+---------------------------------+-----------------------+------------+
| **BROOKHAVEN NATIONAL           | GCRC POLICY: IC-06.01 | PAGE 1 OF  |
| LABORATORY**                    |                       | 7          |
|                                 |                       |            |
| ######  GENERAL                 |                       |            |
| CLINICAL RESEARCH CENTER POLICY |                       |            |
+---------------------------------+-----------------------+------------+
|                                 | PREPARED BY: B. Pyatt |            |
|                                 | Infection Control     |            |
+---------------------------------+-----------------------+------------+
| SUBJECT: Bloodborne Pathogens   | REVIEWED BY: W.       |            |
| Exposure Control Plan           | Gunther GCRC Manager  |            |
+---------------------------------+-----------------------+------------+
|                                 | APPROVED BY: G. J.    |            |
|                                 | Wang Medical Dept.    |            |
|                                 | Chair                 |            |
+---------------------------------+-----------------------+------------+
|                                 | EFFECTIVE DATE:       |            |
|                                 | 4-18-08               |            |
+---------------------------------+-----------------------+------------+
|                                 | REVISION HISTORY: 5   |            |
+---------------------------------+-----------------------+------------+

**INTRODUCTION**

This plan has been developed in order to comply with the OSHA rule 29
CFR 1910.1030 entitled Occupational Exposure to bloodborne pathogens.

Infection with HIV, hepatitis B, C and other bloodborne pathogens
including those found in the blood, organs, or other tissues from
experimental animals infected with HIV or HBV(including primate blood)
can occur in both subjects and health care workers. Infection with these
pathogens cannot be predicted by superficial inspection of either
subject or health care worker and knowledge of this information cannot
be mandated. Therefore, the policy of the Medical Department is to
assume that all blood and other body fluids from all subjects are
potentially infectious. This plan is intended to limit occupational
exposure to bloodborne pathogens. It is based on CDC guidelines and OSHA
regulations and is available to all health care workers in this
Department. It is kept in the Medical Department's Infection Control
Manual on the SBMS database.

Infection Control and the GCRC Manager, shall review the plan at least
annually and the Department Chair to reflect modified tasks and
procedures, and revised employee positions with occupational exposure.

Other information related to this plan is available in the following
documents:

1\. OSHA Final Rule 29 CFR Part 1910.1030

2.  Bloodborne Pathogens Training documentation

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2.  Animal Studies at Clinical Facilities IC-13

Each employee is expected to comply with the provisions of the Exposure
Control Plan. It is, however, the responsibility of Principal
Investigators of Research Programs and Laboratory Supervisors to ensure
full compliance.

All full and part-time employees shall comply with all requirements of
this document if they are Category I (see Exposure Determination,
below). Students and on-site collaborators who will be in Category I
shall have Bloodborne Pathogen Training. On-site collaborators in
Category I shall produce evidence of hepatitis immunization or
declination from their home institution. The Quality Assurance, Care and
Safety Committee has determined that students in Category I shall be
apprised of the requirement for hepatitis immunization by their Sponsor
and advised to obtain and be prepared to document two of three required
injections prior to beginning work or sign the declination. The final
injection may be obtained at the Occupational Medicine Clinic. (See
OMC's Bloodborne Hazards (BBH) and Healthcare Provider (HCP) protocols.

#####  DEFINITIONS

**Blood** means human blood, human blood components, and products made
from human blood.

**Bloodborne Pathogens** means pathogenic microorganisms that are
present in human blood and can cause disease in humans. These pathogens
include, but are not limited to, hepatitis B virus (HBV) and human
immunodeficiency virus (HIV) also primate blood.

**Clinical Laboratory** means a workplace where diagnostic or other
screening procedures are performed on blood or other potentially
infectious materials.

**Contaminated** means the presence or the reasonably anticipated
presence of blood or other potentially infectious materials on an item
or surface.

**Contaminated Laundry** means laundry, which has been soiled with blood
or other potentially infectious materials or may contain sharps.

**Contaminated Sharps** means any contaminated object that can penetrate
the skin including, but not limited to, needles, scalpels, broken glass,
broken capillary tubes and exposed ends of dental wires.

**Decontamination** means the use of physical or chemical means to
remove, inactivate, or destroy bloodborne pathogens on a surface or
items to the point where they are no longer capable of transmitting
infectious particles, and the surface or item is rendered safe for
handling, use, or disposal.

**Engineering Controls** means controls (e.g., sharps disposal
containers, self-sheathing needles safer medical devices, such as sharps
with engineered sharps injury protections and needleless systems) that
isolate or remove the bloodborne pathogens hazards from the workplace.

**Exposure Incident** means a specific eye, mouth, other mucous
membrane, nonintact skin, or parenteral contact with blood or other
potentially infectious materials that results from the performance of
the employee\'s duties.

**Handwashing Facilities** means a facility providing an adequate supply
of potable water, soap and single use towels or hot air drying machines.

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 2 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

**HBV** means hepatitis B virus.

**HCV** means hepatitis C virus.

**HIV** means human immunodeficiency virus. Can be found both in humans
and primates.

**B-virus** is a virus carried by primates

**Needleless systems** means a device that does not use needles for:

1.  The collection of bodily fluids or withdrawal of body fluids after
    initial venous or arterial access is established;

2.  The administration of medication or fluids; or

3.  Any other procedure involving the potential for occupational
    exposure to bloodborne pathogens due to percutaneous injuries from
    contaminated sharps.

**Occupational Exposure** means reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or other

potentially infectious materials that may result from the performance of
an employee\'s duties.

**Other Potentially Infectious Materials** means

> 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
> body fluid that is visible contaminated with blood, and all body
> fluids in situations where it is difficult or impossible to
> differentiate between body fluids;
>
> 2\. Any unfixed tissue or organ (other than intact skin) from a human
> (living or dead); and
>
> 3\. HIV-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, HBV or
> B-virus.

**Parenteral** means piercing mucous membranes or the skin barrier
through such events as needlesticks, human bites, cuts, and abrasions.

**Personal Protective Equipment** is specialized clothing or equipment
worn 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.

**Regulated Waste** means 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.

**Research Laboratory** means a laboratory producing or using
research-laboratory-scale amounts of HIV or HBV. Research laboratories
may produce high concentrations of HIV or HBV but not in the volume
found in production facilities.

**Sharps with engineered sharps injury protections** means a nonneedle
sharp or a needle device used for withdrawing body fluids, accessing a
vein or artery, or administering medications or other fluids, with a
built in safety feature or mechanism that effectively reduces the risk
of an exposure incident.

**Source Individual** means 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 subjects; 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.

**Standard Precautions** is an approach to infection control. According
to this concept (1) blood; (2) all body fluids, secretions except sweat,
regardless of whether or not they contain visible blood; (3) nonintact
skin; and (4) mucous membranes of [ALL]{.underline} subjects considered
infectious for HIV, HBV and other bloodborne pathogens. Developed by the
CDC and used during the care of [all]{.underline} subjects whether or
not they are known to have an infection. .

**Sterilize** means the use of a physical or chemical procedure to
destroy all microbial life including highly resistant bacterial
endospores.

**Universal Precautions** is another 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 other bloodborne pathogens.

**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).

**EXPOSURE DETERMINATION**

All employees with a potential occupational hazard of exposure to blood
or other infectious body fluids shall be required to undergo training
according to this Exposure Control Plan.

The following list of tasks with risk of exposure to bloodborne
pathogens includes, but is not limited to:

**Category I**

a\. Task requires exposure to blood or potentially infectious body
fluids:

Phlebotomy

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 3 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

Insertion of intravenous catheter, contrast material or medication

Dressing change of wounds

Performing any laboratory procedure requiring processing of blood, body
fluids or tissue

Cleaning up any blood or body fluid spills

> Changing the bed or stretcher that has become contaminated with blood
> or body fluids, excluding urine, or non-bloody feces

Removal or manipulation of intravenous or arterial catheters.

b\. Task does not normally involve exposure to blood or potentially
infectious body fluid or tissue, but may require performing unplanned
Category I a. tasks:

> Disinfection, sterilization, or cleaning equipment involved in subject
> care or invasive procedures requiring phlebotomy

Transporting subjects within the GCRC

> Transporting laboratory specimens which have been properly packaged
> for transport
>
> Routine cleaning of General Clinical Research Center (GCRC) or Medical
> Department areas and laboratories

**Category II**

Task where exposure is highly unlikely, but not impossible:

Secretarial duties

Clerical duties not based in a subject care area

All tasks related to the handling of medical records

**Exposure Determination List**

The following job descriptions (Job Training Assessments \"JTA\") are
defined in the Medical Department\'s Training Plan and require
Bloodborne Pathogen Training:

1\. Laboratory /Research Position - Bloodborne Pathogen Qualified.

2\. Physician Medical Laboratory/Clinical Researcher

3\. Physician/Researcher - Dispersible Radionuclide Qualified

4\. Nurse

5\. Clinical Care Support Position

6\. Clinical Laboratory Position

7\. Radiology Technician

8\. Electronics Technician

#####  EXPOSURE CONTROL PROCEDURES

**STANDARD PRECAUTIONS: GENERAL PRINCIPLES**

1\. a. All employees should routinely use appropriate barrier precaution
to prevent skin and mucous membrane exposure when contact with blood or
other body fluids of any subject is anticipated. Gloves shall be worn
for touching blood and body fluids, mucous membranes, or non-intact skin
of all subjects, for handling items or surfaces soiled with blood or
body fluids, and for performing venipuncture, other vascular access or
invasive procedures. Gloves shall be changed after contact with each
subject, and whenever they are damaged. They shall not be washed for
reuse. Change gloves between tasks and procedures on the same subject.

> b\. Masks and protective eye-wear or face shields (or combinations or
> goggles or glasses with side shields or masks with side shields) shall
> be worn during procedures that are likely to generate splashes,
> sprays, splatters or droplets of blood or other body fluids or
> potentially infectious materials in order to prevent exposure of
> mucous membranes. These shall be examined and maintained or replaced
> on a regular schedule to ensure their effectiveness.
>
> c\. All procedures involving blood or other potentially infectious
> material shall be performed in such a manner as to minimize splashing,
> splattering, spraying or generation of droplets of these substances.
> Lab bench shields shall be used when opening and closing blood tubes
> and other body fluids. In addition, aerocarriers shall be used in all
> clinical centrifuges to prevent aerosolation.
>
> d\. Lab coats shall be worn when handling blood or other body fluids
> and when engaging in subject care activities. These shall be removed
> as promptly as possible if soiled and hands washed immediately.

2\. Handwashing facilities should be readily accessible whenever
feasible and are equipped with appropriate soaps for proper handwashing,
or an alternative method (i.e., alcohol scrub) is made available until
hands can be washed with soap and water. Hands and other skin surfaces
shall be washed immediately and thoroughly if contaminated with blood or
other body fluids. Hands should be washed immediately after gloves are
removed. Handwashing also done when touching contaminated items, whether
or not gloves are worn.

**Note: Handwashing is the single most effective deterrent to the spread
of infection.**

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 4 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

3\. Sharps: All health care workers should take precaution to prevent
injuries caused by needles, scalpels and other sharp instruments or
devices such as broken glass, during procedures, especially when
cleaning used instruments, during disposal of used needles, and when
handling sharp instruments after procedures. To prevent needlestick
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 syringes and needles, scalpel
blades, and other sharp items shall be placed in puncture-resistant
containers for disposal. Where available, self-sheathing safety needles
should be used. If unavailable, no attempt to recap used needles shall
be made.

4\. These red puncture-resistant containers shall be labeled in
accordance with this standard and leak proof on the sides and bottom.
They should be easily accessible and located as close as is feasible to
the area where sharps are used or can be anticipated to be found. They
should be maintained upright and replaced routinely and not allowed to
overfill.

5\. When doing emergency mouth-to-mouth resuscitation; mouthpieces,
resuscitation bags, and other ventilation devices are available in all
crash carts and at all CPR stations.

6\. Pregnant health care workers are not known to be at greater risk of
contracting HIV infection than health care workers who are not pregnant.
However, if a health care worker develops HIV infection during
pregnancy, the infant is at risk of infection resulting

from perinatal transmission. Because of this risk, pregnant health care
workers should be especially familiar with and strictly adhere

to precautions to minimize the risk of HIV transmission.

7\. 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.

8\. Food and drink shall not be kept in refrigerators, freezers,
shelves, and cabinets or on countertops or benchtops where blood and
other potentially infectious materials are present.

9\. Equipment which may become contaminated with blood or other
potentially infectious materials shall be examined prior to servicing or
shipping, and shall be decontaminated as necessary unless
decontamination of such equipment is not feasible due to potential
damage to equipment. In such case, the contaminated portion of the
equipment shall be designated with a readily observable biohazard label
warning that the equipment is contaminated. Such equipment shall be
handled very carefully so that all potentially effected persons
(employees, service staff etc.) must be informed so they may take
appropriate precautions.

10\. All personal protective equipment shall be removed prior to leaving
work and placed in designated areas for storage, washing and
decontamination.

In addition to Standard Precautions there are other categories that
shall be adhered to when certain communicable diseases are suspected.

**Airborne Precautions:**

For subjects known or suspected to be infected with microorganisms
transmitted by airborne droplet (small particle residue 5um for smaller
in size which remain suspended in air).

Use N95 respirator for suspect or known AFB (isolation for TB) or gloves
and mask for varicella.

Droplet Precautions are used for subjects known or suspected to be
infected with microorganisms transmitted by droplets (large-particle
droplets larger than 5um in size that can be generated by the subject
during coughing sneezing, talking or by the performance of certain
procedures. Mask and eye protection required. Try and maintain spatial
separation of at least 3 feet.

Contact Precautions are used for subjects known or suspected to be
infected or colonized with epidemiologically important microorganisms
that can be transmitted by direct contact with the subject (hand or skin
to skin contact that occurs when performing subject care activities that
require touching the subject's dry skin) or direct contact with
(touching) environmental surfaces or subject care items in environment.
Wear gloves and gown. If use of common equipment is necessary, then
adequately clean and disinfect each item before use or another subject

**STERILIZATION AND DISINFECTION**

Standard sterilization and disinfection procedures for subject -care
equipment currently recommended by the Quality Assurance, Care and
Safety Committee are adequate to sterilize or disinfect instruments,
devices, or other items contaminated with blood and other body fluids
from persons infected with bloodborne pathogens, including HIV.

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 5 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

Instruments or devices that enter sterile tissue or the vascular system
of any subject, shall be sterilized before reuse. Devices or items that
contact intact mucous membrane should be sterilized or receive
high-level disinfection, a procedure that kills vegetative organisms and
viruses, but not necessarily large numbers of bacterial spores. Chemical
germicides that are registered with the US EPA as \"sterilants\" may be
used either for sterilization or for high-level disinfection depending
on contact time.

Medical devices or instruments that require sterilization or
disinfection shall be thoroughly cleaned before being exposed to the
germicide, and the manufacturer\'s instructions for the use of the
germicide should be followed. Further, it is important that the
manufacturer\'s specifications for compatibility of the medical device
with the commercial germicides be closely followed. Information on
specific label claims of commercial germicides can be obtained by
writing to the Disinfectants Branch, Office of Pesticides, Environmental
Protection Agency, 401 M Street SW, Washington, DC 20460.

In addition to commercially available chemical germicides, a solution of
sodium hypochlorite (household bleach) prepared weekly,

is an inexpensive and effective germicide. Concentrations ranging from
approximately 500 ppm (1:100 dilution of bleach) are effective depending
upon the amount of organic material (e.g., blood, mucus) present on the
surface to be cleaned and disinfected. Commercially available chemical
germicides may be more compatible with certain medical devices that
might be corroded by repeated exposure to sodium hypochlorite.

**HOUSEKEEPING**

**General Principles**

The Medical Department and the GCRC shall be maintained in a clean and
sanitary condition. Environmental surfaces such as walls, floors, and
other surfaces are not associated with the transmission of infections to
patients or health care workers, including the spread of bloodborne
pathogens. Therefore, extraordinary measures to sterilize or disinfect
these surfaces are unnecessary. However, cleaning and removal of dirt
should be done first before disinfecting. Cleaning of walls, blinds and
curtains are recommended only when they become visibly soiled.
Disinfectant fogging is an unsatisfactory method of decontaminating the
air and surface and is not recommended.

The actual removal of microorganisms by scrubbing is at least as
important as the choice of the disinfectant or detergent. Disinfectant
or detergent formulations registered by the EPA [and]{.underline}
approved by the Quality Assurance, Care and Safety Committee, can be
used for cleaning environmental surfaces. The manufacturer\'s
instructions for appropriate use should be followed.

All bins, pails, cans, and similar receptacles intended for reuse which
have a reasonable likelihood for becoming contaminated with blood or
other potentially infectious materials shall be inspected and
decontaminated on a regularly scheduled basis and cleaned and
decontaminated immediately or as soon as feasible.

Broken contaminated glassware shall not be picked up by hand. Mechanical
means of cleanup shall be used (brush, dustpan, forceps, tongs, etc.).

Employees should not reach by hand into containers used to store
reusable sharps.

Contaminated instruments shall be handled using gloves at all times.

**Cleaning and Decontaminating Spills of Blood and Other Body Fluids**

All equipment and environmental and working surfaces shall be cleaned
and decontaminated after contact with blood or other potentially
infectious materials. Work surfaces shall be decontaminated with an
appropriate disinfectant, such as a 1:10 household bleach solution after
completion of procedures, as soon as feasible after any spill of blood
or other potentially infectious materials.

Small blood or body fluid spills (for example one or two drops) can be
decontaminated by wiping them up with gauze soaked with 1:10 bleach.
Large blood spills of cultured or concentrated infectious agents should
be flooded with a liquid germicide detergent before cleaning and then
decontaminated with a 1:10 household bleach solution. In subject care
areas, visible material should first be removed and then the area should
be decontaminated with 1:10 bleach. In both settings, gloves should be
worn during the cleaning and decontaminating procedures. Broken glass
should be picked up by a mechanical means. Used gloves and materials for
wiping spills should be treated as medical waste. For larger emergency
spills call the custodians or ext 2222.

**Laundry**

1\. Contaminated laundry shall be handled as little as possible with a
minimum of agitation. Soiled laundry that is contaminated with visible
blood shall be handled as contaminated. Contaminated laundry shall be
bagged or contained at the location where generated **and not sorted or
rinsed in the Medical Department or GCRC areas**.

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 6 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

2\. Contaminated laundry shall be transported in bags or containers. Wet
or leaking laundry shall be contained in leak-proof bags in addition to
the above, prior to transport.

3\. Gloves and other protective clothing should be used when handling
contaminated laundry

4\. All Medical Department Laundry is picked up and delivered by an
outside contractor, Dept. Guideline,IC-5.0/5, "Laundry".

**Infectious Waste**

See Dept. Guideline IC-6.2/8, "Handling and Disposable of Regulated
Medical Waste".

**Labels and Signs**

> Biohazard signs, which are fluorescent orange or red-orange, shall be
> affixed to all containers and storage areas where blood or body fluids
> are stored. Red bags or red containers may be substituted for labels.
> (Attachment 1)

##### Precautions for Clinical and Research Laboratories

> Blood and other body fluids from **all** subjects should be considered
> infected. To supplement the Standard Precautions listed

above, the following precautions are recommended for health care workers
in clinical laboratories.

> 1\. All specimens of blood and body fluids should be transported in a
> manner that will prevent leaking during transport. Care should be
> taken when collecting each specimen to avoid contaminating the outside
> of the container and of the laboratory form accompanying each
> specimen, and to clean the container or to place it in a secondary
> container. When transporting specimens in buckets, secondary
> containers shall be used. When transporting specimens between
> buildings a laboratory designated vehicle shall be used.
>
> 2\. All persons processing blood and body fluids specimens (e.g.,
> removing tops from vacuum tubes) must wear gloves. Masks and
> protective eyewear shall be worn if mucous membrane contact with blood
> or body fluids is anticipated. Gloves shall be changed and hands
> washed after completion of specimen processing.
>
> 3\. For routine procedures such as histologic and pathologic studies
> or microbiologic culturing, a biological safety cabinet is not
> necessary. However, biological safety cabinets (Class I or II) should
> be used whenever procedures are conducted that
>
> have a high potential for generating droplets. These include
> activities such as blending, sonicating and vigorous mixing.
>
> 4\. Mechanical pipetting devices **MUST** be used for manipulating all
> liquids in the laboratory. **MOUTH PIPETTING SHALL NOT BE DONE FOR ANY
> PROCEDURE IN THE LABORATORY**.
>
> 5\. Use of needles and syringes should be limited to situations in
> which there is no alternative, and the recommendation for preventing
> injuries with needles outlined above should be followed.
>
> 6\. Laboratory work surfaces should be decontaminated with a 1:10
> bleach solution after a spill of blood or other body fluids and when
> work activities are completed.
>
> 7\. Contaminated materials used in laboratory tests should be
> decontaminated before reprocessing, or be placed in bags and disposed
> of in accordance with the Medical Department\'s guidelines for the
> disposal of infectious medical waste (IC-6.2).
>
> 8\. Scientific equipment that has been contaminated with blood or
> other body fluids shall be decontaminated and cleaned before being
> repaired in the laboratory or transported to the manufacturer.
>
> 9\. All persons should remove protective clothing before leaving the
> laboratory and wash their hands after completing laboratory
> activities.

10\. Gloves must be worn by the phlebotomist when it is \"reasonably
anticipated\" that his/her hands will be contaminated with blood. This
includes, but is not limited to work:

• with uncooperative subjects

• with non-intact skin

• during training

• when performing skin punctures

They should also be changed between subjects

**Hepatitis B Vaccine and Post Exposure Evaluation**

> Hepatitis B vaccine and post-exposure evaluation and follow-up for
> exposure to bloodborne pathogens is available to all full-time and
> eligible part-time BNL employees, through Brookhaven National
> Laboratory Occupational Medicine Clinic (OMC).
>
> All exposure incidents should be reported to OMC promptly.
>
> Protocols for pre-exposure vaccination and post-exposure follow-up are
> available in accordance with [OMC]{.underline} policy.

**TRAINING**

All employees with the potential for occupational exposure shall receive
training prior to initial assignments, annually thereafter, and at any
time there is a modification in tasks, procedures or requirements.

Training of employees shall address:

> 1\. Explanation of the epidemiology and symptoms of bloodborne
> diseases.

+---------------------------------+---------------+-------------------+
| **BROOKHAVEN NATIONAL           | NUMBER:       |                   |
| LABORATORY**                    | IC-06.01/5    |                   |
|                                 |               |                   |
| ######  GENERAL                 |               |                   |
| CLINICAL RESEARCH CENTER POLICY |               |                   |
+---------------------------------+---------------+-------------------+
|                                 |               |                   |
+---------------------------------+---------------+-------------------+
| Bloodborne Pathogens Exposure   | DATE:         | PAGE: 7 OF 7      |
| Control Plan                    |               |                   |
+---------------------------------+---------------+-------------------+

> 2\. The mode of transmission of bloodborne hazards.
>
> 3\. A copy and explanation of this exposure control plan.
>
> 4\. Recognizing job related activities, which could result in
> exposures.
>
> 5\. An explanation of the uses and limitations of engineering
> controls, work practices, and personal protective equipment.
>
> 6\. Information on the types, proper use, location, removal, handling,
> decontamination and disposal of personal protective equipment.
>
> 7\. How to select personal protective equipment.
>
> 8\. Information on the safety, efficacy, administration and benefits
> of hepatitis B vaccine and that it is offered to eligible employees at
> no cost.
>
> 9\. Information regarding appropriate actions and persons to contact
> following exposure to bloodborne pathogens.

10\. An explanation of procedures to follow, method of reporting, and
medical follow-up after an exposure incident.

11\. Explanation of signs, labels, and color-coding as required.

**Training Program**

ESH Services will be responsible for providing training and information
to all employees who have the potential for

1.  exposure to bloodborne pathogens by giving the Bloodborne Pathogen
    Course. This course is currently on the SBMS database.

> Activities falling under the responsibility of the Training
> Coordinator include:

a\. Maintaining an up-to-date list of facility personnel requiring
training.

b\. Periodically reviewing the training programs to include new
information.

Training shall be provided as follows:

a\. At the time of initial assignment to tasks where occupational
exposure may take place.

> b\. An optional challenge exam may be taken annually.

c\. At any time there is a modification in tasks, programs or
requirements.

**Training Records**

Training Records shall be maintained according to ESH Services Standard
Operating Procedures.

**T**he only official copy of this file is the one online at the Medical
Department website under "Clinical Research Center Policy Manual."
Before using a printed copy, verify that it is the most current version
by checking the document effective date on the website.

ATTACHMENT 1

![](media/image1.png)

#  BIOHAZARD