood or OPIM

Specimens of blood or OPIM shall be placed in a properly labeled, closed container that prevents leakage during collection, handling, processing, storage, transport or shipping. If the specimen could puncture the primary container, the primary container shall be placed within a properly labeled, leak proof, puncture-resistant secondary container.

F. Handling and Discarding Contaminated Equipment

Equipment contaminated with blood or OPIM shall be decontaminated as necessary before servicing or shipping unless decontamination of the equipment or portions of it is not feasible
A readily observable label shall be attached to the equipment stating which portions remain contaminated
This information shall be conveyed to all affected employees, servicing representative and/or manufacturer, as appropriate, prior to handling, servicing or shipping so that appropriate precautions will be taken
Written confirmation of contamination will be maintained on file for at least 5 years in the department or college office.

XIII. Personal Protective Equipment (PPE)

Where the potential for occupational exposure to BBP remains after implementation of engineering and work practice controls, the supervisor shall provide, at no cost to the employee, appropriate PPE. PPE will be considered “appropriate” only if it does not permit blood or OPIM to pass through or reach the employee’s work clothes, skin, eyes, mouth or mucous membranes under normal conditions of use, and for the duration of time in which the PPE will be used. The supervisor shall ensure the following practices:

The employee uses appropriate PPE
Appropriate PPE in the correct sizes is readily accessible at the worksite or is issued to employees beforehand. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
PPE is cleaned, laundered, and disposed of at no cost to the employee.
PPE is repaired or replaced as needed to maintain its effectiveness, at no cost to the employee.

A. Removal of PPE

If a garment(s) is penetrated by blood or OPIM, the garment(s) shall be removed immediately or as soon as feasible.
All PPE shall be removed prior to leaving the work areas where unfixed human tissues, human blood or OPIM are handled.
When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

B. Gloves

Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, OPIM, mucous membranes, or non-intact skin, and when handling contaminated items or surfaces.
Disposable (single use) gloves, such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn or punctured, or when their ability to function as a barrier is compromised.
Disposable (single use) gloves shall not be washed or decontaminated for re-use.
Utility type gloves may be decontaminated for re-use if the integrity of the glove is not compromised. The gloves must be discarded, however, if they are cracked, peeling, torn, or punctured.

C. Masks, Eye Protection, Face Shields and Respirators

Masks, in combination with eye protection devices, such as goggles or glasses with wraparound side shields or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated and eye, nose, or mouth contamination can be reasonably anticipated. (This protective equipment is usually recommended in medical or injury environments where blood spatter is a concern.)

For medical or first aid personnel, surgical masks designed for use with blood and bodily fluids may be used in accordance with current acceptable medical practices for this purpose.

Note that NIOSH N95 dust masks ARE NOT air-purifying respirators. They are designed to filter out particulates and aerosols only, including aerosolized blood droplets. Contact the EH&S Dept for details concerning the policy for using dust masks (filtering facepiece respirators) for exposure to human blood or OPIM.

If air purifying respirators are deemed necessary, contact the EH&S Dept to ensure compliance with the CSUN Respiratory Protection Program at ehs@csun.edu.

D. Gowns, Aprons, and Other Protective Body Clothing

Appropriate protective clothing including, but not limited to, gowns, aprons, lab coats, work uniforms, or similar outer garments shall be worn in occupational exposure situations.

XIV. Biohazardous/Medical Waste Disposal

The information below describes the general procedures for handling waste contaminated with human blood or OPIM. Medical waste storage and disposal procedures must comply with the California Medical Waste Management Act (MWMA) found in the Health and Safety Code: CA HSC Section 117600 – 118360 and with Cal/OSHA’s Bloodborne Pathogen standard.

Sharps containers, biohazard bags, and biohazardous/medical waste containers must meet the requirements described in the current version of the MWMA.

Properly dispose of contaminated waste as described below and full sharps containers promptly.

A. Medical Waste/Human Blood or OPIM Waste

The term, “Medical Waste” includes biohazardous, pathology and sharps waste, not regulated by the federal Resource Conservation and Recovery Act of 1976 (RCRA), as amended. Some of the sources specified in the MWMA definition of “medical waste”, section 117690 are listed below:

Waste generated in the care of humans and animals in a health care setting
Waste generated from the cleanup of trauma scenes
Waste generated in research using human or animal pathogens
Waste generated from the consolidation of home-generated sharps
Sharps waste, including hypodermic needles, hypodermic needles with syringes, blades, needles with attached tubing, and broken glass items used in health care.

Tampons, tissues, and other OPIM in public areas, such as restrooms, hallways and housing units, are not considered “medical” waste.

1. Medical Facility and Laboratory Waste

Collect “Sharps” waste in commercially purchased sharps containers indicated as approved by the US FDA as required in CA HSC Section 117750.
Collect other contaminated waste in hard-sided containers lined with a red biohazard bag. All sides and lid must have the international biohazard symbol, the words “biohazard” or “biohazardous waste”, be hard-sided and have a tightly closeable lid. Biohazard bags must meet the requirements in CA HSC Section 117630.
Waste is picked up by a licensed contractor weekly from designated storage areas in the Student Health Center, and Science buildings.

2. Waste from Restrooms, Athletics and Other Public Areas

Collect “Sharps” waste in commercially purchased sharps containers meeting approved by the US FDA as required in CA HSC Section 117750.
Collect contaminated materials in an opaque heavy-duty trash bag, seal or tie it shut, and dispose of in an outdoor municipal trash bin.
Place heavily blood-soaked clothing, towels, etc. in a red biohazard bag, taped or tied shut, and take to Student Health Services for disposal.

3. Waste Resulting from Police Activities

This is a special case where contaminated materials may be evidence. University Police protocols will be followed.

Remaining contaminated materials may be collected in an opaque heavy-duty trash bag, sealed shut, and disposed of in an outdoor municipal trash bin.
Heavily blood-soaked clothing, towels, etc. should be placed in a red biohazard bag, sealed shut, and taken to Student Health Services for disposal.
Collect needles and syringes “Sharps” waste in commercially purchased sharps containers.
Major trauma scene waste and clean up must be handled by an outside contractor.

Hire a registered Trauma Scene Waste Management Practitioner to clean up and collect contaminated materials from crime and trauma scenes where there is a lot of blood —more than is reasonable for Custodial Services to handle.

4. Storage in Designated Biohazardous/Medical Waste Areas

To ensure the safety of medical waste handlers, the person responsible for the waste room must check the following prior to pick-up by the EH&S approved contractor:

The collection container must be closed.
The container must be constructed to contain all contents and is not leaking.
The container is not over-filled. The red biohazard bag liner must be able to tie or be taped securely closed.
All bins, pails, and cans intended for reuse, which have reasonable likelihood for becoming contaminated with blood or OPIM, shall be inspected and decontaminated immediately, or as soon as feasible, upon seeing evidence of visible contamination.

Supervisors must review the specific procedures in their ECP for contaminated waste collection and disposal for their group, which includes the general procedures above.

B. Additional Campus Documents

This BBP Program Manual describes the general requirements for handling and storing waste contaminated with human blood and OPIM to protect the health and safety of employees. Other campus documents provide additional information and procedures for contaminated waste:

CSUN Medical Waste Management Plan
- Describes how the campus will comply with California’s Medical Waste Management Act.
CSUN Biosafety Program Manual
- Provides detailed procedures for the storage, treatment, and disposal of the different types of biological wastes generated in science research and academic laboratories.
Work-specific Exposure Control Plan
- Provides detailed procedures for handling waste contaminated with human blood, unfixed human tissues and OPIM for a specific group, department, or laboratory that meets the requirements of the campus BBP Program manual.

C. Additional Requirements for Handling Contaminated Sharps

1. Requirements for Handling Contaminated Sharps

Immediately after use, contaminated sharps shall be placed in sharps containers. Sharps containers shall be:

Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found
Replaced as necessary to avoid overfilling (the fill line or 3⁄4 full is considered the point at which a container is full)
Rigid and puncture resistant
Leak proof on the sides and bottom
Portable, if portability is necessary to ensure easy access by the user
Labeled with the International Biohazard Symbol and word “biohazard”

2. Disposal of Sharps Containers

When ready for disposal, the sharps container shall be:

Closed and secured immediately upon reaching the 3⁄4 full line to prevent protrusion or leakage of contents during handling, storage, transport, or shipping
Placed in a secondary container prior to pick-up by the contractor
Disposed of within 30-days of becoming full.

3. Pipette Disposal

Glass pipettes may puncture biohazard bags and should be disposed of similarly to sharps.

Pipettes must be placed in a pipette disposal pouch or box (shown below) prior to placement in a biohazard bag for disposal.
Plastic pipettes or pipette tips may be placed directly in a bag if the length or configuration will not puncture the bag.
Otherwise, pipettes must be disposed in a rigid container, such as a sharps container.

D. Trauma Scene Waste

California’s Trauma Scene Waste Management Act is included as Chapter 9.5 of the MWMA and

regulates “...the handling and treatment of waste that, but for contamination with large quantities of human blood or body fluids as a result of death, serious injury, or illness, would otherwise be solid (municipal) waste”. Contractors must be registered with the CA Department of Public Health as Trauma Scene Waste Management Practitioners.

XV. Cleaning and Decontamination of the Work Area

Decontamination of surfaces where human blood or OPIM was spilled is essential to preventing the spread of potentially infectious materials. Allow the disinfectant enough time to work as specified by the manufacturer or CDC recommendations for bleach solutions.

A. Public Areas on Campus

Spills and contamination in public areas must be cleaned and disinfected as soon as possible by trained Custodial Services staff.

Put on gloves and protective eyewear
Blot spilled body fluids with paper towels to remove as much liquid as possible
Use pre-approved disinfectant cleaner and allow to sit for the time recommended by the manufacturer.
- Ifusingafresh10%bleachsolution, let sit for at least 20 minutes.
- Follow up with a water rinse if concerned about residue left by bleach
Wipe down and dispose of cleaning materials and gloves into a sturdy dark plastic bag

B. Research and Teaching Laboratories

Laboratory work areas must be maintained in a clean and sanitary condition. All equipment, the environment, and work surfaces shall be cleaned and decontaminated after contact with blood or OPIM no later than the end of the shift.

Contaminated work surfaces shall be cleaned and decontaminated with an appropriate disinfectant immediately or as soon as feasible when:

Surfaces become visibly contaminated
There is a spill of blood or OPIM
Procedures are completed

70% ethanol, 10% bleach, or other approved disinfectant solution or product may be used to wipe down surfaces in teaching and research laboratories and allowed to sit for the recommended time.

Remove or replace protective coverings, such as plastic wrap, aluminum foil, or imperviously- backed absorbent paper used to cover equipment and environmental surfaces, as soon as feasible when they become visibly contaminated, or at the end of the work shift if they may have become contaminated during the shift.

C. Disinfectants and Sanitizers: Antimicrobial Pesticides

Effective disinfectants and sanitizers are regulated as “antimicrobial pesticides” by the US EPA.

An antimicrobial pesticide is intended to disinfect, sanitize, reduce, or mitigate growth or development of microbiological organisms or protect inanimate objects, industrial processes or systems, surfaces, water, or other chemical substances from contamination, fouling, or deterioration caused by bacteria, viruses, fungi, protozoa, algae, or slime.

Under the BBP Program, “approved” disinfectants must be registered with the US EPA, have appropriate documentation available, and include the registration number on the label.

XVI. Recordkeeping

The Environment, Health, & Safety department is responsible for the occupational medical and exposure incident records as described in this BBP Program Manual.

A. Medical Records

California regulations require employers, such as CSUN, to establish and maintain an accurate record for each employee with occupational exposure. This record shall include:

The name and social security number of the employee;
A copy of the employee's hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination
A copy of all results of examinations, medical testing, and follow-up procedures
The employer's copy of the healthcare professional's written opinion
A copy of the information provided to the healthcare professional

Records are kept confidential and not disclosed or reported without the employee's express written consent to any person within or outside the workplace, except as required by law. Records are maintained for at least the duration of employment plus 30 years.

B. Exposure Incident

Following a report of an exposure incident, CSUN shall make immediately available to the exposed employee a confidential medical evaluation and follow-up through their approved occupational medicine provider. This medical evaluation and follow-up will include at least the following elements:

Document the route(s) of exposure, and the circumstances under which the exposure incident occurred;
Identify and document the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law;
Test the source individual's blood as soon as feasible and after consent is obtained in order to determine HBV, HCV and HIV infectivity. If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.
- When the source individual is already known to be infected with HBV, HCV or HIV, testing for the source individual's known HBV, HCV or HIV status need not be repeated.
Make available the results of the source individual's testing to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

CSUN or approved occupational medical services provider shall provide for collection and testing of the employee's blood for HBV, HCV and HIV serological status; the exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained. If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.

Additional collection and testing shall be made available as recommended by the U.S. Public Health Service.

The following consent forms are required after reporting an incident involving a potentially exposed employee. These forms are provided by the medical services provider during the follow- up evaluation:

Informed Consent for Blood Testing of Source Person Following Staff Exposure to Bodily Fluids
Employee Consent to Perform HIV (AIDS Virus) Antibody Test
Post-Exposure Evaluation and Follow-up Form

XVII. References

California Code of Regulations Title 8, Section 5193

OSHA 29 CFR 1910.1030

Biosafety in Microbiological and Biomedical Laboratories

XVIII. Forms Used

Exposure Incident Report Form

Hepatitis B Vaccine Declination Form

Post-Exposure Evaluation & Follow-up Form

Sharps Injury Log