X. Infection Control Program (Bloodborne Pathogens)

The purpose of this program is to reduce or eliminate occupational exposure to blood and other potentially infectious materials to state employees. This exposure control plan can minimize or eliminate exposure through the use of protective equipment, training, clean up procedures and medical protocol involving post exposure evaluation.

All bodily fluids will be considered infectious regardless of the perceived status of the source individual. Procedures for providing first aid and decontaminating/sanitizing contaminated areas will duplicate those developed and used by health industry.


Engineering Controls – means controls (sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.
Infection Control Program – each employer having an employee(s) with occupational exposure must establish a written Infection Control Program designed to eliminate or minimize employee exposure.
Occupational Exposure – means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from performance of duties by faculty, staff, students or visitors.
containing cell or tissue cultures, organ cultures, and HIV or HBV containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Regulated Waste – means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other 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.
Work Practice Controls – means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two handed technique).
Other Potentially Infectious Materials means:
a.  The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate body fluids.
b.   Any unfixed tissue or organ (other than intact skin) from human (living or dead).
c.   HIV-containing cell or tissue cultures, organ cultures, and HIV or HBV-containing culture medium or other solutions; and blood, organs, or other tissue from experimental  animals infected with HIV or HBV.

Components of the Infection Control Program
A.  Exposure Determination
B.   Controls Methods

  • Universal Precautions
  • Engineering Controls
  • Work Practice Controls
  • Personal Protective Equipment

C.     HBV Vaccination
D.     Medical (Post-Exposure Evaluation and Follow-up)
E.      Infectious Waste Disposal
F.     Tags, Labels and Bags
G.     Housekeeping Practices
H.     Laundry Practices
I.      Training and Education of Faculty, Staff, and Students
J.      Recordkeeping

A. Exposure Determination
Nicholls State University shall identify all faculty, staff, students, and visitors when possible, who are directly exposed or whose jobs have the likelihood of exposure to blood or other potentially infectious materials. Those at risk are those whose work may involve potentially infectious materials. They will include, but are not limited to:

  • Physicians
  • Health Services Personnel
  • Nurses
  • University Police
  • Athletic Trainers and Coaches
  • Accident Investigators
  • Designated Maintenance Personnel
  • Designated Housekeeping Personnel
  • Designated Laundry Workers
  • Health and Physical Education Workers
  • Swimming Pool Personnel (Life Guards, Swimming Instructors)
  • Recreation Instructors

Fluids that have been recognized by the Center for Disease Control (CDC) as directly linked to the transmission of HBV and/or HIV are: blood, blood products, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, concentrated HBV and HIV viruses, and saliva in dental settings.

Nicholls State University shall make exposure determination without regard to the use of personal protective equipment (PPE).

B. Control Methods
Universal Precautions – the term “Universal Precautions” refers to a method of infection control in which all human body and other potentially infectious materials are treated as if known to be infected for HBV and HIV. This concept emphasizes that all people treated by faculty, staff, and students should be assumed to be infectious for HIV and other bloodborne pathogens.

In all health care settings, “universal Precautions” should be followed when workers are exposed to blood, certain other body fluids, or any other body fluid visibly contaminated with blood. Since HBV and HIV transmission has not been documented from exposure to other body fluids (feces, nasal secretions, sputum, sweat, tears, urine, and vomit), “Universal Precautions” do not apply to these fluids, unless they contain visible blood. However, when emergency medical and public safety workers encounter body fluids under controlled circumstances in which differentiation between body fluid types is difficult, if not impossible, they should treat all body fluids as potentially hazardous.

Engineering Controls – an “Engineering Control” is the use of available technology and devices to isolate or remove hazards to the individual.

  • Engineering controls should be used in preference to other control methods to eliminate or minimize exposure to blood or other potentially infectious materials.
  • Engineering controls should be examined and maintained or replaced on a regular basis to ensure their effectiveness.
  • Examples of engineering controls include but are not limited to: puncture resistant sharps containers, splash guards, mechanical pipetting, and self-sheathing needles.

Work Practice Controls – “Work Practice Controls” are alterations in the manner in which a task is performed in an effort to reduce the likelihood of an individual’s exposure to blood or other potentially infectious materials.

  • Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which universal precautions apply, or potentially contaminated articles. Hands should always be washed after gloves are removed, even if the gloves appear to be intact. Hand washing should be completed using appropriate facilities, such as utility or restroom sinks. Waterless antiseptic hand cleanser should be provided on responding units when hand washing facilities are not available. When hand washing facilities are available, wash hands with warm water and soap. When hand washing facilities are not available, use a waterless antiseptic hand cleanser.
  • All personal protective equipment (PPE) should be removed immediately, or as soon as possible upon leaving the work area, and placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

Personal Protective Equipment (PPE)
Appropriate personal protective equipment should be made available routinely by the employer to reduce the risk of exposure as defined above. For many situations, the chance that the rescuer will be exposed to blood and other fluids to which universal precautions apply can be determined in advance. Therefore, if the chance of being exposed to blood is high (e.g. CPR, IV insertion, trauma), the individual should put on protective equipment before administering aid.

The following list sets forth examples and recommendations for personal protective equipment in the pre-hospital setting; the list is not intended to be all inclusive.

Task/Activity Gloves Gown Mask Eyewear
Bleeding control w/ spurting blood YES YES YES YES
Bleeding control w/ minimal bleeding YES NO NO NO
Emergency Childbirth YES YES YES YES
Blood Drawing ALWAYS NO NO NO
Starting an IV YES NO NO NO
Endotracheal intubation YES NO YES YES
Oral/Nasal Suctioning YES NO YES YES
Handling/Cleaning instruments with microbial contamination YES NO, Unless soiling likely NO NO
Measuring Blood Pressure & Temp. NO NO NO NO
Giving an injection YES NO NO NO

Gloves- disposable gloves should be a standard component of emergency response equipment, and should de donned by all personnel prior to initiating any emergency patient care tasks involving exposure to blood or other body fluids to which universal precautions apply. Extra pairs should always be available. Considerations in the choice of disposable gloves should include dexterity, durability, fit, and the task being performed. For situations where larger amounts of blood are likely to be encountered, it is important that gloves fit tightly at the wrist to prevent blood contamination of hands around the cuff. It is recommended to wear two (2) pair of gloves when this type of situation is encountered. For multiple trauma victims, gloves should be changed between patient contacts, if the emergency situation allows. Of course greater personal protective equipment measures are indicated for situations where broken glass and sharp edges are likely to be encountered.

While wearing gloves, avoid handling personal items, such as combs and pens that could be soiled or contaminated. Gloves that have been contaminated with blood or other body fluids to which universal precautions apply should be removed as soon as possible, taking care to avoid skin contact with the exterior surface. Contaminated gloves should be placed and transported in disposable, intact bags that prevent leakage and should be disposed of in red, biohazard containers, or in the case of reusable gloves, cleaned and disinfected properly.

Masks, Eyewear, and Gowns – this equipment should be present for all emergency response personnel that respond to medical emergencies or victim rescues. These protective barriers should be used in accordance with the level of exposure encountered. Minor lacerations or small amounts of blood do not merit the same extent of barrier use as required for massive bleeding. Management of the patient who is not bleeding, and who has no body fluids present, should not routinely require use of barrier precautions. Masks and eyewear (safety glasses) should be worn together, or all personnel prior to any situation should use a face shield where splashes of blood or other body fluids to which universal precautions apply are likely to occur. Gowns or aprons (disposable) should be worn to protect clothing from splashes with blood. If large splashes or quantities of blood are present or anticipated, impervious gowns or aprons should be worn. An extra change of work clothing should be available at all times.

Resuscitation Equipment – No transmission of HBV or HIV infection during mouth-to-mouth resuscitation has been documented. However, because of the risk of salivary transmission of other infectious diseases (e.g., herpes simplex and Neisseria meningitidis) and the theoretical risk of HBV and HIV transmission during artificial ventilation of trauma victims, disposable airway equipment or resuscitation bags should be used. Disposable resuscitation equipment and devices should be used once and disposed of or, if reusable, thoroughly cleaned and disinfected after each use according to the manufacturer’s recommendations.

Pocket mouth-to-mouth resuscitation masks (two-way valve system) designed to isolate emergency response personnel (i.e., double lumen systems) from contact with victim’s blood and blood contaminated salvia, respiratory secretions, and vomit should be provided to all personnel who provide or potentially provide emergency treatment.

C. HBV Vaccination
All workers whose jobs involve participation in tasks or activities with exposure to blood or other body fluids to which universal precautions apply should receive or be offered the Hepatitis B vaccine. The OSHA standard requires the employer to offer the three injection vaccination series free to all employees who are exposed to blood or other potentially infectious materials as part of their job duties. The vaccination must be offered within ten (10) days of initial assignment to these type job duties.

If the individual declines the HBV vaccine, he or she must sign a declination form (any time after an individual initially declines to receive the vaccine, he or she may opt to take it). A current medical file will be maintained at University Health Services during the employee’s current employment. This information will also be kept in the individual’s personnel and medical file for thirty (30) years after they terminate employment or permanently leave school.

The cost of the HBV vaccine will be assumed by Nicholls State University and administered by a medical facility of the University’s choice.

D. Medical (Post-Exposure Evaluation and Follow-Up)
OSHA’s bloodborne pathogens standard includes provisions for medical follow-up for individuals who have an exposure incident. The most obvious exposure incident is needlestick. But any specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials is considered an exposure incident and should be reported to University Health Services immediately. Reporting an incident right away permits immediate medical follow-up. Early action is crucial. Prompt reporting can help the individual avoid spreading bloodborne infection to others.

Nicholls must provide medical evaluation and treatment to employees who experience an exposure incident. Once an exposure has occurred, a blood sample should be drawn after consent is obtained from the individual from whom exposure has occurred and tested for Hepatitis B antigen (HBsAg) and antibody to human immunodeficiency virus (HIV). Policies should be available for testing source individuals in situations where consent cannot be obtained (e.g., an unconscious patient). Testing of the source individual should be done at a location where appropriate pretest counseling is available; post-test counseling and referral for treatment should be provided. It is extremely important that all individuals that seek consultation for any HIV-related concerns receive counseling as outlined in the “Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS”.

Any employee who wants to participate in the medical evaluation program must agree to have blood drawn. However, the employee has the option to give the blood sample but refuse permission for HIV testing at the same time. The employee’s blood sample shall be maintained for ninety (90) days in case the employee changes his or her mind about testing, should symptoms develop that might relate to HIV or HBV infection.

If a Nicholls State University employee or student is referred for counseling to a health care provider, the health care provider will provide a written report to the Human Resources Department. This report will identify whether Hepatitis B vaccination was recommended for the exposed employee or student, and whether or not a vaccination was received. The health care provider must also note that the individual has been informed of the results of the evaluation and told of any medical conditions resulting from exposure to blood which requires further evaluation or treatment. Any added findings must remain confidential.

Hepatitis B Virus Post Exposure Management
For an exposure to a source individual found to be positive for HBsAg, the individual who has not previously been given Hepatitis B vaccine should receive the vaccine series. A single dose of Hepatitis B immune globulin (HBIG) is also recommended, if this can be done within seven (7) days of exposure. For exposures from an HBsAg-positive source to individuals who have previously received the vaccine, the exposed individual should be tested for the antibody to Hepatitis B surface antigen (anti-HBs), and given one dose of vaccine and one dose of HBIG if the antibody level in the employee’s blood sample is inadequate (i.e., <10 SRU by RIA, negative by EIA).

If the source individual is negative for HBsAg and the other person has not been vaccinated, this opportunity should be taken to provide the Hepatitis B vaccination

If the source individual refuses testing or he/she cannot be identified, the unvaccinated person should receive the Hepatitis B vaccine series. HBIG administration should be considered on an individual basis when the source individual is suspected or known to be at high risk of HBV infection. Management and treatment, if any, of previously vaccinated individuals who receive an exposure from a source who refuses testing or is not identifiable should be individualized.

HIV Post Exposure Management
For any exposure to a source individual who has AIDS, who has been found to be positive for HIV infection, or who refuses testing, the person who was exposed to this individual should be counseled regarding the risk of infection and evaluated clinically and serologically for evidence of HIV infection as soon as possible after the exposure. The exposed person should be advised to report and seek medical evaluation for any acute febrile illness that occurs within twelve (12) weeks after exposure.

Such an illness, especially one characterized by fever, rash, or lymphadenopathy, may be indicative of a recent HIV infection. Following the initial test at the time of exposure, seronegative individuals should be retested 6 weeks, 12 weeks, and 6 months after exposure to determine whether transmission has occurred. During the follow-up period (especially the first 6-12 weeks after exposure, when most people are expected to seroconvert) exposed individuals should follow U.S. Public Health Service (PHS) recommendations for preventing transmission of HIV. These include refraining from blood donation and using appropriate protection during sexual intercourse. During the follow-up, the person’s confidentially should be honored.

Management of Human Bites
On occasion, suspects or prisoners may bite University Police personnel. When such bites occur, routine medical and surgical therapy (including an assessment of tetanus vaccination status) should be implemented as soon as possible, since such bites frequently result in infection with organisms other than HBV or HIV. Victims of such bites should also be evaluated for exposure to blood or other infectious body fluids and receive follow-up evaluation when indicated.

Disinfection, Decontamination, and Disposal
Needle and Sharps Disposal – all individuals should take precautions to prevent injuries caused by needles, scalpel blades, and other sharp instruments or devices used during procedures; when cleaning contaminated instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needle stick injuries, needles must not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable needles and syringes, scalpel blades and other sharp instruments must be placed in puncture resistant, biomedical containers for disposal. The puncture resistant containers must be located as close as practical to the use area (includes portable equipment).

Hand Washing – Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which universal precautions apply, or potentially contaminated articles. Hands should always be washed after gloves are removed, even if gloves appear to be intact. Hand washing should be completed using appropriate facilities, such as utility or restroom sinks. Waterless antiseptic hand cleanser should be provided on responding units for use when hand washing facilities are not available. When hand washing facilities are available, wash hands thoroughly with warm water and soap.

Cleaning and Decontaminating Spills of Blood – All spills of blood and blood-contaminated fluids should be promptly cleaned up using EPA approved germicide or a 1:10 solution of household bleach (this solution must be fresh daily and not contaminated) in the following manner while wearing gloves. Visible material should be first removed with disposable towels or other appropriate means that will ensure against direct contact with blood. If splashing is indicated, protective eyewear should be worn along with an impervious gown or apron which provides an effective barrier to splashes. The area should be decontaminated with an effective germicide or approved bleach solution. Hands should be washed after the removal of gloves. Soiled clothing should be cleaned for waste disposal. Plastic bags of at least 6 mil thicknesses should be available for removal of contaminated items from the spill site.

Laundry – Although soiled linen may be contaminated with pathogenic microorganisms, the risk of actual disease transmission is negligible. Laundry facilities or services should be made routinely available by Nicholls. Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linen should be handled at the site where it was used. Linen soiled with blood or other body fluids should be transported in bags that prevent leakage.

Decontamination of Protective Clothing – Protective clothing should be decontaminated per manufacturers’ recommendations. All protective clothing should be transported in plastic bags or containers which prevent leakage. Personnel involved in cleaning this clothing should wear gloves.

Infective Waste – Infective waste should be incinerated or decontaminated for disposal in a sanitary landfill. Bulk blood, suctioned fluids, excretions, and secretions may be carefully poured down a drain connected to a sanitary sewer, where permitted. Sharp items should be placed in puncture-proof containers and other blood–contaminated items should be placed in leak-proof plastic bags for transport to an appropriate disposal location.

E. Infectious Waste Disposal (Procedures and Guidelines)
Disposal of all infectious waste shall be in accordance with local, state and federal regulations.

All infectious waste shall be placed in closable leak-proof container or bags that are color-coded, labeled and tagged. All regulated waste containers, including sharps containers, must be color-coded (orange or orange-red) or labeled with an orange or orange-red label containing the biohazard symbol or phrase “BIOHAZARD” in contrasting colors. If a label is used, it must be securely attached to the container to prevent accidental or unintentional removal.

University Health Services will be designated as the “Collection Center” for all infectious/biohazard waste generated on campus.

Clipping, cutting, shearing or breaking of contaminated needles is prohibited. Contaminated, broken glassware is considered a “sharp”. And must be picked up via mechanical methods (i.e., tongs, dust pan, etc.), never by hand, and then placed directly into a sharps container for proper disposal. Furthermore, all other items such as scalpel blades, needles, and disposable syringes shall be placed in puncture resistant, biohazard containers for disposal.

Puncture resistant sharps containers shall be easily accessible to workers and located in areas where they are commonly used.

Disposable sharps containers shall be used for disposable sharps. In addition to color-coding or labeling, these containers must be:

  • Closable
  • Puncture Resistant
  • Leak-proof on sides and bottom
  • Maintained upright throughout use
  • Routinely replaced and not allowed to refill

Other non-sharp regulated waste such as contaminated gauze, paper products, bandages, etc., must be placed into biohazard containers which are color-coded or labeled and are:

  • Closable
  • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping
  • Closed prior to removal to prevent spillage or leakage of contents during handling , storage, transport or shipping
  • If outside contamination of this waste container occurs, it must be placed into a secondary container which meets all the above criteria

Lab specimens of body fluids shall be transported in a container that will prevent leaking and disposed of in accordance with regulatory requirements.

F. Tags, Labels, and Bags
Tags that comply with 29CFR 1910.145 (f) shall be used to identify the presence of an actual or potential biological hazard.

Tags shall contain the word “BIOHAZARD” or the biological hazard symbol and state the specific hazardous condition or the instructions to be communicated to faculty, staff and students.

The word and message shall be understandable to all faculty, staff and students who may be exposed to the identified hazard.

Labels/Tags may be an integral part of the container or affixed as close as safely possible to their respective hazards by string, wire, or adhesive to prevent their loss or unintentional removal.

Red bags or red containers (orange-red) may be substituted for labels on containers of infectious waste.

All faculty, staff and students shall be informed of the meaning of various labels, tags and color-coding system.

G. Housekeeping Practices
Nicholls shall maintain its facilities in a clean and sanitary condition.

Nicholls, in conjunction with affected departments, shall determine and implement an appropriate cleaning schedule for rooms where blood or body fluids are present.

Nicholls will ensure that housekeeping personnel wear appropriate PPE including general purpose utility gloves during all cleaning of blood or other potentially infectious materials and during decontaminating procedures.

Initial cleanup of blood or other potentially infectious materials shall be followed by the use of an approved hospital disinfectant chemical germicide that is tuberculocidal or a solution of household bleach diluted 1:10 with water.

Equipment contaminated with blood or other potentially infectious material shall be checked routinely and decontaminated if possible prior to shipping or servicing.

H. Laundry Practices
Nicholls will ensure that those employees doing laundry work wear protective gloves and other appropriate personal protective equipment to prevent exposure to blood or other potentially infectious materials during handling or sorting of laundry items.

Laundry that is contaminated with blood or other body fluids, or that may contain contaminated needles or sharps shall be treated as if it were HBV/HIV infectious and handled as little as possible with a minimum of agitation.

Contaminated laundry shall be bagged at the location where it was used.

Contaminated laundry shall be placed and transported in bags that are labeled or color-coded and that prevent liquid seepage if such potential exists.

I. Training and Education of Faculty, Staff, and Students
Environmental Health and Safety Department will ensure that all faculty, staff, students, and visitors with exposure to blood or other potentially infectious materials participate in a training and education program. Any department initiating a training program, other than the one administered by Environmental Health and Safety, must submit their curriculum plan to Environmental Health and Safety for review and approval before implementation (records of training will be submitted to Environmental Health and Safety).

Material appropriate in content and vocabulary or educational level, literacy, and language background shall be used in the training/education program.

Workers with a high risk of occupational exposure shall receive training within ninety (90) days of hire and annually thereafter. All low-risk employees shall participate in a BBP training program within one (1) year of employment and every five (5) years thereafter.

The training/education program shall include the following:

  • A general explanation of the epidemiology and symptoms of HBV and HIV.
  • An explanation of the modes of transmission of HBV and HIV.
  • An explanation of Nicholls’ Infection Control Program.
  • An explanation of the use and limitations of methods of control that may prevent or reduce exposure including universal precautions, engineering controls, work practices and personal protective equipment (PPE).
  • An explanation of the basis of selection of PPE.
  • Information on the HBV vaccine, including its efficacy, safety and the benefits of being vaccinated.
  • An explanation of the procedure to follow if an exposure incident occurs, method of reporting the incident, and the medical follow-up that will be available.
  • An explanation of the signs, labels, tags, and/or color-coding used to denote biohazards.

Training records shall include the following:

  • Date of the training session
  • Contents or summary of the training session(s)
  • Names and qualifications of the person(s) conducting the training
  • Names and job titles of person(s) attending the training session(s)

Training records shall be maintained for three (3) years from the date the training occurred. Records shall be made available according to the following requirements:

  • Environmental Health and Safety will ensure that all training records required to be maintained shall be made available upon formal request by employees for examination and copying.
  • Employees medical records shall be provided upon request for examination and copying to the subject employee or to anyone having written consent of the subject employee, otherwise confidentiality requirements must apply.

NOTE: Medical records must remain confidential. They are not available to the employer. The employee or student must give specific written consent for anyone to see their record. Records must be maintained for the duration an employee or student is active at Nicholls State University, plus thirty (30) years in accordance with OSHA’s standard on access to employee exposure and medical records.

All visitors to the Nicholls campus, who may be on campus for an extended visit, such as visiting professors, health care personnel, contractors, etc. and may be exposed to blood, infectious body fluids, or infectious materials during the scope of their temporary stay, will receive appropriate Infection Control Program (ICP) training and education.

J. Biohazard Incidents
Any biohazard cleanup must be handled only by qualified personnel. If such a spill occurs, University Police should be contacted at extension 4911. The dispatcher should be given the necessary information such as building name, room number, floor level, injuries (if any) and the name of the person calling. University Police will then notify Environmental Health and Safety for cleanup. In the event biohazard cleanup is needed within departments of University Health, Allied Health, and the Nursing Programs department specific procedures shall be followed.

K. Recordkeeping
Nicholls will tract each person’s reported exposure incident to blood or other potentially infectious materials. Employee’s records of exposure are to be kept on file at Nicholls State University, in the Human Resources Department, for thirty (30) year after termination of employment.