Environmental Health & Safety

In Compliance with 29 CFR 1910.1030 OSHA Standard for Occupational Exposure to Bloodborne Pathogens

Bloodborne Pathogens Exposure Control Plan

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Post-Exposure, Evaluation and Follow-up

The plan for post-exposure evaluation and follow-up will ensure that: measures are taken to minimize the risk of infection secondary to the exposure; that the circumstances surrounding the exposure are investigated and documented; and that the employee receives medical consultation, follow-up, and treatment, if necessary, in a timely and expeditious fashion.

Any employee sustaining skin, mucous membrane, or percutaneous contact with blood or other potentially infectious materials shall cleanse the affected areas as soon as possible, as follows:

Intact skin - wash with soap and water.
Non-intact skin and needlesticks/scalpel cuts - wash with soap and water.
Intra-oral exposure - spit and rinse the mouth well with water.
Eyes - rinse well with sterile saline or water (if available), or with tap water. (Note: Remove contact lenses first. After rinsing eyes, disinfect contacts per manufacturer's recommendation.)

An employee who has had an exposure is required to:

Report exposure, as soon as possible, to the Blood Exposure Hotline 24/7 at 275-1164. During off-hours, the answering service will notify the Employee Health nurse on-call to triage the exposure incident.
Contact his/her supervisor
Fill out an incident report form (www.safety.rochester.edu/SMH115.html

Post-exposure evaluation and follow-up will include the following:

Date, time, and location of exposure
Route(s) of exposure
Type of infectious material
Circumstances under which the exposure incident occurred, including task performed, type of accident, equipment malfunction, personal protective equipment in use, etc.
Identification of the source individual, if known, unless not feasible or prohibited by state law.

If possible, the source individual's blood shall be tested for human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV). Written consent is required for HIV testing.

When the source individual is already known to be infected with HIV, retesting is not usually necessary. When the source individual is known to be HBV or HCV positive, additional confirmatory tests of infectiousness may be appropriate.

If a notification waiver is obtained from the source individual (as required by New York law), results of the source individual's testing shall be made available to the exposed employee (through the evaluating UHS healthcare provider), and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

If consent for testing or notification waiver cannot be obtained from the source individual, this will be documented in writing.

An exposed employee will be referred, as soon as possible, for medical evaluation and follow-up. (An evaluation may be initiated by telephone for nights, weekends, holidays). An exposed employee may designate his/her own physician for post-exposure medical evaluation and/or follow-up.

The provider will have access to the following information. If the employee designates his/her own physician for post-exposure medical evaluation, upon notification of this designation, SMH Employee Health will forward to that healthcare provider the following information:

A copy of the OSHA Bloodborne Pathogens Standard;
A description of the exposed employee's duties as they relate to the exposure incident;
Documentation of the route(s) of exposure and circumstances under which exposure occurred;
Results of the source individual's testing, if available, except as prohibited by law;
All medical records relevant to the treatment of the employee, including vaccination status, which are the employer's responsibility to maintain.

The healthcare provider will obtain the employee's blood for baseline serologic testing as soon as feasible. Serologic testing for HBV and HCV antibody status will be offered and performed in accordance with CDC recommendations. HIV testing will be performed only after written, informed consent is obtained and pretest counseling is provided. If the employee consents to baseline blood collection, but does not consent at that time to 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.

The healthcare provider will advise and counsel the exposed employee with respect to the risk of infection with bloodborne pathogens resulting from the exposure; appropriate treatment and follow-up, based on CDC recommendations and current standards of practice, will be provided.

Post-exposure hepatitis B prophylaxis will be provided in accordance with CDC guidelines
Post-exposure prophylaxis (PEP) following HIV exposure will be evaluated and provided on a case-by-case basis in accordance with CDC recommendations and current practice. PEP may be offered with combinations of antiretroviral drugs depending on the type of exposure, the source material involved, and the likelihood of resistance to various antiretroviral agents. PEP, when indicated, should be initiated as soon as possible after the exposure incident, preferably within hours.
Evaluation of reported illnesses - the employee will be advised to report and seek medical evaluation at SMH Employee Health or at their designated healthcare provider for any acute illness during the follow-up period, especially the first 12 weeks following exposure. Such illness, particularly if characterized by fever, rash, myalgia, malaise, or lymphadenopathy may be indicative of recent HIV infection.
The healthcare provider will inform the employee of his/her baseline test results and provide post-test counseling.
Following a documented or suspected exposure to HIV, HBV, and/or HCV, the exposed employee will be offered repeat follow-up testing at 4 weeks, 3 months, and 12 months, as appropriate per CDC recommendations.

SMH Employee Health will provide to the employee a copy of the evaluating healthcare provider's written opinion within 15 working days of the completion of the evaluation. This written opinion is limited to the following:

Whether hepatitis B vaccination is indicated for the employer, and whether such vaccination has been administered.
That the post-exposure evaluation was performed, and that the employee has been informed of the results of that evaluation.
That the employee had been told about any medical conditions resulting from the exposure which require further evaluation or treatment.
All other findings, including diagnoses and test results, remain confidential and shall not be included in the written report.

Continue to References and Appendices

QUESTIONS? Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 8/22/2019. Disclaimer