Guide To Managing

An Emergency Service

Infection Control

Program

FA-112 / January 2002

United States Fire Administration

2002
GUIDE TO MANAGING AN EMERGENCY 

SERVICE INFECTION CONTROL PROGRAM 

2002

UNITED STATES FIRE ADMINISTRATION 

As an entity of the Federal Emergency Management Agency, the 

mission of the U.S. Fire Administration is to reduce life and 

economic losses due to fire and related emergencies through 

leadership, advocacy, coordination, and support. We serve the 

Nation independently, in coordination with other Federal agencies 

and in partnership with fire protection and emergency service 

communities. With a commitment to excellence, we provide public 

education, training, technology, and data initiatives.
PREFACE 

In 1992, the United States Fire Administration (USFA) developed the Guide to 

Developing an Emergency Service Infection Control Program in conjunction with the 

National Fire Academy (NFA) field course, Infection Control for Emergency Response 

Personnel: The Supervisor’s Role. These two major Federal initiatives were designed to 

provide accurate information and guidance to the emergency services regarding 

communicable disease infection control. Both were developed with the support and 

assistance of the Centers for Disease Control and Prevention (CDC) and the Occupational 

Safety and Health Administration (OSHA), to coincide with the promulgation of 29 CFR 

Part 1910.1030, Occupational Exposure to Bloodborne Pathogens, Final Rule. 

Since the original publication, many advances have occurred in the field of infection 

control, and all emergency services should have some form of infection control program. 

The initial guide focused on the development of an infection control program. The new 

Guide to Managing an Emergency Service Infection Control Program updates relevant 

information from the original 1992 guide and focuses on the management of an infection 

control program. The guide is designed to meet or exceed all applicable Federal/national 

laws, regulations, standards, and guidelines in effect at the time of publication. Many of 

these are included in their entirety in Appendix B of the guide. The guide also contains 

Internet Web addresses for accessing those guidelines not included in their entirety. 

The principal development team for the guide included: Judy Janing, Ph.D., R.N., EMTP, Emergency Program Specialist, IOCAD Emergency Services Group, Omaha, NE; 

Murrey Loflin, M.S., EMT-B, Battalion Chief, Virginia Beach Fire Department, Virginia 

Beach, VA.; Gordon Sachs, MPA, Director, IOCAD Emergency Services Group; Mike 

Grill, Captain, Sierra Vista Fire Department, Sierra Vista, AZ; David Barillo, M.D., 

Associate Professor of Surgery, Medical University of South Carolina, Charleston, SC. 

Sandy Bodgucki, M.D., Ph.D., Assistant Professor, Yale University School of Medicine, 

Department of Surgery, Section of Emergency Medicine, New Haven, CT. 

Members of the Technical Review Panel for the development of this guide were: 

Jonathan M. Lieske, M.D., M.P.H., International Association of Fire Fighters (IAFF); 

Richard Knopf, International Association of Fire Chiefs (IAFC), Health and Safety 

Committee; Philip Stittleburg, National Volunteer Fire Council; Decker Williams, 

Phoenix Fire Department; Richard Patrick, VFIS, Inc.; Scott Deitchman, M.D., Centers 

for Disease Control and Prevention (CDC); Ron Thackery, American Ambulance 

Association; and Susan McHenry, National Highway Transportation and Safety 

Administration (NHTSA). 

3 
TABLE OF CONTENTS 

Preface..................................................................................................................................3 

Table of Contents.................................................................................................................5 

INTRODUCTION..............................................................................................................7 

SECTION 1: OVERVIEW OF INFECTION CONTROL..........................................11

Chapter One: Technical Background.....................................................................13 

Introduction to Infection Control...............................................................15 

 Basic Concepts...........................................................................................16 

 Assessing Risk Potential............................................................................17 

 Bloodborne Diseases..................................................................................18 

 Airborne Diseases......................................................................................21 

 Infection Control Techniques ....................................................................22 

 Summary....................................................................................................23 

Chapter Two: Laws, Regulations, and Standards..................................................29 

 Public Law .................................................................................................32 

 OSHA Regulations.....................................................................................34 

 National Fire Protection Association (NFPA)...........................................37 

Centers for Disease Control and Prevention..............................................40 

 Summary....................................................................................................46 

SECTION 2: COMPONENTS OF AN INFECTION CONTROL PROGRAM .......47 

 Risk Management ..................................................................................................49 

Risk Management Model.......................................................................................50 

 Training and Education..........................................................................................53 

 Members ................................................................................................................54 

 Health Maintenance ...............................................................................................55 

Roles and Responsibilities.....................................................................................56 

 Policies and Procedures.........................................................................................62 

Exposure Control Plan ...........................................................................................64 

Standard Operating Procedures..............................................................................65 

Interactions with Other Departments.....................................................................65 

SECTION 3: VEHICLES, EQUIPMENT, AND SUPPLY CONSIDERATIONS 69 

 Vehicles..................................................................................................................71 

Personal Protective Equipment..............................................................................76 

Equipment and Supplies ........................................................................................81 

 Equipment Advances.............................................................................................82 

5 
 Other Considerations .............................................................................................85 

 Summary................................................................................................................87 

SECTION 4: FACILITIES CONSIDERATIONS........................................................89 

The Need for Facility Safety..................................................................................91 

 Facility Issues.........................................................................................................93 

 Summary................................................................................................................98 

SECTION 5: ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS..99 

 Overview..............................................................................................................101 

 Assessing Effectiveness.......................................................................................102 

 Information Management.....................................................................................104 

 Program Revision.................................................................................................113 

 Action Plan...........................................................................................................114 

 Summary..............................................................................................................115 

SECTION 6: SPECIAL SITUATIONS .......................................................................117 

Overview..............................................................................................................119 

The Training Environment...................................................................................119 

Protecting the Patient...........................................................................................121 

 Summary..............................................................................................................122 

BIBLIOGRAPHY..........................................................................................................123 

APPENDICES................................................................................................................129 

Appendix A: Glossary of Common Terms......................................................131 

Appendix B: Laws, Regulations, and Standards.............................................143 

Health Care Worker Needlestick Prevention Act (PL 106-430)..........................145 

Occupational Exposure to Bloodborne Pathogens: Final Rule. 

(29 CFR Part 1910.1030).....................................................................................149 

Occupational Exposure to Bloodborne Pathogens: NeedlesticksAnd Other Sharps 

Injuries: Final Rule. (29 CFR Part 1910.1030)...................................................173 

Updated U.S. Public Health Service Guidelines for the Management of 

Occupational Exposures to HBV, HCV,And HIV and Recommendations for 

Postexposure Prophylaxis(June 29, 2001/MMWR 50 (RR11); 1-42.)................197 

 

Appendix C: Sources of Additional Information............................................241

6 
INTRODUCTION 

INTRODUCTION 

7 
INTRODUCTION 

SCOPE AND PURPOSE 

Since infection control requirements vary by agency type, local regulations, 

department size, etc., emergency response organizations cannot simply adopt a generic 

infection control program as their program. Therefore, this Guide is designed as a 

resource to help emergency response organizations tailor the requirements identified in 

regulations and standards to their own unique situations. 

The structure of the Guide facilitates its use for different purposes. The first 

section, Overview of Infection Control contains two chapters. 

• Chapter 1: Technical Background summarizes basic terms and concepts, and 

describes the risks associated with various communicable diseases particularly 

relevant to emergency services. 

• Chapter 2: Laws and Regulations summarizes applicable laws, regulations, 

and standards. 

The second section, Components of an Infection Control Program, covers the 

aspects of an infection control program that organizations need to address. These 

components include risk management, training and education, health maintenance, roles 

and responsibilities of department personnel, policies and procedures, standard operating 

procedures, and interactions with other departments. 

The third section, Vehicles, Equipment, and Supply Considerations, addresses 

issues related to vehicle design, decontamination of disposable and non-disposable 

equipment, equipment advances (including needleless systems), and considerations 

related to clothing/linen and volunteers responding from and returning to home or the 

primary workplace. 

The fourth section, Facilities Considerations, discusses infection control in 

relation to the various functioning areas of emergency services facilities. 

The fifth section, Assessing Effectiveness, provides a description of the 

evaluation process. A step-by-step approach for developing performance standards and 

compliance (evaluation criteria) for measuring effectiveness is described. Other aspects 

addressed include information management and program revision. 

The final section, Special Situations, provides a brief overview of infection 

control practices in the training environment and as they relate to protecting the patient. 

9 
INTRODUCTION 

In addition, the Guide also contains a bibliography of useful reference documents 

and several appendices: 

• Glossary of Common Terms used in infection control. 

• Text of major Laws, Standards, and Guidelines of interest to managers of 

infection control programs. 

• Sources of Additional Information for special needs in infection control. 

The USFA Guide incorporates all requirements specified by applicable regulations and 

standards at the time of publication. However, users are encouraged to go beyond the 

information contained in the Guide to address specific needs. 

Managers also should remember that infection control is a rapidly evolving field. 

OSHA’s Occupational Exposure to Bloodborne Pathogens, 29 CFR Part 1910.1030 

requires that the department’s exposure control plan be reviewed and updated at least 

annually, and that the consideration and implementation of safer medical devices be 

documented. It is imperative to review new medical developments, consensus standards, 

and regulations. This will ensure that mechanisms exist to integrate that new information 

into a department's existing program. The goal of the infection control program is to 

provide the best protection available for members. 

10 
SECTION 1 

SECTION 1 

OVERVIEW OF INFECTION CONTROL 

11 
TECHNICAL BACKGROUND 

CHAPTER 1 

TECHNICAL BACKGROUND 

13 
TECHNICAL BACKGROUND 

OVERVIEW 

This chapter provides an introduction to the basic principles of infection control in 

the emergency service environment. Technical terms are defined. The risk of 

occupational exposure to communicable disease is discussed. 

INTRODUCTION TO INFECTION CONTROL

In the mid-1800’s in Vienna, Austria, a physician named Ignaz Semmelweis 

demonstrated the importance of hand washing in decreasing the incidence of infection in 

women following childbirth. He observed that medical students were conducting cadaver 

dissections in the morning and then delivering babies in the afternoon without wearing 

gloves or washing their hands. When the medical students were on vacation, the 

incidence of infection was reduced. Semmelweis traveled to other European cities to 

demonstrate that hand washing could reduce deaths related to infection. Even though he 

had reduced infection from 18 percent to 1 percent in the Vienna hospital, at the time the 

medical community did not take him seriously. 

Although hand washing remains the most fundamental measure for controlling 

infection, it is still not taken as seriously as it should be. Infection rates in patients, 

hospital personnel, and emergency responders continue to be a national problem, despite 

continuing improvements in medical technology. 

Infection control procedures have been developed and refined continuously over 

the years. Unfortunately, research on the incidence of infection, the spread of infection 

from patient to care provider, and the incidence of infection related to contaminated 

medical equipment continues to be limited almost exclusively to hospital-based studies. 

To date, there are few studies related to the incidence of disease in the emergency 

response environment. As a result, recommended practice and/or procedures for 

emergency responders are generally modifications of those established for in-hospital 

personnel. 

Without definitive data, it is difficult to demonstrate the need for infection control 

procedures specifically for emergency services. However, the U.S. Centers for Disease 

Control and Prevention (CDC) has classified emergency response personnel as being at 

high risk for exposure. They face the same potential for exposure as hospital personnel. 

15 
TECHNICAL BACKGROUND 

In many instances, the volatility and unpredictability of the emergency scene increases 

the level of risk. The Guidelines for Prevention of Transmission of Human 

Immunodeficiency Virus and Hepatitis B Virus to Health Care and Public Safety Workers

(MMWR Vol. 38, No. 2-6, 1989) states 

 

The unpredictable and emergent nature of exposures 

encountered by emergency and public-safety workers 

may make differentiation between hazardous body 

fluids and those which are not hazardous very 

difficult and often impossible. For example, poor 

lighting may limit the worker’s ability to detect 

visible blood in vomitus or feces. Therefore, when

emergency medical and public-safety workers 

encounter body fluids under uncontrolled, 

emergency circumstances in which differentiation 

between fluid types is difficult, if not impossible, 

they should treat all body fluids as potentially 

hazardous. 

BASIC CONCEPTS

An effective infection control program requires a basic understanding of key 

infection control concepts. 

Disease-Producing Organisms

Viruses and bacteria are the organisms commonly responsible for the spread of 

disease. Viruses normally reside in a living host and cannot multiply outside of a living 

cell. However, viruses can spread disease through contact with inanimate surfaces that 

are contaminated with fluids/blood containing the virus. Bacteria can multiply outside 

the body, i.e., on surfaces or objects. Therefore, proper cleaning of equipment is critical. 

Infectious Versus Communicable Disease

 An infectious disease results from invasion of a host by disease-producing 

organisms, such as bacteria, viruses, fungi, or parasites. A communicable (contagious) 

disease is one that can be transmitted from one person to another. 

16 
TECHNICAL BACKGROUND 

Not all infectious diseases are communicable. For example, there are many cases 

involving people getting salmonella “food poisoning” from poorly prepared food 

containing salmonella bacteria. Salmonella is highly infectious, but it is not contagious. 

Chickenpox is an infectious disease that also is communicable. It can be transmitted 

easily from one person to another by airborne droplets. Infection control for emergency 

services is primarily, but not solely, concerned with communicable disease. 

Modes of Transmission

A communicable disease can be spread directly or indirectly. Direct 

transmission occurs through direct contact with the blood or other body substances of an 

infected individual. Indirect transmission occurs without person-to-person contact; the 

disease-producing organism passes from the infected individual to an inanimate object. 

Another person comes in contact with the contaminated object and contracts the disease. 

Although a communicable disease may be transmitted by body fluids other than 

blood (e.g., cytomegalovirus), those of primary concern to emergency responders are 

those communicable diseases that are bloodborne or airborne. Bloodborne diseases are 

spread by direct contact with the blood or other body substances of an infected person. 

Bloodborne diseases of most concern to emergency responders include Human 

Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C. 

Airborne diseases are spread by droplets of the disease-producing organism

being expelled into the air by a productive cough or sneeze or by direct contact with 

infected bodily secretions. Airborne diseases include tuberculosis, meningitis, mumps, 

rubella, and chickenpox. 

ASSESSING RISK POTENTIAL 

Any exposure to a communicable disease carries a certain amount of risk. For 

bloodborne pathogens, an exposure occurs whenever there is contact with blood or other 

body fluids through open wounds, mucous membranes, or parenteral (by injection) 

routes. The degree of risk depends on the degree of exposure. Five factors are critical in 

assessing potential risk in any exposure situation: 

17 
TECHNICAL BACKGROUND 

• Communicability – Identification of the causative agent is critical. As noted 

previously, some disease-producing organisms are more readily 

communicable than others; some are capable of causing more serious effects. 

• Dosage of the Disease-Producing Organism – Dosage refers to the number 

of viable (live) organisms received during an exposure. Each illness requires 

that a certain number of infectious agents be present in order to cause disease. 

For example, one Hepatitis B virus in 1 milliliter of blood may be all that is 

needed to spread the infection, while 100,000 HIV viral particles may be 

needed. 

• Virulence of the Disease-Producing Organism – Virulence is the diseaseevoking power of the organism, in other words, the strength or ability of the 

organism to infect or overcome bodily defenses. 

• Hardiness of the Organism – Hardiness is the organism’s ability to survive 

in the environment. This varies from one situation to another. In most cases, 

the organism must be one that survives outside the body. For example, the 

hepatitis B virus has been shown to live on a surface for days to weeks and 

still be infectious. 

• Host Resistance – Host resistance is the ability of the host to fight infection. 

Infection occurs as a result of an interruption in the body’s normal defense 

mechanisms, which allows the organism to enter the body. Typically, the 

healthier you are, the less likely you are to become ill. 

BLOODBORNE DISEASES 

HIV/AIDS 

The number of new HIV cases reported in the United States has decreased slightly 

over the past decade. CDC reported 47,915 new cases of HIV (17.4 cases/100,000 

population) in 1998 and 46,400 new cases (16.7 cases/100,000 population) in 1999. As 

of the 1999 report, there were 113,000 persons living with HIV and 290,542 persons 

living with AIDS in the United States. CDC reported twelve potential and no 

documented cases of HIV in emergency services personnel in 1999. This low number 

18 
TECHNICAL BACKGROUND 

can probably be attributed to the use of personal protective equipment, but it must be 

remembered that emergency services personnel remain in a high-risk group. 

Hepatitis B 

Hepatitis B virus (HBV) infection is the major infectious hazard for health-care 

personnel. The risk of HBV infection after percutaneous exposure varies from 2 percent 

if the patient is negative for the Hepatitis B early antigen (HBeAg) to 40 percent if

HBeAg antigen is present. Overall, the estimated risk of HBV infection after an 

occupational exposure ranges from 20 to 30 percent.1

 During 1993, an estimated 1,450 

workers became infected through exposure to blood and serum-derived body fluids, a 90 

percent decrease from the number estimated to have been thus infected during 1985.2

This decline is partly due to widespread adoption of preventive immunization, increased 

adherence to universal precautions, and use of personal protective equipment by healthcare workers. Hepatitis B immunization is a critical preventative factor of an Emergency 

Medical Service infection control program. 

Hepatitis C 

Hepatitis C (HCV) is a leading cause of cirrhosis of the liver, liver cancer, and 

one of the major causes of the need for liver transplants. CDC estimates that the annual 

number of newly acquired HCV infections ranged from 180,000 in 1984 to 28,000 in 

1995. Of these, an estimated 2-4 percent occurred among health-care personnel who were 

occupationally exposed to blood. After an unintentional needlestick from an HCVpositive source, the average risk for HCV infection is 1.8 percent. Transmission rarely 

occurs from mucous membrane exposures to blood, and no transmission has been 

 1

 Swinker, M. (1997). Occupational Infections in Health Care workers: Prevention 

and intervention. American Family Physician, 56 (9), 2291-2303. 

2 U.S. Department of Health and Human Services, Centers for Disease Control. 

(1997). Immunization of health-care workers: Recommendations of the advisory 

committee on immunization practices (ACIP) and the hospital infection control 

practices advisory committee (HICPAC). Morbidity Mortality Weekly Report; 46 

(RR-18):1-42. 

19 
TECHNICAL BACKGROUND 

documented from intact or non-intact skin exposures to blood.3 At least 50-80 percent of 

persons who contract HCV infection become chronically infected, and half of those 

chronically infected develop cirrhosis or liver cancer. Up to 10 percent of parenterally 

transmitted hepatitis may be caused by other bloodborne viral agents not yet 

characterized. 

Hepatitis A

Occupational exposure generally does not increase health-care workers’ risk for 

Hepatitis A virus (HAV) infection.4

 When proper infection control practices are 

followed, nosocomial HAV transmission is rare. Transmission of HAV from adult 

patients to health-care workers usually is associated with fecal incontinence in the 

patients. There is a vaccine for Hepatitis A. Currently it is recommended only for 

travelers and the military. 

Other Hepatitis Viruses

There have been three additional Hepatitis viruses (E, F, and G) identified in 

addition to Hepatitis A, B, and C. Knowledge regarding these viruses is limited; however 

it is known that the mode of transmission for E is the fecal-oral route, for G is 

bloodborne, and F may be bloodborne. 

Risk of Infection 

Risk of infection from bloodborne diseases varies according to the type of 

exposure. The following list was published by the CDC to help evaluate risk levels. Risk 

decreases from top to bottom.

 3 U.S. Department of Health and Human Services, Centers for Disease Control. (2000). 

Hepatitis C virus infection among firefighters, emergency medical technicians, and 

paramedics - Selected Locations, United States, 1991--2000. Morbidity Mortality Weekly 

Report; 49 (29); 660-665. 

4 U.S. Department of Health and Human Services, Centers for Disease Control. (1997). 

Immunization of health-care workers: Recommendations of the advisory committee on 

immunization practices (ACIP) and the hospital infection control practices advisory

committee (HICPAC). Morbidity Mortality Weekly Report; 46 (RR-18):1-42. 

20 
TECHNICAL BACKGROUND 

• Contaminated needle stick injury (large-bore, hollow needle carries more risk 

than small bore solid needle). 

• Cuts with sharp objects covered with blood/body fluid. 

• Blood/Body fluid contact with an open area of the skin. 

• Blood/Body fluid contact to the mucous membrane surface of the eyes, nose, 

or mouth. 

• Blood/Body fluid contact to intact skin. 

Although incidence of the major bloodborne diseases have decreased over the 

past several years, emergency service personnel remain at risk for contracting these 

diseases. If these declines are to be sustained, emergency service personnel must 

continue to adhere to protection strategies. 

AIRBORNE DISEASES

Tuberculosis (pulmonary) 

The airborne disease of greatest concern to emergency services providers is 

tuberculosis (TB). Nationally, the number of reported cases of TB increased by 14 

percent from 1985 to 1993. Consequently, concern about this disease increased, and 

more attention was focused on control measures. At the same time drug-resistant 

tuberculosis also increased, creating a serious concern. From 1982 to 1986, only 0.5 

percent of new cases were resistant to both isoniazid and rifampin. By 1991, this 

proportion had increased to about 3.1 percent. Among recurrent cases, 3.0 percent were 

resistant to both drugs during the 1982 to 1986 period, but in 1991 this proportion had 

more than doubled, to 6.9 percent. 

The reported cases of TB began a decline in the years following this increase. 

There were 26,673 cases (10.5/100,000 population) in 1992. This decreased to 17,531 

cases (6.4/100,000 population) in 1999. Of the cases reported in 1999, 2.5 percent 

occurred in health-care workers. Statistics specific to emergency services are not 

available, since CDC does not break out emergency services workers as a separate 

category in their TB surveillance program. 

21 
TECHNICAL BACKGROUND 

Drug-resistant cases also have decreased. In 1999, 12.2 percent of new cases and 

8.4 percent of recurrent cases were resistant to isoniazid alone and 3.8 percent of new 

cases and 1.1 percent of recurrent cases were resistant to both isoniazid and rifampin. 

It is well known that the organism that causes TB dies when exposed to light and 

air, however there are factors that can affect the potential for infection from TB as well as 

other airborne diseases. These factors are duration of exposure and ventilation. Some

diseases require prolonged exposure in order to contract the disease. Therefore shorter 

transport times can reduce risk potential. Risk potential also can be reduced by 

maximum ventilation. Ventilation systems for vehicles are addressed in depth in Section 

3 of this Guide. On older vehicles without modern ventilation systems, personnel should 

open windows whenever possible. 

INFECTION CONTROL TECHNIQUES

Hand washing is the most effective overall infection control measure, yet it is 

frequently ignored. Hands should be washed whenever gloves are removed, after all 

patient contacts, and after disinfecting equipment, as well as before eating and after using 

the bathroom. Hands should be well lathered with regular soap and scrubbed for at least 

15 seconds before rinsing and drying. The towel should be used to turn off the faucet. 

Universal precautions is an infection control strategy developed by the CDC for 

hospital workers. Specific precautionary procedures are recommended for reducing 

potential exposure to bloodborne pathogens. Universal precautions are based on the 

concept that blood and certain body fluids (any body fluids containing visible blood, 

semen, vaginal secretions, tissues, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, 

peritoneal fluid, pericardial fluid, and amniotic fluid) of all patients should be considered 

potentially infectious for HIV, HBV, HCV, and other bloodborne pathogens. 

In 1996, CDC published standard precautions. Standard precautions synthesize 

the major features of body substance isolation and universal precautions and apply to 

isolation precautions in the hospital setting. 

Body substance isolation (BSI) goes beyond universal precautions and considers 

all body substances potentially infectious. Thus, in addition to those listed under 

universal precautions, feces, nasal secretions, sputum, sweat, tears, urine, and vomitus 

22 
TECHNICAL BACKGROUND 

also are considered potentially infectious. Such an approach obviously is safer in the 

emergency response environment, where medical histories are often incomplete or not 

known at all and differentiation between body fluids may be impossible. In effect, each 

emergency incident has exposure potential. 

BSI is generally accomplished through the barrier technique, using personal 

protective equipment (gloves, masks, protective eyewear, gowns, and resuscitation 

devices) to prevent personal contact with blood or other potentially infectious materials. 

Other infection control techniques include proactive preventive measures such as health 

maintenance, immunization programs, decontamination procedures, proper waste 

handling and disposal practices, and both initial and ongoing training. 

SUMMARY

The intent of this chapter was to provide a brief overview of communicable 

disease and infection control principles, as background information for the rest of the 

Guide. Table 1-1-1, on the following pages, summarizes the most common 

communicable diseases encountered by emergency services personnel. 

It must be emphasized that a crucial component of an effective infection control 

program is learning as much as possible about various types of communicable disease 

and updating the infection control program as new knowledge becomes available. 

Organizations should capitalize on all available expertise by enlisting the help of local 

health and medical practitioners and/or infection control experts. Additional sources of

information are provided in the References and Bibliography, and in Appendix C. 

23 
TECHNICAL BACKGROUND 

Table 1-1-1 

 DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNEL 

Disease/Infection Mode of 

Transmission 

Vaccine 

Available 

Signs/Symptoms Post-Exposure 

Treatment 

AIDS/HIV 

(Human 

Immunodeficiency 

Virus) 

Needlestick, blood 

splash into mucous 

membranes (e.g., 

eyes, mouth), or 

blood contact with 

open wound 

NO Fever, cough, night 

sweats, weight loss, 

Antiretroviral 

Regimen 

(see complete 

guidelines in 

Appendix B) 

Chickenpox 

(Varicella) 

Respiratory 

secretions and 

contact with moist 

vesicles 

YES Fever, rash, 

cutaneous vesicles 

(blisters) 

Vaccine 

Diarrhea: 

 

Campylobactor 

Cryptosporidium 

Giardia 

Salmonella 

Shigella 

Viral 

Yersinia 

Fecal/Oral NO Loose, watery 

stools 

None 

German Measles 

(Rubella) 

Respiratory 

droplets and contact 

with respiratory 

secretions 

YES Fever, rash Vaccine in 72 

hours, immune 

globulin 

Hepatitis A (HAV) Fecal/Oral YES Fever, loss of 

appetite, jaundice, 

fatigue 

Immune 

globulin, 

vaccine 

Hepatitis B (HBV) Needlestick, blood 

splash into mucous 

membranes (e.g., 

eye or mouth), or 

blood contact with 

open wound. 

Possible exposure 

during mouth-tomouth resuscitation 

YES Fever, fatigue, loss 

of appetite, nausea, 

headache, jaundice 

Booster and/or 

immune 

globulin 

24 
TECHNICAL BACKGROUND 

 DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNEL (cont'd)

Disease/Infection Mode of 

Transmission 

Vaccine 

Available 

Signs/Symptoms Post-Exposure 

Treatment 

Hepatitis C (HCV) Same as Hepatitis B NO Same as Hepatitis B None 

Hepatitis D (HDV) Same as Hepatitis B 

dependent on HBV 

(past or present) to 

cause infection 

NO Same as Hepatitis B None 

Hepatitis E,F, & G Several viruses 

with different 

modes of 

transmission 

NO Fever, headache, 

fatigue, jaundice 

None 

Herpes Simplex 

(Cold Sores) 

Contact of mucous 

membrane with

moist lesions. 

Fingers are at 

particular risk for 

becoming infected. 

NO Skin lesions located 

around the mouth 

Herpes Zoster 

(Shingles) 

localized 

disseminated 

(See Varicella) 

Contact with moist 

lesions 

Varicella 

vaccine 

may be 

effective 

even if 

person has 

already had 

varicella 

Skin lesions, 

regional associated 

pain 

Influenza Airborne YES 

(changes 

yearly 

based on 

strains 

expected to 

cause 

infection) 

Fever, fatigue, loss 

of appetite, nausea, 

headache 

Antivirals 

(amantadine, 

rimantadine, 

zanamivir, and 

oseltamivir) 

25 
TECHNICAL BACKGROUND 

 DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNE L (cont'd) 

Disease/Infection Mode of 

Transmission 

Vaccine 

Available 

Signs/Symptoms Post-Exposure 

Treatment 

Lice: Head, Body, 

Pubic 

Close head to head 

contact. Both body 

and pubic lice 

require intimate 

contact (usually 

sexual) or sharing 

of intimate 

clothing. 

NO Severe itching and 

scratching, often 

with secondary 

infection. Scalp 

and hairy portions 

of body may be 

affected. Eggs of 

head lice (nits) 

attach to hairs as 

small round, gray 

lumps. 

Wash clothes, 

personal 

articles in hot 

water. 

Gamma

benzene 

hexachloride 

shampoo 

(Kwell, Rid, 

etc.) if 

crawling lice 

or nits are 

noted close to 

the scalp. 

Measles Respiratory 

droplets and contact 

with nasal or throat 

secretions 

YES Fever, rash, cough See German 

Measles 

Meningitis: 

Meningoccocal 

Haemophilus 

influenza (usually 

seen in very young 

children) 

Viral 

Respiratory 

secretions contact 

Respiratory 

secretions contact 

Fecal/Oral 

YES 

YES 

NO 

Fever, severe 

headache, stiff 

neck, sore throat, 

may have 

distinctive rash 

(Same) 

(Same) 

Rifampin, 

Cephlosporin 

Mononucleosis Contact with 

respiratory 

secretions or saliva, 

such as with mouthto-mouth 

resuscitation 

NO Fever, sore throat, 

fatigue, swollen 

lymph nodes/spleen 

26 
TECHNICAL BACKGROUND 

 DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNEL (cont'd) 

Disease/Infection Mode of 

Transmission 

Vaccine 

Available 

Signs/Symptoms Post-Exposure 

Treatment 

Mumps 

(Parotitis) 

Respiratory 

droplets and contact 

with saliva 

YES Fever, swollen 

salivary (parotid) 

glands 

See German 

Measles 

Salmonellosis Foodborne NO Sudden onset of 

fever, abdominal 

pain, diarrhea, 

nausea, and 

frequent vomiting 

Scabies Close body contact NO Itching, tiny linear 

burrows or 

“tracks,” vesicles - 

particularly around 

fingers, wrists, 

elbows, and skin 

folds 

Syphilis Primarily sexual 

contact; rarely 

through blood 

transfusion 

NO Genital and 

cutaneous lesions, 

nerve degeneration 

(late) 

Tuberculosis, 

pulmonary 

Airborne NO Fever, night sweats, 

weight loss, cough 

Isoniazid 

Rifampin, 

pyrazinamide 

Whooping Cough 

(Pertussis) 

Airborne, direct 

contact with oral 

secretions 

YES Violent cough at 

night, whooping 

sound when cough 

subsides 

Note: Post-exposure protocols change frequently based on new information. The 

Centers for Disease Control and Prevention (CDC) and the Morbidity Mortality Weekly 

Report should be checked regularly for the most up-to-date information. 

27 
LAWS, REGULATIONS, AND STANDARDS 

CHAPTER 2 

LAWS, REGULATIONS, AND 

REGULATIONS 

29 
LAWS, REGULATIONS, AND STANDARDS 

OVERVIEW 

A formal infection control program has two basic goals: (1) to provide all 

members with the best possible protection from communicable disease; and (2) to protect 

patients from potential infection. A resultant third goal is to protect the department or 

jurisdiction from potential liability. A properly designed infection control program will 

help reduce the risk of members contracting a communicable disease, manage civil 

liability, lower health insurance costs, minimize “sick time,” and ensure compliance with 

all applicable statutes. Knowledge of applicable laws, regulations, and standards is a 

prerequisite to meeting these goals. This chapter summarizes current national laws, 

regulations, and standards that relate to emergency service infection control. 

LAWS, REGULATIONS, AND STANDARDS 

Many Federal and national organizations play a critical role in establishing 

requirements and recommendations for infection control in the work environment. These 

organizations include: 

• Public Law (U.S. Congress) 

• The Occupational Safety and Heath Administration (OSHA), U.S. Department 

of Labor 

• The National Fire Protection Association (NFPA) 

• The U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention (CDC). 

Ensuring compliance with the standards described in this Guide is crucial in managing an 

effective infection control program. However, additional research will be needed to 

identify State and/or local regulations that also apply. 

While State/local regulations vary from jurisdiction to jurisdiction, some of the 

more common ones include 

• Duty-to-act laws that require emergency response personnel to provide a 

“reasonable level of care” to all patients. 

• Patient abandonment laws that specify that patient care may be relinquished 

only to someone having an equal or higher level of medical expertise. 

31 
LAWS, REGULATIONS, AND STANDARDS 

• Biohazard waste laws that govern the storage, handling, and disposal of 

medical waste. 

PUBLIC LAW 

Ryan White Comprehensive AIDS Resources Emergency Act of 1990 

(PL 101-381) 

This act delineates specific notification requirements that allow emergency 

response personnel to find out if they have been exposed to an “infectious disease” while 

providing patient care. Diseases covered include Hepatitis B, tuberculosis, 

meningococcal (bacterial) meningitis, and HIV. 

Each employer of emergency response personnel is required to name a 

“designated officer” to coordinate communication between the treating facility (hospital) 

and the emergency response organization. Notification of exposure may be “routine” or 

“by request.” 

Routine notification - Notification must be provided by the treating facility to the 

designated officer when it is determined that a patient transported by emergency response 

personnel has an airborne communicable disease. This includes patients that expire in 

transit, or shortly after. Notification must be made no later than 48 hours after the 

diagnosis is made. Routine notification only pertains to transportation crews. It does not 

cover responders who provide on-scene care but not transportation. 

Notification by request - Any member who “attended, treated, assisted, or 

transported” a victim of an emergency where exposure to infectious disease may have 

occurred can request notification. The request is made through the designated officer, 

who reviews the case and notifies the treating facility. The treating facility reviews the 

case and notifies the designated officer that: a) an exposure took place; b) an exposure 

did not take place; or c) insufficient information exists to determine exposure risk. In 

disputed cases, or cases of insufficient information, the designated officer may use the 

services of the local public health officer in resolution. This Act does not authorize 

mandatory patient testing for infectious diseases. 

32 
LAWS, REGULATIONS, AND STANDARDS 

Americans with Disabilities Act (ADA) (PL 101-336)

This Act provides a national mandate for the elimination of discrimination against 

individuals with disabilities. The ADA prohibits discrimination against disabled 

individuals in the areas of hiring, firing, promotion, benefits, and management of staff. 

The ADA obligates employers to make reasonable accommodation to the disabilities of

otherwise qualified people, in order to guarantee equal employment opportunities. 

“Contagious diseases,” such as tuberculosis and HIV infection, are considered 

disabilities under the ADA. People with contagious (communicable) diseases are 

protected against discrimination, as long as they can perform the essential functions of a 

job and do not pose a threat to the health and safety of others in the workplace. Cases 

must be considered individually; one individual who has a communicable disease and 

poses a serious health threat does not justify excluding all persons with actual or 

perceived communicable diseases. 

Fear expressed by other employees of being infected by an “otherwise qualified” 

employee with a communicable disease must be supported by objective evidence of risk. 

If a person poses a significant risk of transmission of infection that cannot be eliminated 

by reasonable accommodation, the person may be found to constitute a direct threat to the 

health or safety of others. 

The ADA poses a substantial potential liability to any employer who fails to heed 

the requirements of the Act. Lawsuits and/or fines may be a result of discriminatory acts 

in hiring, firing, promotion, benefits, and/or management of staff. Compliance may be 

costly, and must be considered in budgetary planning. This includes training of 

employees, supervisors, and managers if necessary. 

Health Care Worker Needlestick Safety and Prevention Act (PL 106-430) 

Passed unanimously by Congress, the Needlestick Safety and Prevention Act 

became effective in November 2000. This Act directed OSHA to make specific revisions 

to the Occupational Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030) within 

6 months. These revisions went into effect January 18, 2001 with the release of 

Occupational Exposure to Bloodborne Pathogens; Needlesticks and Other Sharps 

33 
LAWS, REGULATIONS, AND STANDARDS 

Injuries; Final Rule (29 CFR Part 1910.1030). The text of the law can be found in 

Appendix B1. 

OSHA REGULATIONS

The Occupational Safety and Health Administration (OSHA), U.S. Department of 

Labor, is the branch of the Federal government responsible for safety in the workplace. 

OHSA publishes Federal regulations that establish minimum standards for workplace 

safety and health. Each State, territory, or possession has the option of adopting OSHA 

regulations as published, or enacting “State” OSHA plans that are at least as stringent as 

the Federal standards. Table 1-2-1 lists the States that have their own OSHA plans. 

Table 1-2-1 

STATES/TERRITORIES WITH OSHA PLANS 

Alaska Michigan South Carolina

Arizona Minnesota Tennessee

California Nevada Utah

Connecticut New Jersey Vermont

Hawaii New Mexico Virginia

Indiana New York Virgin Islands 

Iowa North Carolina Washington

Kentucky Oregon Wyoming

Maryland Puerto Rico

Applicability

Emergency service personnel are not always covered by OSHA regulations. 

Determining whether or not a particular agency is required to comply with OSHA 

regulations requires research. However, the following general guidelines apply. 

Federal OSHA regulations generally apply only to Federal, military, and private 

employers. Thus, in States that have simply adopted the Federal OSHA regulations, most 

emergency service personnel (whether paid or volunteer) are not covered. 

34 
LAWS, REGULATIONS, AND STANDARDS 

If a State opts to develop its own OSHA plan, all paid State and local government 

employees (including emergency response personnel) must be covered. (In some States, 

only State and local employees are covered.) However, each specific State decides 

whether or not to include volunteer emergency response personnel. At present, 24 States, 

the Virgin Islands, and Puerto Rico have “State” OSHA plans. OSHA maintains a list of

States with their own plans and contact information on their Web site at 

http://www.osha.gov/as/opa/worker/. 

Emergency response personnel involved in hazardous material response in States 

and territories having a State OSHA plan are covered under OSHA 29 CFR Part 

1910.120. For workers not covered by a State OSHA plan, the Environmental Protection 

Agency (EPA) issued a regulation (40 CFR Part 311) in 1989. This regulation is 

functionally similar to OSHA’s Hazardous Waste Operations and Emergency Response 

(HAZWOPER) regulation, specifically citing that the requirements in the OSHA 29 CFR 

Part 1910.120 will be applicable in all States, regardless of OSHA status.

Communicable disease risks and hazards are the same in each State, regardless of 

local compliance requirements. Thus, adherence to OSHA regulations is recommended 

for all emergency service agencies. 

Occupational Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030) 

This regulation establishes standards for workplace protection from bloodborne 

diseases. The primary diseases of concern are Hepatitis B (HBV), Hepatitis C (HCV), 

and Human Immunodeficiency Virus (HIV). The primary methods of protection are 

training, engineering and work practice controls, immunization against HBV, and the use 

of universal precautions. Recognizing that the tasks performed by emergency responders 

often are undertaken during uncontrolled situations, the regulation states that all body 

fluids are considered infectious when differentiation between fluid types is difficult. 

Each employer must establish an “exposure control plan.” The plan must 

• Identify and categorize all job classifications and tasks that reasonably can be 

anticipated to have a potential for exposure to blood or body fluids. 

• Delineate the implementation plan and schedule for the infection control 

program. 

35 
LAWS, REGULATIONS, AND STANDARDS 

• Identify the procedures for evaluating/investigating exposure incidents. 

This regulation prohibits eating, drinking, smoking, applying cosmetics, or 

handling contact lenses in work areas where there is potential for occupational exposure 

to bloodborne pathogens. Hands must be washed as soon as feasible after removal of 

gloves or other personal protective equipment. If hand-washing facilities are not 

available (e.g., at the scene), alternative hand-washing provisions must be provided by 

the employer. 

Personal protective equipment (PPE) is covered in detail. Employers are required 

to supply, repair, and replace PPE including gloves, gowns, face shields or masks and eye 

protection, and resuscitation equipment. Exemptions to the use of PPE are allowed 

where “its use would have prevented the delivery of health-care of public safety services 

or would have posed an increased hazard to the safety of the worker or co-workers.” 

These exemptions are meant to apply to unexpected, “rare and extraordinary 

circumstances.” The decision not to use PPE rests with the employee, and not the 

employer. 

A general framework for post-exposure care that follows Public Health Service 

guidelines is presented, including the need for medical recordkeeping. Each employee 

must receive a copy of the regulation and, to assure understanding, must receive training 

in communicable disease/infection control. Written training records must be maintained, 

including attendance. Training must be provided annually in each of the following 

subjects: 

• Epidemiology, modes of transmission, and symptoms of bloodborne diseases. 

• The employer’s exposure control plan. 

• Recognition of tasks that may result in exposure to bloodborne diseases. 

• Use and limitations of practices that will reduce or prevent exposures. 

• Proper selections, use, location, removal, handling, decontamination, and 

disposal of PPE. 

• Information on Hepatitis B vaccine. 

• Emergency procedures, including post-exposure requirements. 

• Recognition of standard biohazard markings, color-coding, and labeling. 

36 
LAWS, REGULATIONS, AND STANDARDS 

Subpart Z of Occupational Exposure to Bloodborne Pathogens; Final Rule.

(OSHA 29 CFR Part 1910.1030) are included in Appendix B2. The entire regulation is 

available on the Web at http://www.osha-slc.gov/OshStd_data/1910_1030.html. 

Occupational Exposure to Bloodborne Pathogens; Needlesticks and Other 

Sharps Injuries; Final Rule (29 CFR Part 1910.1030, January 18, 2001) 

This regulation updates the original Occupational Exposure to Bloodborne 

Pathogens (29 CFR Part 1910.1030) to include the requirements of the Health Care 

Worker Needlestick Safety and Prevention Act (PL 106-430). This adds new 

requirements for exposure control programs and requires the use of a sharps/needlestick 

injury log. The revision clearly specifies engineering controls necessary for minimization 

of employee exposure. It clarifies the need to involve employees in identifying and 

choosing the devices and includes provisions designed to maintain the privacy of 

employees who have experienced needlesticks. The text of this regulation can be found 

in Appendix B3 of this manual and also is available on the Web at http://www.oshaslc.gov/needlesticks/index.html. 

Access to Employee Exposure and Medical Records (29 CFR Part 1910.20)

This section provides for employee access to their own medical and exposure 

records and regulates the storage of such records. Employers must make medical and 

relevant exposure records available within fifteen days of any formal request. A 

physician representing the employer may recommend that the records be released as a 

summary rather than the complete chart, or that the records be released only to a 

physician. This section also allows OSHA access to medical and exposure records. 

Employee medical/exposure records must be maintained for the duration of 

employment plus thirty years. Instruction on transfer of records is provided for 

businesses that close before the thirty-year limit is reached. 

NATIONAL FIRE PROTECTION ASOCIATION (NFPA)

Standards and codes published by the NFPA represent the consensus opinions of a 

committee of experts representing different interests relating to the subject matter 

involved. NFPA standards are not mandatory until official adoption by the authority 

37 
LAWS, REGULATIONS, AND STANDARDS 

having jurisdiction. Nor does NFPA enforce or monitor compliance. However, since 

NFPA standards reflect the national “industry standard” or “standard of care”, a 

department not meeting these standards could face possible liability in the event of 

litigation. 

NFPA 1500 (1997 Edition) 

 NFPA 1500, Standard on Fire Department Occupational Safety and Health 

Program, is an umbrella document intended to establish a framework for a 

comprehensive safety and health program. It requires an official written department 

occupational safety and health policy, and the appointment of an occupational safety and 

health officer, an occupational safety and health committee, and a fire department 

physician. Health maintenance issues addressed include pre-entry health examinations 

and periodic health reassessment as specified in NFPA 1582, Standard on Medical 

Requirements for Fire Fighters and Information for Fire Department Physicians, and 

after “debilitating illnesses or injuries.” 

Infection control recommendations include active attempts to identify and limit 

member exposure to contagious diseases and making available “inoculations, 

vaccinations, and other treatment.” It requires departments to operate an infection control 

program as specified in NFPA 1581, Standard on Fire Department Infection Control 

Program, and to maintain a confidential health database that documents occupational 

injuries, illnesses, and exposures to hazardous materials, toxic products, or contagious 

diseases. 

Preventive health measures recommended include a member assistance and 

wellness program and a critical incident stress program. Recordkeeping requirements 

and confidentiality safeguards for member assistance programs are listed. 

NFPA 1521 (1997 Edition) 

 NFPA 1521, Standard on Fire Department Safety Officer, differentiates between 

the roles of Incident Safety Officer (ISO) and Health and Safety Officer (HSO). The 

Health and Safety Officer must “have and maintain a knowledge of the current health and 

physical fitness factors” that affect the work environment. The Health and Safety Officer 

38 
LAWS, REGULATIONS, AND STANDARDS 

has the authority to “cause immediate correction of situations that create an imminent 

hazard to members.” The Incident Safety Officer must “have and maintain a knowledge 

of safety and health hazards involved in emergency operations” and has the authority to 

“alter, suspend, or terminate” activities at an emergency incident that are judged to be 

“unsafe or to involve an imminent hazard.” 

The standard also requires the establishment of a department database to maintain 

records of all “accidents, occupational deaths, injuries, illnesses, and exposures.” The 

Health and Safety Officer is responsible for management and analysis of this information. 

NFPA 1581 (2000 Edition)

 NFPA 1581, Standard on Fire Department Infection Control Program, 

establishes minimum requirements for an infection control program in emergency service 

organizations. Specific areas addressed include 

• Program components, including the designation of an Infection Control 

Officer. 

• Station facilities and apparatus requirements. 

• Personal Protective Equipment. 

• Cleaning, disinfection, and disposal procedures. 

• Post-exposure procedures. 

• Immunization requirements. 

Immunization requirements vary somewhat from CDC recommendations. CDC currently 

recommends immunizations for Hepatitis B, measles, mumps, rubella, influenza, and 

chickenpox. NFPA recommends immunization for Hepatitis B and influenza, and 

“where specific or local conditions dictate”: Hepatitis A, measles, mumps, rubella, 

tetanus and diptheria (Td) booster every 10 years, and meningococcal disease. 

NFPA 1582 (2000 Edition) 

 NFPA 1582, Standard on Medical Requirements for Fire Fighters and 

Information for Fire Department Physicians, addresses the medical requirements 

necessary for persons who perform firefighting tasks. Two categories of medical 

conditions are identified. Category A identifies the medical conditions that “would not 

39 
LAWS, REGULATIONS, AND STANDARDS 

allow a person to perform firefighting operations.” Category B identifies medical 

conditions that must be evaluated “on a case-by-case basis” to determine if the condition 

would prevent a person from performing firefighting operations. 

The standard specifically requires “a tuberculosis monitoring program that will 

test members at least annually and as indicated by CDC guidelines.” Medical 

evaluations, medical examinations, recordkeeping, and confidentiality also are addressed. 

CENTERS FOR DISEASE CONTROL AND PREVENTION 

The Centers for Disease Control and Prevention (CDC) publishes the Morbidity 

Mortality Weekly Report (MMWR), a weekly update of information on communicable 

diseases. The infection control officer should review periodically MMWR for new 

information. A subscription is expensive; however, the contents are available for both 

the latest and past issues of MMWR online at 

http://www2.cdc.gov/mmwr/mmwr_wk.html. Liaison with a local infection control 

practitioner is another possible source of current information. The most current issues 

dealing with worker protection from HIV, HBV, HCV, tuberculosis, and immunization 

recommendations are summarized on the following pages. All of the MMWR 

publications discussed in this Guide can be viewed and downloaded in Adobe format in 

their entirety by accessing the “Search” at http://www2.cdc.gov/mmwr/mmwr_wk.html

and typing in the Volume, Number, and Date. 

Recommendations for Prevention of HIV Transmission in Health-Care 

Settings (MMWR Vol. 36, No. 2, August 21, 1987)

This document established the concept of “universal precautions.” Under 

universal precautions, the blood and certain body fluids of all patients are considered 

potentially infectious. Although saliva still has not been implicated as a mode of 

transmission for HIV, the use of mouthpieces or resuscitation bags to minimize the need 

for mouth-to-mouth resuscitation was recommended. 

Additional information is available from CDC regarding respiratory protection 

against tuberculosis. CDC Recommendations from Respiratory Protection updates the 

1994 recommendations to account for subsequent national Institute for Occupational 

40 
LAWS, REGULATIONS, AND STANDARDS 

Safety and Health (NIOSH) respiratory classifications and contains the recommendation 

for respirators meeting Class N95 or better. This document is available at 

http://www.cdc.gov/niosh/tb.html. NIOSH also has produced several reference 

documents on this subject, including Protect Yourself Against Tuberculosis

(http://www.cdc.gov/niosh/tb.html) and Respiratory Protection Program In Health Care 

Facilities – Administrator’s Guide (http://www.cdc.gov/niosh/99-143.html). 

Universal Precautions for Prevention of Transmission of Human 

Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne 

Pathogens in Health Care Settings (MMWR Vol. 37, No. 24, June 24, 1988)

This document extended universal precautions to include body tissues and 

cerebrospinal, synovial, pleural, pericardial, and amniotic fluids. Universal precautions 

are not required for feces, nasal secretions, sputum, saliva, urine, tears, or vomitus, unless 

they contain visible blood. 

Blood was cited as the most important source of HIV/HBV infection in 

occupational settings. Semen and vaginal secretions also can transmit HIV/HBV as 

sexual diseases. 

Guidelines for Prevention of Transmission of Human Immunodeficiency

Virus and Hepatitis B Virus to Health Care and Public Safety Workers 

(MMWR Vol. 38, No. 2-6, 1989)

This document was published in response to the Health Omnibus Programs 

Extension Act of 1988 (PL 100-607). Universal precautions were expanded to the extent 

that “when emergency medical and public-safety workers encounter body fluids under 

uncontrolled, emergency circumstances in which differentiation between fluid types is 

difficult, if not impossible, they should treat all body fluids as potentially hazardous.” 

This document is often considered the “Bible” of emergency service infection control. 

However, much of the information contained in these guidelines was taken from other 

MMWR’s. 

41 
LAWS, REGULATIONS, AND STANDARDS 

Recommendations for Preventing Transmission of Human 

Immunodeficiency Virus and Hepatitis B Virus to Patients During ExposureProne Invasive Procedures (MMWR Vol. 40, No. RR-08, July 12, 1991) 

This document addresses the status of health-care workers who have HIV or 

HBV. Although directed at hospital personnel, this document identifies exposure-prone 

procedures as those that include digital palpation of a needle tip in a body cavity or the 

simultaneous presence of the health-care worker’s fingers and a needle or other sharp 

instrument or object in a poorly visualized or highly confined anatomic site. 

The document also outlines the scope of practice for infected health-care workers 

as follows. Health-care workers who are infected with HIV or HBV (and are positive for 

the HbeAg antigen) should not perform exposure-prone procedures unless they have 

sought counsel from an expert review panel and been advised under what circumstances, 

if any, they may continue to perform these procedures. Such circumstances would include 

notifying prospective patients of the health-care worker’s seropositivity before they 

undergo exposure-prone invasive procedures. 

Health-care workers whose practices are modified because of their HIV or HBV 

infection status should, whenever possible, be provided opportunities to continue 

appropriate patient-care activities. Career counseling and job retraining should be 

encouraged to promote the continued use of the worker’s talents, knowledge, and skills. 

Health-care workers whose practices are modified because of HBV infection should be 

reevaluated periodically to determine whether their seropositive status changes due to 

resolution of infection or as a result of treatment 

Guidelines for Preventing the Transmission of Mycobacterium 

Tuberculosis in Health-Care Facilities, 1994 (MMWR Vol. 43, No. RR-13, 

October 28, 1994) 

This document updates the 1990 guidelines and focuses on the importance of a) 

the hierarchy of control measures, including administrative and engineering controls and 

personal respiratory protection; b) the use of risk assessments for developing a written 

tuberculosis (TB) control plan; c) early identification and management of persons who 

have TB; d) TB screening programs for health-care workers; e) health-care worker 

42 
LAWS, REGULATIONS, AND STANDARDS 

training and education; and f) the evaluation of TB infection control programs. The 

following criteria are identified for respiratory protective devices: 

• “The ability to filter particles 1 um in size in the unloaded state with a filter 

efficiency of greater than or equal to 95percent (i.e., filter leakage of less than 

or equal to 5 percent), given flow rates of up to 50 L per minute. 

• The ability to be qualitatively or quantitatively fit tested in a reliable way to 

obtain a face-seal leakage of less than or equal to 10 percent. 

• The ability to fit the different facial sizes and characteristics of health care 

workers, which can usually be met by making the respirators available in at 

least three sizes. 

• The ability to be checked for face piece fit, in accordance with standards 

established by the Occupational Safety and Health Administration (OSHA) 

and good industrial hygiene practice, ... each time they put on their 

respirators.” 

Two recommendations specific to emergency medical services are 

• “When EMS personnel or others must transport patients who have confirmed 

or suspected active TB, a surgical mask should be placed, if possible, over the 

patient's mouth and nose. Because administrative and engineering controls 

during emergency transport situations cannot be ensured, EMS personnel 

should wear respiratory protection when transporting such patients. If feasible, 

the windows of the vehicle should be kept open. The heating and airconditioning system should be set on a nonrecirculating cycle. 

• EMS personnel should be included in a comprehensive PPD screening 

program and should receive a baseline PPD test and follow-up testing as 

indicated by the risk assessment. They should also be included in the followup of contacts of a patient with infectious TB.” 

43 
LAWS, REGULATIONS, AND STANDARDS 

Immunization of Health-Care Workers: Recommendations of the Advisory

Committee on Immunization Practices (ACIP) and the Hospital Infection 

Control Practices Advisory Committee (HICPAC) (MMWR Vol. 46, No. RR18, December 26, 1997) 

This report discusses all the immunizations recommended for health-care workers 

and provides the regime for those immunizations. ACIP strongly recommends that all 

health-care workers be vaccinated against (or have documented immunity to) Hepatitis B, 

influenza, measles, mumps, rubella, and varicella. 

The report identifies Hepatitis B virus (HBV) infection as the major infectious 

hazard for health-care personnel. Prevaccination serologic screening for prior infection is 

not indicated. Postvaccination testing for antibody to Hepatitis B surface antigen (antiHB’s) response is indicated for health-care workers who have blood or patient contact 

and are at ongoing risk for injuries with sharp instruments or needlesticks. Studies 

among adults have demonstrated that, despite declining serum levels of antibody, 

vaccine-induced immunity continues to prevent clinical disease or detectable viremic 

HBV infection. Therefore, booster doses are not considered necessary. This is a change 

from the 1990 recommendations. Table 1-2-2 summarizes these recommendations. 

44 
LAWS, REGULATIONS, AND STANDARDS 

Table 1-2-2 

Immunization of Health-Care Workers: Recommendations of the Advisory

Committee on Immunization Practices (ACIP) and the Hospital Infection 

Control Practices Advisory Committee (HICPAC) 

Disease Immunization Notes

Hepatitis B Series of three doses Mandated by OSHA that it is 

offered to employees at 

employer's expense. 

Influenza Yearly in the fall Each year influenza vaccine 

recommendations are reviewed 

and amended to reflect updated 

information concerning influenza 

activity in the United States for 

the preceding season. These 

recommendations are published 

annually in the MMWR, usually 

during May or June. 

Measles, Mumps, Rubella Series of two doses MMR is the vaccine of choice. 

Varicella Series of two doses Recommended for all health-care 

workers 

Tetanus, Diptheria Primary vaccination 

of previously 

unvaccinated adults 

consists of three doses 

of adult tetanusdiphtheria toxoid. 

Booster is recommended every 10 

years. 

When wound is incurred, booster 

should be administered if last 

booster was more than 5 years 

prior. 

ACIP does not recommend routine immunization of health-care workers against tuberculosis, 

Hepatitis A, pertussis, meningococcal disease, typhoid fever, or vaccinia. However, 

immunoprophylaxis for these diseases may be indicated in certain circumstances. 

Catch-Up Vaccination Programs 

Managers of health-care facilities should consider implementing catch-up vaccination 

programs for those already employed, in addition to policies to ensure those newly hired 

receive necessary vaccinations. This strategy will help prevent outbreaks of vaccinepreventable diseases. Because education enhances the success of many immunization 

programs, reference materials should be available to assist in answering questions

regarding the diseases, vaccines, and toxoids, and the program or policy being 

implemented. 

45 
LAWS, REGULATIONS, AND STANDARDS 

Updated U.S. Public Health Service Guidelines for the Management of 

Occupational Exposures to HBV, HCV, and HIV and Recommendations for 

Postexposure Prophylaxis (MMWR, Vol. 50, No. RR-11, June 29, 2001) 

This report updates and consolidates all previous U.S. Public Health Service 

recommendations for the management of health-care workers who have occupational 

exposure to blood or other body fluids that might contain Hepatitis B (HBV), Hepatitis C 

(HCV), or HIV. 

Recommendations for HBV postexposure management include initiation of 

Hepatitis B vaccine series to susceptible unvaccinated persons and Hepatitis B immune 

globulin and/or Hepatitis B vaccine series after evaluation of the Hepatitis B surface 

antigen status. 

Immune globulin or antiviral drugs are not recommended for HCV. However, the 

HCV status of the source person and the exposed person should be determined. If the 

source person is positive, follow-up testing should be conducted to determine if an 

infection develops. 

Recommendations for HIV include a basic 4-week course of two drugs 

(zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] 

and d4T). For exposures that pose an increased risk of transmission, an expanded 

regimen includes the addition of a third drug. The complete text of this guideline is 

included in Appendix B4. 

 SUMMARY 

The department infection control program is designed to protect both the health of 

the members and the department against related liability. For these reasons, it is 

important to review and remain current on Federal, State, and local statutes affecting 

infection control/environmental issues. 

Infection control is a rapidly expanding field. As new knowledge is gained, the 

laws, standards, and regulations based on this knowledge will change. The department 

Infection Control Officer needs to stay up-to-date on both medical and legal changes. 

The department plan must be reviewed and revised to incorporate these changes at 

appropriate intervals. 

46 
SECTION 2 

SECTION 2 

COMPONENTS OF AN INFECTION 

CONTROL PROGRAM 

47 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

INTRODUCTION 

Developing, implementing, and managing an effective and efficient infection 

control program is a process that involves several key components. After it is developed, 

changes continually take place that require the program be updated and revised to provide 

the best protection possible for members. 

RISK MANAGEMENT 

Risk management is comprised of many elements including liability, insurance, 

safety, health, security, financial impact, and several others. The risks encountered by 

emergency services personnel are many, such as traffic, response hazards, blood and 

body fluids, and violence. To control these risks effectively, a fire or EMS department 

must use a risk management program. The primary focus of the internal 

(organizational) risk management plan is firefighter safety and health. 

Occupational exposure to blood, body fluids, or communicable or infectious 

disease is a very real hazard for department members on a daily basis. A written 

infection control policy or program is one essential component that must be incorporated 

into the risk management plan. Regardless of the type of service delivery (first 

responder, Basic Life Support (BLS), or Advanced Life Support (ALS)), departments 

need to have an infection control program and a risk management plan. 

The safety and health component of risk management was incorporated into 

NFPA 1500, Standard on Fire Department Occupational Safety and Health, during the 

1992 revision process. Simply stated, the requirements of the risk management program

are 

• The fire department shall adopt an official written risk management plan 

which addresses organizational policies and procedures. 

• The risk management plan shall be developed to address the following areas: 

administration, facilities, training, vehicle operations, protective clothing and 

equipment, operations at emergency incidents, operations at non-emergency 

incidents, and other related activities. 

• The risk management plan shall include the following components: 

 

49 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

 risk identification 

 risk evaluation 

 risk control techniques 

 risk monitoring 

There is an additional step that can be added or incorporated into this process, 

which is typically inserted between the risk identification and risk control techniques. 

This step is called prioritization of risks. 

RISK MANAGEMENT MODEL 

There is no single method or solution for managing risk effectively. Determining 

how to manage risk is a decision each department should make based on the risk 

management model. In order for the risk management plan to be effective, the following 

components must be included 

Risk Identification: Actual or potential hazards for all job functions. 

Compile a list of all emergency and non-emergency operations provided by the 

department. There are many sources to assist with this identification process. The first, 

and possibly the most effective, is the department’s loss prevention data. 

Risk Evaluation: The potential of occurrence of a given hazard and the 

severity of its consequences. 

Once the risks are identified, they can be evaluated from the standpoint of both 

frequency and severity. Frequency addresses the likelihood of occurrence. Typically, if 

a particular type of incident, such as back injuries have occurred repeatedly, they will 

continue to occur until effective control measures are implemented. 

Severity addresses the degree of seriousness of the incident. This can be 

measured in a variety of ways such as time away from work, cost of damage, cost of and 

time for repair or replacement, disruption of service, or legal costs. Using the 

information gathered in the identification step, the risks then can be classified based on 

severity. 

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COMPONENTS OF AN INFECTION CONTROL PROGRAM 

Prioritizing Risk: The degree of a hazard based upon the frequency and 

severity of occurrence. 

Taken in combination, the results of the frequency and severity determinations 

will help to establish priorities for determining action. Any risk that has a high 

probability of occurrence combined with serious consequences, deserves immediate 

action, and would be considered a high priority item. On the other end of the scale, nonserious incidents with a low likelihood of occurrence are a lower priority, and can be 

placed near the bottom of the "action required" list. 

Risk Control Measures: Solutions for elimination or reduction of real or potential 

hazards by implementing an effective control measure. 

There are several approaches for controlling risk, including risk avoidance, 

implementation of control measures, and risk transfer. 

In any situation, the best choice is risk avoidance. Simply put, this means avoid 

the activity that creates the risk. Frequently in an emergency services organization this is 

not a practical choice. Lifting a patient onto a stretcher presents a serious back injury 

risk, but you cannot avoid this risk and still provide effective service! 

An example of where avoidance has been very practical is the widespread use of 

sharps containers. The risks associated with recapping needles are well documented, so 

recapping is no longer an accepted practice. This risky behavior can be avoided through 

the proper use of a sharps container. 

The most common method used for the management of risk is the adoption of 

effective control measures. While control measures will not eliminate the risk, they can 

reduce the likelihood of occurrence or mitigate the severity. Safety programs, ongoing 

training and education programs, and well-defined standard operating procedures (SOP’s) 

are all effective control measures. 

Some typical measures instituted for infection control include appropriate use of

personal protective equipment (PPE) (gloves, masks, goggles, etc.) during patient 

contact, training and education, and competent SOP’s. The combined use of these 

control measures results in an effective program that reduces the risk of exposure to 

infectious disease. Risk transfer can be accomplished in two primary ways - physically 

51 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

transferring the risk to somebody else, or through the purchase of insurance. For a fire or 

EMS organization, the transfer of risk may be difficult, if not impossible. However, 

examples of risk transfer would be 1) scheduling a routine transfer patient in protective 

isolation in a newer vehicle with circulating air rather than an older vehicle, and 2) 

contracting out the laundering of contaminated linen/clothing to a commercial laundry. 

The risks associated with example two have been transferred to a private contractor. 

The purchase of insurance transfers financial risk only. It does nothing to affect 

the likelihood of occurrence. Buying fire insurance on the station, while highly 

recommended to protect the assets of the department, does nothing to prevent the station 

from burning down. Therefore, insurance is no substitute for effective control measures. 

Risk Monitoring: Evaluation of effectiveness of risk control 

 measures. 

 

The last step in the process is risk management monitoring. Once control 

measures have been implemented, they need to be evaluated to measure their 

effectiveness. Any problems that occur in the process have to be revised or modified. 

This final step ensures that the system is dynamic, and will facilitate periodic reviews of 

the entire program. 

The intent of the risk management plan is to develop a strategy for reducing the 

inherent risks associated with fire department operations. Regardless of the size or type 

of fire department, every organization should operate within the parameters of a risk 

management plan. This is a dynamic and aggressive process that must be monitored and 

revised annually by the health and safety officer. 

The risk to members providing care to a patient with a communicable disease 

poses a real hazard and should be properly addressed through a written infection control 

program. The infection control program should include, at a minimum, the following 

issues: 

• Training and education 

• PPE 

• Health maintenance 

• Immunizations 

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COMPONENTS OF AN INFECTION CONTROL PROGRAM 

• Exposure management 

• Fire department facilities 

• Fire department vehicles 

• Cleaning, disinfecting, and disposal 

Infection control is a preventive means of controlling risks associated with patient 

care. By incorporating infection control into the risk management process, frequency 

and severity of risks associated with communicable diseases are adequately controlled. 

The health and safety officer, designated infection control officer, incident safety officer, 

and the department’s Occupational Safety and Health Committee should ensure that 

evaluations and revisions to the risk management plan occur at least annually. 

Safety is a major component of risk management. Most of the emphasis placed 

on risk management from a fire service perspective is from a safety approach. The safety 

component affects other risk management components in areas such as liability and 

finance. An aggressive, proactive occupational safety and health program will reduce 

accidents, injuries, occupational illnesses, and health exposures. This, in turn, reduces 

the department’s liability claims and payments and also provides a positive effect on the 

financial well being of the organization. Many fire departments are self-insured, which 

means that the entity, jurisdiction, or the fire department generates funding for various 

types of insurance such as workers’ compensation, vehicle and general liability. 

TRAINING AND EDUCATION 

Training and education is a vital component to ensure a successful program, and 

is a crucial element of the risk management process. The department shall conduct 

initial and annual training and education programs for all members in accordance with 

Federal or State regulations. Members will receive bloodborne pathogen training at the 

time of initial assignment of job functions (recruit training or company in-service) 

whenever exposure potential exists. Additional training shall be provided whenever 

there are changes in work assignments, job functions, or new protective clothing and 

equipment is placed in service. Training will include an opportunity for members to 

have their questions answered by the instructor. 

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COMPONENTS OF AN INFECTION CONTROL PROGRAM 

Topics for the infection control training program include 

• Epidemiology 

• Proper use of PPE 

• SOP’s for safe work practices relating to infection control 

• Proper methods of disposal of contaminated medical waste 

• Cleaning and decontamination 

• Reporting process of exposures 

• Exposure management. 

• Medical followup care and treatment. 

All training and education programs for infection control will be properly 

documented in writing. The training report needs to include 

• Dates of training session 

• Contents and/or summary of the training session 

• Names and qualifications of instructor(s) 

• Names and job titles of members attending. 

MEMBERS 

Each member of the fire department has the right to be protected by an effective 

occupational safety and health program and shall participate and comply with the 

requirements of the occupational safety and health program. Each member can also 

participate or be represented in the research, development, implementation, evaluation, 

and enforcement of this program. 

The infection control program has the goal of identifying the risks of exposures to 

members and the means to prevent those exposures. All members have the individual 

responsibility for their own health, safety, and welfare. Each member is responsible for 

complying with all departmental SOP’s, including occupational safety and health. Each 

member must ensure his or her own safety and health against occupational exposures by: 

• Participating in available health maintenance programs (annual medical 

examinations, immunizations, medical screenings, etc.) 

• Practicing good personal hygiene 

• Reporting any personal medical conditions which could require work 

54 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

restrictions 

• Following infection control procedures at emergency incidents or while 

conducting patient care at any time 

• Properly using all infection control protective clothing and equipment 

• Reporting and documenting all exposures 

• Complying with medical followup treatment 

• Assuring proper decontamination of equipment after each incident 

• Proper storage/disposal of contaminated waste 

• Attending annual retraining of all members as required by Occupational 

Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030). 

HEALTH MAINTENANCE 

All members of fire departments and emergency medical services organizations 

must participate in a health maintenance process. The health maintenance program is a 

significant part of the infection control process. The health maintenance process as it 

relates to infection control includes 

• Access to an appropriate immunization program which includes immunization 

against influenza and Hepatitis B; 

• Members shall be offered immunizations for the following: 

 Hepatitis A 

 Measles, Mumps, and Rubella 

 Tetanus/Diptheria 

 Meningococcal disease 

 Other diseases as required by specific incidents or local conditions 

• Access to tuberculosis screening on an annual basis. 

• Health maintenance program which complies with NFPA 1582, Standard on 

Medical Requirements for Fire Fighters and Information for Fire Department 

Physicians. 

• The development of a confidential health database is established and 

maintained for each member in accordance with NFPA 1582, Standard on 

Medical Requirements for Fire Fighters and Information for Fire Department 

55 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

Physicians and 29 CFR Part 1910.20, Access to Employee Exposure and 

Medical Records. 

• In the event of an exposure, the member shall receive a confidential medical 

evaluation, post-exposure prophylaxis, counseling, and evaluation. 

• Return-to-work policy. 

ROLES AND RESPONSIBILITIES 

Many different individuals within a department or organization have a valuable 

role to ensure that the infection control program is developed, implemented, and properly 

and effectively managed. Each individual must understand his/her role and responsibility 

in this process for the safety, health, and welfare of the members. Role definition must 

spell out specific areas of responsibility and accountability throughout the organization. 

Specific role definitions will vary in each department, depending on organizational 

structure, available resources, and program requirements. The most vital issue is 

assigning and managing the necessary components of the infection control program. 

Chief of the Department 

Although the chief of the department may have little direct involvement in daily 

operations, he/she has the ultimate responsibility for the health and welfare of department 

members. The chief of the department is responsible for ensuring that an infection 

control program has been developed and implemented, adequate funding is available for 

the training, resources, procurement of equipment, supplies, and health maintenance 

requirements. The chief must ensure that adequate staffing is available to accomplish 

program goals and objectives and must define authority and responsibility for each 

position identified in the infection control program. In addition, he/she has the ultimate 

responsibility of holding each member accountable for assigned functions. 

Safety Officer 

The Safety Officer is defined by two distinct functions - Health and Safety Officer 

(HSO) and Incident Safety Officer (ISO). Each of these job functions has a defined 

responsibility relating to infection control. In larger departments, the HSO serves as the 

56 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

manager of the department’s occupational safety and health program, while the ISO is 

assigned to particular shifts or at emergency incidents to manage the operational issues 

relating to firefighter health and safety. In smaller departments, the Safety Officer may 

have both titles, as well as the additional title of infection control officer. 

Health and Safety Officer 

The HSO has the responsibility of ensuring that the department has an effective 

occupational safety and health program. As the manager of this program, the HSO is 

responsible for ensuring that the fire department’s infection control program meets the 

requirements of 29 CFR Part 1910.1030, Occupational Exposure to Bloodborne 

Pathogens, 29 CFS Part 1910 Occupational Exposure to Bloodborne Pathogens; 

Needlesticks and Other Sharps Injuries; Final Rule, Guidelines for the Management of 

Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure 

Prophylaxis (MMWR, May 15, 2001), and NFPA 1581, Standard on Fire Department 

Infection Control Program. 

If the department does not have an infection control officer, the HSO fills this 

void. If the department does have an infection control officer, the HSO maintains a 

liaison with this individual to assist in achieving the objectives of the infection control 

program as required by NFPA 1581, Standard on Fire Department Infection Control 

Program. 

Incident Safety Officer 

As an operational function, the ISO monitors for compliance at an emergency 

incident. The ISO can monitor emergency operations relating to infection control. The 

ISO must ensure compliance with NFPA 1581, Standard on Fire Department Infection 

Control Program during EMS operations. Any problems that are encountered relating to 

infection control can be channeled through the HSO for changes in appropriate areas such 

as SOP’s, training and education, and PPE. 

57 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

Infection Control Officer 

The Ryan White Comprehensive AIDS Resource Emergency Act of 1990 requires 

each department to name a designated infection control officer. One of the primary 

responsibilities of the infection control officer is to serve as a liaison between the 

department and the treating facility in a potential or actual exposure. 

The infection control officer should be a member of the department’s 

occupational safety and health committee. The infection control officer works closely 

with the HSO and the ISO to ensure compliance with program goals. The infection 

control officer is responsible for ensuring the availability of PPE, monitoring compliance, 

and quality assurance throughout the department, as well as maintaining required 

documentation and recordkeeping. 

Chief of Training 

The chief of training is responsible for ensuring that all members have met their 

initial and annual training requirements as required by 29 CFR Part 1910.1030, 

Occupational Exposure to Bloodborne Pathogens, 29 CFS Part 1910 Occupational 

Exposure to Bloodborne Pathogens; Needlesticks and Other Sharps Injuries; Final Rule, 

and NFPA 1581, Standard on Fire Department Infection Control Program. Each 

member must demonstrate the necessary knowledge, skills, and abilities required to 

perform his/her assigned tasks safely and to meet the mandated laws and standards. 

The chief of training must work with the HSO and the infection control officer to 

ensure a competent training program. Program managers must be provided with an 

overview of the entire program. Officers must receive training in SOP’s, compliance, 

monitoring, recordkeeping requirements, and proper use of protective clothing and 

equipment. 

Occupational Safety and Health Committee 

Each department should establish an occupational safety and health committee. 

This committee provides an avenue for department members to voice their concerns 

regarding safety and health issues, provide guidance to the HSO, participate in research 

and development projects, and suggest development of policies and procedures related to 

58 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

occupational safety and health. The primary purpose of the committee is to study, 

review, and make recommendations pertaining to occupational health and safety within a 

department. Objectives of this committee should include 

• Review department health and safety issues related to SOP’s 

• Research and make recommendations concerning all fire department related 

equipment 

• Review causes of accidents and injuries within the department and develop 

means of reducing these incidents 

• Develop and implement an infection control program which meets the 

applicable laws, codes, and standards 

• Effect a reciprocal flow of information to all department members as it 

pertains to health and safety. 

The occupational safety and health committee will be involved with policy 

development, research of proper PPE, make recommendations for facility safety issues, 

and participate in training programs. The participation and involvement by members of 

this committee brings expertise that improves the safety and health within the 

department. 

Field Supervisors/Company Officers/Battalion Chiefs 

All supervisors in the department are responsible for supporting, promoting, and 

ensuring that each member comply with the infection control program. Leading by 

example is a key component of the leadership and management required for a compliant 

infection control program. First-line supervisors play a critical role in this process by 

serving as a positive role model. The supervisor’s attitude and behavior relating to 

infection control have a profound influence on actions or inactions of subordinates. 

Supervisors must ensure that all components of the infection control plan are 

properly followed, particularly: 

• Health maintenance (assuring members are fit for duty) 

• Notification and documentation of exposures 

• Storage, maintenance, and availability of all necessary supplies, protective 

clothing, and equipment 

59 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

• Training 

• Decontamination and waste disposal 

• Proper use of protective clothing and equipment. 

Supervisors also have the responsibility for managing an incident scene, including 

ensuring effective customer service when dealing with citizens, maintaining patient 

confidentiality, and being sensitive to the needs of the patient. 

Fire Department Physician 

The fire department physician is responsible for developing, implementing, and 

managing a health maintenance program that is compliant with the requirements of

NFPA 1582, Standard on Medical Requirements for Fire Fighters and Information for 

Fire Department Physicians. This process involves a comprehensive health maintenance 

program for all members, which includes 1) pre-entry and ongoing health assessments, 2) 

immunizations, 3) postexposure procedures, 4) recordkeeping, 5) medical treatment and 

followup care, and 6) member assistance program. 

The size and needs of the organization will dictate whether the fire department 

needs a full-time physician. Fire departments of all sizes and types, including those that 

do not provide EMS, should have a working relationship with at least one designated 

physician who can serve as the primary medical contact with other physicians and 

specialists. Alternately, a department can designate several physicians, use the services 

of a group practice, or have multiple providers -- whichever best meets the needs of the 

organization and its members. The most important aspect is to have a physician who is 

aware of the medical needs of the department members and who is available on an 

immediate basis. 

The fire department physician is responsible for guiding, directing, and advising 

members regarding their health and fitness to perform assigned duties and 

responsibilities. He/She oversees the health components of the department’s 

occupational safety and health program and serves as a resource for the infection control 

officer, particularly in assessing potential exposure incidents. 

Another key requirement is to be available for consultation and counseling 

following members’ exposures. The physician should provide objective information 

60 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

regarding risk of disease based on specific type of exposure, potential risk to members’ 

families, recommended followup treatment, possible long-term effects of the disease, and 

prophylactic therapy. Maintaining confidentiality is an important responsibility of the 

fire department physician. 

The fire department physician should have specific expertise and experience 

relating to the needs of firefighters and emergency medical personnel and a thorough 

knowledge of the physical demands involved in emergency operations. If possible, 

he/she should be a specialist in the field of occupational medicine. 

Local Medical Facility

The local medical facilities (hospitals) must have procedures in place which 

provide adequate feedback to the department regarding exposures to a communicable 

disease. The medical facility’s infection control officer must work jointly with the 

department’s infection control officer so feedback in either direction will ensure the 

health and welfare of the members. The process must enable members to report a 

potential or actual exposure to the department’s infection control officer. This individual 

forwards the information to the medical facility’s infection control officer for proper 

action. If the medical facility determines a patient has a communicable disease (e.g. 

tuberculosis), this information must be passed onto the responders who treated and 

transported the patient. Immediate notification must be made by the medical facility’s 

infection control officer to the department’s infection control officer. Exposures occur at 

various times, and the notification process must be functional 24 hours a day/7 days a 

week in order to meet the medical requirements specified for testing, prophalyxsis, and 

reporting. 

Municipal/County Risk Manager 

Those fire and EMS departments that are self-insured must provide the funding 

for workers’ compensation, medical care and treatment, medical followup, and other 

components of the infection control process funded by the government entity. A 

funding process must be established to ensure the program is financially capable of 

maintaining this program. If fire and EMS departments carry private insurance, these 

61 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

costs are covered by the insurance policy. Prevention is a key to the success of the 

infection control program. A risk manager prefers to fund a preventive program rather 

than the financial impact of long-term or chronic health problems or conditions. 

POLICIES AND PROCEDURES 

NFPA 1581, Standard on Fire Department Infection Control Program, requires that a 

fire department develop and implement a written infection control plan and Occupational 

Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030) requires the department to 

have a written exposure control plan. For members to practice effective control 

procedures and practices, the department must have a written infection policy statement 

and procedures. Simply stated, the goal of the infection control plan is to identify and 

limit the exposure of members to communicable or infectious disease during the course 

of their assigned duties and while in fire department facilities. 

Policy Statement 

The policy statement discusses purpose, scope, and content and sends a safety and 

health message regarding the severity of the issue to all members. Figure 2-1 is an 

example of an infection control policy statement. 

62 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

Figure 2-1 

Virginia Beach Fire Department 

Virginia Beach, VA 

Infection Control Program 

Policy Statement 

Purpose: To provide control measures to prevent an exposure to a communicable

disease during the delivery of patient care. 

Scope: To provide specific procedures that comply with the requirements of 29 CFR

Part 1910.1030, Exposure to Bloodborne Pathogens and NFPA 1581,

Standard on Fire Department Infection Control Program. 

These procedures define the minimum requirements for an infection control program. 

In order to have a successful program, this plan utilizes the primary components of

29 CFR Part 1910.1030 and NFPA 1581. These components include engineering and work

practices controls, personal protective clothing and equipment, training, medical

surveillance, vaccinations, hazard communication, and risk management. 

It is the policy of the department to: 

• The goal of this policy is to provide all members with the best available

protection from an occupational exposure to a communicable disease. 

• To provide fire, rescue, and emergency medical services to the public without

regard to known or suspected diagnoses of communicable disease in any patient. 

• To provide all members with the necessary immunizations and personal

protective equipment (PPE) needed for protection from communicable diseases. 

• To regard all patient contacts as potentially infectious. 

 

• To regard all medical information as strictly confidential. No member health

information will be released without signed consent of the member. 

• Training will be conducted annually regarding infection control procedures and

practices. 

• Each member is responsible for his or her safety and health and the department

will provide as safe a workplace as possible. 

63 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

EXPOSURE CONTROL PLAN 

An exposure control plan is designed to minimize and prevent the exposure of 

department members to infectious diseases transmitted through human blood, body 

fluids, and other potentially infectious materials. The Occupational Exposure to 

Bloodborne Pathogens, 29 CFR Part 1910.1030 requires an exposure control plan. The 

exposure control plan encompasses all members who must comply with the requirements 

of an infection control program. The exposure control plan compliments the specific 

procedures of individual departments. All members with a reasonable potential for 

exposure to blood, body fluids, and other potentially infectious materials as part of their 

assigned job tasks are included in the exposure control plan. 

The basic components of the exposure control plan include 

• Exposure Determination 

• Methods of Compliance 

• Hepatitis B Vaccination Policy 

• Procedures for Evaluation and Followup 

• Exposure Incidents 

• Member Training 

• Recordkeeping Procedures 

The exposure control plan mandates that the employer identify those tasks and 

procedures with the potential for an occupational exposure. The employer also must 

identify the positions in the department with duties and responsibilities that may result in 

an occupational exposure. Lastly, the exposure control plan requires the employer to 

identify the members who will receive training, protective clothing and equipment, 

vaccination, and other benefits of the OSHA Occupational Exposure to Bloodborne 

Pathogens regulation. 

The exposure control plan will be designed to include an implementation schedule 

and methods of compliance with the OSHA Occupational Exposure to Bloodborne 

Pathogens regulation. Once the written program is in place, the employer is charged with 

providing copies to all members. Initial and annual update training must be conducted. 

Training also must be conducted as needed to educate members about new or modified 

64 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

changes to procedures which affect infection control practices or changes in member 

duties and responsibilities. 

STANDARD OPERATING PROCEDURES 

A SOP is defined as an organizational directive that establishes a course of action. 

A fire department uses a SOP to provide the necessary control measures to prevent an 

occupational exposure to a communicable disease. 

Topics that should be covered in an infection control SOP are training and 

education, health maintenance, PPE, respiratory protection, eye protection, operational 

procedures, handling sharps, skin washing, facility disinfecting and cleaning areas, 

disinfecting and cleaning of equipment, disinfecting and cleaning vehicles, biohazard 

waste, exposure incidents and medical follow-up, and the infection control officer. The 

U.S. Fire Administration’s Developing Effective Standard Operating Procedures for Fire 

and EMS Departments (1999) is an additional resource for information regarding SOP’s. 

It can be downloaded from http://www.usfa.fema.gov/usfapubs/. 

INTERACTION WITH OTHER DEPARTMENTS 

With the implementation of an infection control program, the fire department 

should have interaction with other city or county public safety agencies. These agencies 

face similar problems and issues relating to compliance with infection control standards 

and regulations. Combining resources and efforts will improve this process for all 

members involved. As a city or county entity develops a comprehensive infection control 

program, an exposure control plan can incorporate all applicable departments. 

Law Enforcement 

Law enforcement agencies face a variety of issues relating to infection control. 

Police, sheriffs, and other law enforcement departments must consider the same infection 

control factors as a fire and EMS department. Compliance may be more difficult due to 

work schedules, station and precinct locations, proper cleaning, disinfecting and disposal 

facilities, and type of services provided. 

65 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

By combining and/or sharing resources with fire and EMS departments, law 

enforcement agencies may be able to develop and implement more effective infection 

control programs. Law enforcement can use resources related to 

• training and education issues 

• cleaning and disinfecting facilities 

• disposal facilities 

• laundry areas 

• protective clothing and equipment 

• health maintenance 

• joint infection control officer 

• notification and verification of exposures relating an infectious disease 

Fire and EMS departments can also provided guidance during the development 

and implementation of an infection control program, while tailoring the program to law 

enforcement needs. 

Other Municipal/County Departments 

Other municipal or county departments have the potential for possible exposure to 

airborne or bloodborne pathogens. Examples of departments or divisions that might be 

affected include, but are not limited to, medical examiner/coroner’s office, social 

services, community mental health, general services (housekeeping), and sanitation. 

These departments also need an infection control program tailored to meet the needs of 

their specific duties and responsibilities relating to an exposure to a communicable 

disease. These departments may not have the expertise to develop a comprehensive 

infection control program and may need assistance from fire and EMS. Fire and EMS

can provide direction, support, and share resources to ensure that members are adequately 

protected. 

Vital issues for these departments can include 

• training and education 

• protective clothing and equipment 

• health maintenance 

• design of cleaning and disinfecting areas 

66 
COMPONENTS OF AN INFECTION CONTROL PROGRAM 

• disposal areas 

The most important factor is to ensure that proper control measures are in place in 

the event of an exposure. When providing medical care, regardless of the frequency and 

severity, the risk is still very real for any department's members. 

67 
SECTION 3 

SECTION 3 

VEHICLES, EQUIPMENT, AND 

SUPPLY CONSIDERATIONS 

69 
VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

VEHICLES

All department vehicles involved in providing emergency medical services should 

comply with applicable and appropriate health and infection control laws, regulations, 

and standards. In addition, there are several factors that must be taken into consideration. 

Vehicle operations pose many risks for a fire department and the firefighters that 

drive and ride on these vehicles. The operation of fire apparatus and vehicles during 

emergency and non-emergency response creates a liability for any fire department. 

Another safety and health issue regarding vehicle safety relates to infection 

control procedures. As departments design new vehicles, consideration must be given to 

the ability to decontaminate the patient compartment and equipment. Other 

considerations, regarding infection control include ventilation, air filtration, and interior 

surfaces. 

Emergency Vehicle Safety

An important component of the fire department’s occupational safety and health 

program is vehicle operations. Vehicle operations encompass a wide spectrum of issues 

such as specifications, design, construction, purchase, operation, inspection, maintenance, 

response procedures, and repair of apparatus. In terms of member safety, a fully enclosed 

cab, seatbelts for all passengers, noise, warning lights and sirens, braking capacity, gross 

vehicle weight, infection control, and tool and equipment storage must be addressed 

during the initial specification phase. 

Vehicles currently in use must be evaluated for risks and an action plan 

established to address and correct any safety issues. The HSO, the infection control 

officer, and the department’s occupational safety and health committee must take a 

leading role to ensure the development and implementation of the action plan. 

Ergonomics 

The field of ergonomics studies methods used to perform a job task with the 

necessary tools and equipment and the physical skills used by an employee to perform

that task. Any occupational task may be studied, but the focus is on repetitive tasks, 

particularly those that have resulted in numerous occupational injuries. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

The fire service must incorporate ergonomics into the design of fire department 

vehicles and the use of tools and equipment. Before placing tools and equipment on 

vehicles, accessibility and the number of members needed to use them should be 

considered. Examples of ergonomics for tool and equipment placement include: 

backboards stored in compartments that allow removal without twisting or stretching, soft 

sleeves preconnected or stored near the inlet, traffic cones, and EMS equipment stored in 

a location for easy, frequent access. 

When designing new vehicles, the placement and accessibility of tools and 

equipment are essential safety and ergonomics issues. As the design and use of enclosed 

fire apparatus continues, more and more tools and equipment are finding their way into 

the riding compartment. EMS equipment is being relocated to the interior for 

convenience, safety, and security. It is important to address the ability to remove 

equipment easily and safely without causing injury to firefighters (Figures 3-1 and 3-2). 

Figures 3-1 and 3-2 Equipment Placement 

Photo courtesy of Murrey Loflin, Battalion Chief, Virginia Beach Fire Department 

72 
VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Fire Apparatus 

Emergency medical services (EMS) equipment assigned to engine companies, 

truck companies, and rescue companies must be located in a designated compartment(s) 

on the apparatus. The compartments may need to be secured if Advanced Life Support 

medications are carried. Another safety and health consideration is the ability to clean 

and disinfect this compartment in the event of contamination from blood and body fluids. 

Although not as great an issue as on an ambulance, procedures must be in place in the 

event contaminated equipment is accidentally placed in the compartment. 

In the event of an exposure to a member, procedures must be in place to 

decontaminate the member before he/she gets in or on the apparatus. An affected 

member may be placed in a disposable garment and transported back to quarters for 

proper cleaning. The personal protective equipment (PPE) must be placed in a biohazard 

bag and taken to quarters for evaluation for decontamination or disposal. 

Ambulances 

To ensure the safety of members operating and riding in an ambulance, the design 

and construction of the vehicle must meet appropriate design criteria such as those 

specified in the U.S. General Services Administration (GSA) Federal Specifications for 

the Star-of-Life Ambulance or KKK-A-1822 Specifications. This ensures that the 

steering, braking, seating capacity, patient care compartment, warning lights, electrical 

system, emergency medical care equipment, infection control, and other components are 

incorporated into the construction of the vehicle. The fire department must ensure that 

the vehicle is inspected prior to use and that regular preventive maintenance is performed 

per the manufacturer’s guidelines. 

NFPA 1500, Standard on Fire Department Occupational Safety and Health 

Program, requires that members performing emergency medical care must be secured to 

the vehicle by a seat belt or a safety harness while in an ambulance or rescue. The 

harness or belt is for the protection of the member providing medical care in the event of 

an accident, sudden stop, or start. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Design Considerations 

As a fire department designs new vehicles used for patient care, strong 

consideration must be given to infection control. This is a prevention issue. Many 

problems can be avoided by effective planning and design of the interior of vehicles. The 

vehicle must be designed to meet the criteria established by applicable health and 

infection control laws, regulations, and standards - specifically criteria established by 

Occupational Safety and Health Administration (OSHA), Centers for Disease Control 

and Prevention (CDC), and the National Fire Protection Association (NFPA). 

Vehicles that are used as rescue vehicles, ambulances, and non-emergency 

vehicles must comply with the guidelines, standards, and regulations established by these 

agencies. Engineering controls will enhance the infection control process when used 

with training, effective infection control practices, appropriate personal protective 

clothing and equipment, and disinfecting and cleaning procedures. 

The ventilation of an ambulance is critical for the safety and health of members 

operating inside the vehicle. NFPA 1581 includes the following criteria for adequate 

and effective ventilation. The ventilation system must provide complete ambient air 

exchange in both the driver and patient compartments on a regular basis. Control of the 

ventilation system should be possible from both compartments. Fresh air intakes should 

be located towards the front of the vehicle to afford maximum intake of fresh air. 

Exhaust vents should be located in the upper rear of the vehicle. To reduce the risk of 

tuberculosis, high efficiency particulate arresting (HEPA) filters should be integrated in 

the patient compartment ventilation system. All seats, mounted cushions, cots, floors, 

counters, shelves, bulkheads, and container linings must be made of or covered by nonabsorbent, washable material. These surface materials should be inert to detergents, 

solutions, and solvents, for disinfecting and cleaning as described by OSHA or CDC. 

Some simple design considerations for an ambulance regarding ventilation are 

• When a vehicle is stationary, the ventilation systems shall provide complete 

exchange of ambient air in both the driver and patient compartment every 2 

minutes. 

• Fresh air intakes for the ventilation shall be located towards the front of the 

vehicle. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

• Exhaust systems should be located on the upper 

rear of the vehicle. 

• Ventilation for the patient compartment shall be 

separate from the power intake or exhaust 

ventilation system. 

• Interior surfaces must be covered by or 

comprised of nonabsorbent, washable material. 

There are now transport units available with self-contained 

purification units that exchange patient compartment air in 

less than 90 seconds and remove particles 0.3 microns and 

larger at 99.97 percent efficiency. (See Figure 3-3.) 

Figure 3-3 Ambulance Air Filtration Photo Courtesy of Wheeled Coach

 

Decontamination and Disinfection of Vehicles 

The fire department must consider engineering controls for proper 

decontamination and disinfecting when designing new vehicles and apparatus. EMS 

compartments on fire apparatus and other vehicles should be designed to facilitate easy 

decontamination and disinfecting in the event contaminated materials are placed in these 

compartments. 

All disinfectants used should be approved and registered with the Environmental 

Protection Agency (EPA) as tuberculocidal. If a disinfectant is tuberculocidal, it is strong 

enough to kill all other bacteria and virus of concern. Members using disinfectants must 

be aware of safety and health precautions such as ventilation, use of appropriate PPE, and 

flammability and reactivity of the disinfectants. A chlorine bleach solution also can be 

used to disinfect compartments, hard surfaces, or other areas of a vehicle or apparatus. 

The CDC’s Recommendations for Prevention of HIV Transmission in Health-Care 

Settings (MMWR, 39:RR17) states that effective concentrations range from 500 ppm

(1:100) to 5,000 ppm (1:10) depending on the amount of organic material present on the 

surface. Surfaces first should be washed with hot soapy water and then rinsed with clean 

water so all visible material has been removed. If organic material has been removed by 

cleaning, the lower concentration of bleach (1:100) appears to be effective. A 1:100 

dilution can be attained by mixing approximately 2 cups of chlorine bleach per gallon of 

75 
VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

water. The lower concentration is preferable whenever possible since stronger 

concentrations may corrode or destroy vulnerable metal with continued use. The bleach 

solution should be prepared daily. Use of commercial disinfectants should follow 

manufacturers’ instructions. 

PERSONAL PROTECTIVE EQUIPMENT 

Hand washing and effective personal hygiene are key factors in reducing the risk 

of contracting a communicable disease. If hand washing is not feasible, antiseptic soap 

(waterless) or wipes should be used. Hands should be washed immediately after PPE is 

removed. Hands, mucous membranes, or exposed skin should be washed after an 

exposure to blood or body fluids. 

PPE serves as a control measure to reduce the risk of an exposure. The purpose 

of PPE is to provide a barrier to prevent personal contact with blood or other potentially 

infectious materials. PPE includes gloves, masks, protective eyewear, and gowns; it must 

be provided at no cost to the employee. Some departments issue waist or "fanny" packs 

for carrying PPE (Figure 3-4). 

The potential risk of an exposure determines the 

type of PPE used. The minimum PPE used should be 

examination gloves. The greater the risk of an exposure to 

blood or body fluids, the more protective clothing should 

be used. Due to health problems resulting from latex 

examination gloves, the employer must provide a variety of 

hypoallergenic gloves in a variety of sizes. Structural 

firefighting protective clothing serves as an excellent 

barrier against blood and body fluids. When firefighters 

are performing vehicle extrication, turnout gear (helmet, 

coat, pants, boots, and gloves) is the optimum choice of 

PPE to prevent injuries/exposures from sharp surfaces or

obstructions. 

Figure 3-4 “Fanny” Pack 

Photo courtesy of Murrey Loflin, 

Battalion Chief, Virginia Beach Fire 

Department, Virginia Beach, VA. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Gloves 

Members providing emergency medical care must don emergency medical gloves. 

Medical gloves are single-use, designed to provide barrier protection against body fluids 

while examining and caring for patients. Medical gloves are a standard component of 

emergency medical response equipment. Latex-free gloves must be provided for 

members with a latex allergy or for use when providing medical care to patients with a 

latex allergy. 

Emergency medical gloves should be removed as soon as possible after the 

completion of patient care. Care must be taken to prevent skin contact with the gloves’ 

surface, and they should be properly disposed of per the department’s SOP. 

Vinyl or latex gloves specifically recommended for patient care should be used on 

all responses where there is any potential for exposure to blood or body fluids. Providers 

should put on gloves before contact with the patient. It is not an uncommon practice for 

providers to don gloves enroute, based on dispatch information. 

Gloves that become grossly contaminated, punctured, or torn at the scene should 

be changed as soon as it can be done safely. Hands should be washed before donning 

new gloves. A waterless hand cleaner should be used if normal hand washing facilities 

are not available at the scene. Double gloving may also be considered when providers are 

in situations with a large amount of blood/body fluids, when there is a potential for 

gloves being torn or punctured by the surrounding environment, or when dealing with 

multiple patients. 

Heavy gloves, such as structural firefighting gloves, should be used for extricating 

a patient and where broken glass or jagged metal is present. Since these gloves do not 

provide a moisture barrier, vinyl or latex gloves should be worn under them. Structural 

firefighting gloves, if available, should be worn where sharp or rough surfaces or 

potentially high heat exposure may be encountered, such as vehicle extrication. Medical 

gloves should not be worn under structural firefighting gloves when there is potential for 

exposure to heat. Heat can cause the emergency medical glove to burn, melt, or drip. 

Structural firefighting gloves that become contaminated should be disinfected and 

cleaned per manufacturer’s instructions. The vinyl or latex gloves used for patient 

77 
VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

contact also are not adequate for cleaning soiled equipment or vehicles. These tasks 

require a more durable glove. 

About 10 percent of health-care workers are allergic to latex.5

 The infection 

control officer should work with the department medical director to determine 

appropriate gloves made of other materials for use by any provider who is allergic to 

latex. 

Masks 

Masks (and protective eyewear) should be used during situations involving 

excessive exposure to blood, trauma, childbirth, and other situations where gross 

contamination is anticipated or encountered. Masks are designed to limit exposure of the 

nasal, oral, respiratory, or mucosal membranes to bloodborne and airborne pathogens. 

Surgical masks (Figure 3-5) are designed to prevent blood or body fluids from

coming in contact with the mouth and nose. These are disposable, single-use masks. 

Some surgical masks are designed with a face shield attached. They do not protect 

against airborne pathogens such as tuberculosis. 

A NIOSH-approved, N-95 or HEPA respirator (Figure 3-6) should be worn the 

entire time a provider is in contact with a patient suspected of having tuberculosis. If the 

patient is not suffering any respiratory distress, placing a surgical mask on the patient will 

reduce the release of droplets from coughing. 

 

 

 

Figure 3-5 St andard Surgical Mask 

Photo courtesy of Fairfield Fire & EMS, 

Fairfield, PA

Figure 3-6 HEPA Mask 

Photo courtesy of Murrey Loflin, Battalion 

Chief, Virginia Beach Fire Department, 

Virginia Beach, VA

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Eye Protection

 Protective eyewear should be donned in any situation with the potential for blood or 

body fluids to come in contact with the eyes. Acceptable 

eye protection includes goggles or glasses with side 

protectors. Providers who normally wear glasses can have 

them modified with clip-on side protectors or use goggles 

designed to be worn over the glasses. Providers should 

remember that touching the eyes while wearing potentially 

contaminated gloves should be avoided. Figure 3-7 shows 

protective eyewear with side protectors. Figure 3-7 Protective Eyewear 

 Photo Courtesy of Fairfield Fire & EMS

Gowns 

Gowns should be worn to provide a barrier to blood/body fluid in situations where heavy 

bleeding may contaminate clothing, including childbirth. Gowns should also be worn while 

cleaning the vehicle after a response if it is heavily contaminated by blood. Table 3-1 

summarizes which type of PPE is indicated in specific situations. 

Table 3-1 When and Which Types of Person Protective Equipment to Use

Activity Gloves Eyewear Mask Gown

Uncontrolled bleeding Yes Yes Yes Yes

Controlled bleeding Yes No No No

Childbirth Yes Yes Yes Yes

Endotracheal intubation Yes Yes Yes No

Oral/Nasal suctioning, manually cleaning 

airway 

Yes Yes Yes Yes

Handling/Cleaning possibly contaminated 

instruments 

Yes Yes Yes Yes

Measuring blood pressure No* No No No 

Giving an injection/Starting an IV Yes No No No 

Measuring temperature Yes No No No

Cleaning patient compartment after a call Yes No** No** No** 

* Unless the patient’s arm is contaminated with blood or body fluids or unless required by department 

policy.

** Unless heavily contaminated by blood or body fluids or unless required by department policy.

Dickinson, E. (1999). Fire Service Emergency Care. Upper Saddle River, NJ; Prentice-Hall, Inc. 

Reprinted with permission. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Sleeves 

Sleeves provide protection of exposed skin of the arms. Sleeves are valuable personal 

protective equipment for services operating in warm climates and when long-sleeved apparel is 

not worn. Figure 3-8 shows the use of protective sleeves. 

Figure 3-8 Protective Sleeves 

Photo courtesy of Murrey Loflin, Battalion Chief, Virginia Beach Fire Department, 

Virginia Beach, VA 

PPE should be cleaned, washed/laundered, or disposed of appropriately by the employer 

at no cost to the worker. All PPE should remain at the worksite. If at all possible, nothing 

should be taken home in order to prevent cross-contamination of family clothing. Contaminated 

PPE that can be decontaminated and cleaned can be reused. If cleaning and decontamination is 

not possible, the equipment must be disposed of properly in an approved method. Laundering 

provisions located in fire stations need to be separate from the laundering equipment used for 

normal cleaning such as linens, uniforms, and towels. The hot water must be above 130 degrees, 

and waste water must empty into a sanitary sewer system. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

EQUIPMENT AND SUPPLIES

Biohazardous Waste Disposal 

Many of the items used for patient care, such as bag-valve-masks (BVM), suction 

catheters, etc., are single-use, disposable and should be properly disposed of after use. 

Some items, such as bag-valve-masks (BVM), may be left with the patient at the hospital 

for continued use, unless they are grossly contaminated. 

Grossly contaminated BVM’s and other single-use 

items, with the exception of needles, must be placed in a 

red bag or container marked with a biohazard seal (Figure 

3-9). Needles and other sharp objects should be placed in a 

puncture-proof container that is designated for biohazard 

waste disposal. Disposal of biohazardous waste should 

follow the department’s written procedure. Figure 3-9. Biohazard Bag

Non-Disposable Equipment 

Surfaces of non-disposable equipment that may have come in contact with a 

patient’s blood or body fluids must be cleaned, disinfected, or sterilized. Non-disposable 

equipment includes blood pressure cuffs, splints, backboards, cervical immobilization 

devices, laryngoscope blades, etc. Cleaning means washing the item with soap and 

water. Disinfecting involves the use of a disinfectant that kills some microorganisms. 

Sterilization, either chemical or superheated steam in an autoclave, kills all 

microorganisms. 

Equipment in Contact with Intact Skin 

In the majority of patient contacts, the blood pressure cuff and stethoscope are in 

contact with intact skin. In many instances, splints, backboards, and cervical 

immobilization devices contact only intact skin. For equipment that contacts only intact 

skin, cleaning and disinfecting with a 1:100 bleach solution or EPA-registered 

tuberculocidal disinfectant is adequate. These disinfectants will destroy mycobacterium

tuberculosis, most viruses, vegetative bacteria, and most fungi. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Equipment in Contact with Mucous Membranes 

Equipment such as laryngoscopes, blades, and handles that come in contact with 

mucous membranes should be either chemically sterilized with an EPA-registered 

chemical sterilant for 10 to 45 minutes after cleaning, or autoclaved. The chemical 

sterilant will destroy mycobacterium tuberculosis, most viruses, vegetative bacteria, and 

most fungi. Many services leave the used equipment at the hospital for sterilization and 

replace it with new equipment from hospital stock. 

Equipment Contaminated with Blood/Body Fluids 

Any equipment contaminated with blood or body fluids first should be cleaned of 

all visible material since disinfectants are less effective when they must penetrate dirt and 

other debris. Gloves that are heavy enough to resist puncture from sharp edges should be 

worn while cleaning the equipment. If there is a potential for splashing, face protection, 

eyewear, and fluid- impervious gown or apron also should be used. Disposable towels 

should be used if available. If disposable towels are not available, use towels that can be 

placed in a plastic bag for contaminated laundry after the cleaning is complete. 

Following cleaning, the equipment should be decontaminated with a germicide 

following manufacturer’s instructions or a 1:100 bleach solution using clean towels. All 

equipment should be allowed to air dry. After decontamination is complete, place gloves 

in a sealed plastic bag for disposal and wash hands. 

EQUIPMENT ADVANCES 

Backboards 

Backboards are now available made of 

material that is resistant to penetration by body 

fluids and chemicals, thus are easier to clean and 

disinfect. Figure 3-10 is an example of one of these 

plastic backboards. 

Figure 3-10. Plastic Backboard 

Photo courtesy of Ferno

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Cervical Immobilization Devices 

Cervical Immobilization Devices (CID) are available in both disposable and nondisposable forms (Figures 3-11 and 3-12). Most disposable CID’s are corrugated 

material that is treated to be water-resistant. The disposable CID’s have some

limitations, but may be an option for mass casualties. Non-disposable CID’s also are 

water-proofed with smooth surfaces that make cleaning easier. 

Although this new construction assists in the ease of cleaning and 

decontaminating, care must be taken to assure that the Velcro straps used to immobilize 

patients to the backboard and to assure placement of CID’s are also cleaned and 

decontaminated appropriately. 

 

Figure 3-11. Disposable CID 

Photo courtesy of Ferno

Figure 3-12. Non-disposable CID 

Photo courtesy of Ferno

Needleless Systems 

The most common bloodborne pathogen exposure is the needlestick that results 

while recapping a needle. This particular cause of needlesticks should be totally 

preventable. As a result of changes in technology, there is a renewed strong focus on 

reducing needlestick injuries. In 1999, several legislative initiatives and regulatory 

agencies began the process of addressing changes to decrease the potential for infectious 

diseases as the result of needlesticks. The Health Care Worker Needlestick Safety and 

Prevention Act was signed into law in November 2000. Sixteen States have already 

passed needle safety legislation and it is pending in one other State. Table 3-2 

summarizes the States that have passed needle safety legislation to date. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Table 3-2 States with Needle Safety Legislation 

California Maryland Oklahoma

Alaska Massachusetts Tennessee

Connecticut Minnesota Texas

Georgia New Hampshire West Virginia 

Iowa New Jersey Pennsylvania (pending) 

Maine Ohio

Revisions to the Occupational Exposure to Bloodborne Pathogens (29 CFR Part 

1910.1030) obligate employers to consider safer needle devices when they conduct their 

annual review of their exposure control plan and requires that a log of injuries from

contaminated sharps be maintained. 

An increasing number and variety of needle devices with safety features are now 

available. Figure 3-13 is an example of one of these devices. This needleless system has 

a built-in flow valve that helps prevent blood exposure.

 

Figure 3-13. Secure IV Needleless System

Photo courtesy of Vadus

Because of the proliferation of needle devices with safety features, many of these 

devices have had only limited use in the workplace. As a result, NIOSH released its 

Alert: Preventing Needlestick Injuries in Health Care Settings, which states that needle 

devices with safety features should be evaluated to ensure that: 

• the safety feature works effectively and reliably 

• the device is acceptable to the health care worker 

• the device does not adversely affect patient care 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

As EMS services evaluate needleless systems, consider cost of the devices and 

resupply issues. If the service resupplies these items on an exchange system with the 

local hospital(s), it would be in the best interest of the EMS service program to work with 

the hospitals in the evaluation process to determine which needle device will be used. 

Even if the service does not obtain resupply from area hospitals, those hospitals should be 

contacted to gather information from their evaluations of, and experience with, different 

types of devices. 

Waterless Hand Cleaners 

As stated earlier in this manual, hand washing with regular soap and water is the 

most important method of preventing the spread of infectious diseases. Hands should be 

washed after each patient encounter, after all cleaning and decontamination of equipment, 

and immediately after each contact with a potentially contaminated patient or item.

There are several occasions when hand washing is desirable, but there is no water 

available. Examples include a patient refusal when the provider removes his/her gloves, 

or when patient care requires a glove change due to a tear. When water is unavailable, 

there are several commercial waterless hand cleaners available for use. Waterless 

cleaners come in both gel or wipe form. The main ingredient in the waterless cleansers is 

alcohol. Several brands also contain PCMX, a manmade phenolic active (antiseptic 

compound). 

OTHER CONSIDERATIONS 

Clothing and Linen 

Although the risk of disease transmission from soiled clothing or linen is minimal, 

the risk should not be ignored. There are several steps that the provider should take to 

reduce the risk. 

Dirty clothes should be changed as soon as possible and the provider should 

shower before donning clean clothes. Providers should keep at least one extra uniform at 

the station while on duty. Volunteers who respond from home should keep an extra 

change of clothes at the station for use if needed when returning from a call, or carry an 

extra set in their vehicle. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Dirty linen and clothing should be handled as little as possible. Soiled items

should be bagged, with blood-contaminated clothing/linen placed in a separate, leakproof bag marked with a biohazard label. Soiled clothing/linen should be washed in the 

normal laundry cycles with regular detergent following label instructions. Gloves should 

be used when handling, bagging, and placing dirty items in the washing machine. 

If a volunteer provider’s clothes are contaminated with blood or body fluid, it 

should be a policy that he/she return to the station to shower, change, and bag the soiled 

clothing in a controlled environment rather than driving home directly following a call. 

It is preferable that the contaminated clothing be washed at the station. If laundry 

facilities are not available at the station, the department must make alternative 

arrangements for laundering so contaminated items are not taken home. This may 

include arrangements with other departments, hospitals, or commercial laundry facilities. 

Responding From/Returning to Home or Work 

Volunteers who respond from and return to home or the primary work site have 

an obligation to protect patients and the public from the potential of infectious disease as 

well as protecting themselves. The issue of contaminated clothing for volunteers 

returning home from a call has been addressed above. What must also be considered is 

the workplace environment and conditions when the volunteer responds. If the work 

environment (e.g., working around animals, food handling of raw meat, construction 

work, etc.) carries the possibility of disease-causing germs to be present, the provider 

must take the time to wash hands thoroughly and be sure clothes are not soiled before 

responding and coming in contact with the patient. The same holds true if the potential 

exists to transmit disease from the patient to co-workers on return to the primary job. 

Since volunteers may respond to the scene in a private vehicle to render care 

while waiting for the ambulance, it is important to be careful that blood or body fluids are 

not carried back to the interior of the personal vehicle. It also may be a reasonable policy 

to supply personnel who do not accompany the patient during transport with waterless 

hand cleaner to use before re-entering their private vehicle to return to work. 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

Resource Management 

Although a rare occurrence, service programs should have a plan in place to 

access additional infection control supplies on short notice in situations such as mass 

casualty incidents that may deplete the normal supply level rapidly. Access to other 

service programs’ supplies through mutual-aid agreements may handle the extra demand. 

Other options include having an emergency number for a local vendor or developing an 

agreement with the local hospital(s) to get an emergency stock if needed. 

SUMMARY 

 

OSHA regulations, CDC guidelines, and NFPA standards have affected the 

operations and management of emergency service agencies. The intent of these 

regulations and standards is to provide protection for employees at risk for an exposure to 

blood or body fluids. 

Occupationally, an exposure to a communicable disease can have devastating 

results for members. Contracting a communicable disease could lead to death, long-term

disability, early retirement, significant health concerns, and reduced life expectancy. It is 

critical that following an exposure, the member be seen for medical follow-up as soon as 

possible. Optimal use of post exposure prophylaxis (PEP) for HIV requires treatment 

within hours. 

Infection control must become a significant part of the daily operations of 

emergency responders. The delivery of emergency medical services continues to be a 

major part of service delivery for fire departments. The potential for an exposure is an 

occupational risk that emergency service personnel face every day. 

This chapter discussed many ways to reduce and eliminate exposures to airborne 

and bloodborne diseases. Members must realize that this is a real occupational threat. 

The cost of treating an exposure is momentous, and can have a major financial impact on 

the department. Moreover, the human side has more cataclysmic results that affect the 

individual, family, department, and community. The exposure to blood or body fluids is 

truly an occupational hazard that must be addressed properly as part of a department’s 

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VEHICLE, EQUIPMENT, AND SUPPLY CONSIDERATIONS 

occupational safety and health program. As a department develops or revises its mission 

statement, infection control should become a vital part of the process. 

88 
SECTION 4 

SECTION 4 

FACILITY CONSIDERATIONS 

89 
FACILITY CONSIDERATIONS 

THE NEED FOR FACILITY SAFETY 

A successful occupational safety and health program must address facility safety, 

which encompasses fire stations, offices, shop areas, and any other area where personnel 

work while on duty. NFPA 1500, Standard on Fire Department Occupational Safety 

and Health Program, defines a fire department facility as 

 

Any building or area owned, operated, occupied, or used by a fire 

department on a routine basis. This does not include locations 

where a fire department can be summoned to perform emergency 

operations or other duties, unless such premises are normally under 

the control of the fire department. 

Most firefighters’ duties and activities focus around the fire station. The majority 

of on-duty time is spent in fire stations, training centers, administrative offices, and 

department shop areas. The facility environment must be routinely examined to ensure 

the safety of the personnel. Hazards and unsafe conditions that exist in the fire station or 

in other fire department facilities can endanger both personnel and visitors who enter 

these facilities. 

The design, construction, maintenance, and general upkeep of fire department 

facilities are a major financial expense. Depending on the funding, operation, and 

composition of a fire department, the facilities may be used for a variety of functions. 

One building may house multiple functions including an assembly area for meetings or 

other social functions, administrative offices, apparatus repair/shop, training center, 

dispatch center, and fire station. 

NFPA 1500 requires the Health and Safety Officer (HSO) to ensure that all 

facilities are inspected at least annually to assure the safest working environment 

possible. Personnel assigned to these facilities must take responsibility to correct any 

unsafe condition by conducting at least a monthly inspection. If unsafe conditions are 

found, procedures must be in place to correct any hazards or code violations and to 

prevent an accident or possible injury. 

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FACILITY CONSIDERATIONS 

Infection Control 

Fire department facilities are not exempt from regulations and standards that 

address a safe and healthy work environment. Facilities must be designed to provide the 

proper working conditions and conform to infection control standards. Proper 

equipment, protective clothing, and disposal of infectious waste must be provided to 

ensure compliance with Occupational Exposure to Bloodborne Pathogens (29 CFR Part 

1910.1030). If emergency medical care is provided by the department, the facility will 

need to be equipped with a decontamination area to clean and disinfect personnel, 

protective clothing, and equipment properly. An excellent resource for guidance in 

developing a fire department infection control program is NFPA 1581, Standard on Fire 

Department Infection Control Program. 

Facility safety and health is just one part of the infection control process. 

Infection control procedures should address issues such as: 

• Hand washing 

• Need for protective clothing and equipment while disinfecting and cleaning 

• How to properly and effectively disinfect medical equipment, protective 

clothing, and protective equipment 

• Disinfecting and cleaning areas once finished 

• Proper disposal of contaminated materials in a container marked infectious 

waste 

• Proper storage and disposal of sharps in a sharps container 

Adherence to all State and local laws governing infection control and compliance 

is required. Failure to comply with these regulations can cause an occupational exposure 

and create added liability for the fire department. Alan Brunacini, Fire Chief of the 

Phoenix Fire Department, summarized the importance of complying with regulations 

when he said, “Safety prevents meetings.”5 Compliance is a less expensive method. 

 5 Brunacini, A. (1985). Fire command. National Fire Protection Association; College Park, 

MD: YBS Productions; p. 244. 

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FACILITY CONSIDERATIONS 

Decontamination Areas 

Decontamination needs to be carried out in separate areas that are properly 

marked and secured. Appropriate disinfecting supplies must be available. A nonporous 

sink, such as stainless steel, with hot and cold running water, should be available. 

Nonporous materials are safer than traditional porous materials such as wood, plastic, and 

porcelain. Porous materials have a tendency to allow foreign matter to permeate the 

surface, which makes disinfecting the sink difficult. Other equipment needed for the 

decontamination area includes 

• Racks or shelves for air-drying of equipment 

• Two sinks 

• Sprayer attachment 

• Drains attached to sanitary sewer system

or septic system

• Faucets that are turned on by elbow, 

foot, or sensor (Figure 4-1) 

• Continuous molded counter tops/splash 

panels 

• Proper lighting 

• Proper ventilation 

• Floor drains attached to the sanitary 

sewer system

Figure 4-1 Sink with foot controls. 

Photo Courtesy of Steve Weissman, Captain 

Fairfax County Fire, Fairfax, VA. 

Most fire stations were not initially designed to incorporate decontamination of

infectious waste. This need surfaced in the early 1990’s. Fire stations that do not have a 

separate or available room for decontamination may have to add a room or a separate 

building. Decontamination of personnel and cleaning and disinfecting equipment must 

never be done in the kitchen, living, sleeping, or personal hygiene areas. 

FACILITY ISSUES 

Each area of a fire station or fire department facility has particular safety and 

health issues and features that need to be identified, evaluated, implemented, and 

monitored. 

93 
FACILITY CONSIDERATIONS 

Kitchen 

The kitchen is the central location of activities in most fire stations. Activities 

routinely occurring in the kitchen include food preparation, eating, discussions/meetings, 

and watching television. With so many activities occurring in this area, safety and health 

procedures are paramount. Medical equipment should never be cleaned, disinfected, 

or stored in the kitchen area. All equipment cleaning should be done in a designated 

area to prevent chemical or biological agents from coming in contact with food and food 

preparation utensils and equipment. 

Double sinks and a dishwasher should be provided to clean dishes and utensils 

properly. The refrigerator/freezer should maintain foods at proper temperatures -- cold 

storage 38o F (3o C) or less, and freezer temperatures at 0o F (-18o C) or less. In addition 

to regular inspections, a thermometer should be placed in a conspicuous place in both the 

refrigerator and the freezer. 

Countertops and shelving should be constructed of nonporous materials. Food 

should be properly heated to kill the parasites or bacteria and leftovers should be covered 

for storage. In the event of an alarm, food should be stored properly to prevent food 

poisoning. 

All members working in the kitchen must use good safety practices. 

Common safety practices include 

• Cleaning up after spills 

• Storing sharp objects, especially knives, in a safe manner 

• Discouraging horseplay 

• Watching food on the stove at all times 

• Promptly turning off all burners and ovens when not in use 

• Using all appliances in accordance with manufacturer’s instructions 

• Exercising extreme caution when using knives, graters, slicers, or can openers 

Sleeping Quarters 

According to NFPA 1581, there should be a minimum of 60 square feet of floor 

space for each bed space in sleeping areas. This provides rapid and easy access during 

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FACILITY CONSIDERATIONS 

alarms. The required floor space per bed also is designed to reduce the chances of 

spreading colds or other airborne diseases among members, and to make sleep easier. 

Separate bedding and clothing lockers should be provided for each member who 

requires a bed. Proper ventilation, heating, and cooling are essential to the health of 

personnel living in the fire station. Sleeping quarters should be separated by a 1-hour 

fire-resistive wall and be equipped with a smoke detector(s), a carbon monoxide detector, 

and a sprinkler system. 

Bathrooms 

Personal hygiene is a fundamental defense against preventing illness and 

communicable diseases. All fire department facilities should have the proper facilities 

for washing and cleaning. Hand washing should be done only in restrooms or bathrooms, 

not in the kitchen. 

Restrooms and bathrooms can be a significant 

source of infection if they are poorly designed and 

maintained. They must be kept sanitary. Bathrooms 

should have push-to-open doors for egress. This eliminates 

a place for infectious agents to accumulate and breed. It 

should not be necessary for members to grip sink controls 

in order to turn them on or off. If the handle must be 

grasped, a paper towel should be used to turn it off after 

drying. Hand drying materials should be disposable, or an 

air-drying machine should be available. Use of a cloth or 

towel presents the potential for infectious agents to 

accumulate. There is minimal potential of bacteria being 

on disposable hand drying material, so it can be disposed of 

like regular household refuse. 

Figure 4-2 Shower curtain to minimize

water reaching the floor. 

Photo courtesy of Murrey Loflin, 

Battalion Chief, Virginia Beach Fire

Showers should be cleaned regularly to prevent the growth of mold and mildew. 

Showers should have curtains or doors to minimize the amount of water that reaches the 

floor (Figure 4-2). Safety glass or plastic panels should be used in the shower doors. 

Drying racks for towels should be available, as well as good ventilation to prevent mold 

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FACILITY CONSIDERATIONS 

and mildew. The flush valves on toilets and urinals should be foot-operated or use an 

electric eye so hands are not required to operate it. Most importantly, a clear and visible 

sign should be mounted prominently in each bathroom to remind members to wash their 

hands. 

Storage 

Clean equipment and unused supplies should have a separate storage area. This 

ensures that contaminants are isolated. The storage area needs to be conspicuously 

marked and secured. In the event a separate area is not available, a secure locker or 

cabinet can be used as a suitable substitute. 

General storage areas have a tendency to become disorganized and cluttered, 

which can cause slips, falls, fire, or injury from a falling object. Some general safety 

considerations should be 

• Limiting storage in utility rooms 

• Assuring storage is well organized and maintained 

• Storing heavy items near the floor 

• Assuring no items block utility boxes or escapes 

• Storing flammable liquids in safety containers 

• Storing containers for flammable liquids away from heat sources, preferably 

in a storage container or outside the facility 

• Properly marking containers’ contents 

Laundry Areas 

The fire department should provide a designated area equipped with a washer and 

dryer in each fire station for cleaning station work uniforms, protective clothing, and 

linens (Figure 4-3). All necessary detergents and prescrub, proper water temperature, and 

laundering instructions should be available. This eliminates the need for members to take 

contaminated uniforms or clothing home, which might cross-contaminate the family 

laundry. 

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FACILITY CONSIDERATIONS 

Figure 4-3. Fire station washer and dryer prevent cross-contamination to family laundry.

Photo courtesy of Murrey Loflin, Battalion Chief, Virginia Beach Fire Department, Virginia Beach , VA. 

To comply with these requirements, most fire departments have provided the following: 

• At least one washer and dryer in the station for laundering station work 

uniforms 

• A laundry service for station work uniforms and protective clothing 

• A centrally located commercial washer and dryer for laundering protective 

clothing 

The laundry area should also provide a means for cleaning and other laundry 

items in a washer and dryer that is used only for non-contaminated items. For 

contaminated items, a commercial washer and dryer must be provided, or a laundry 

service contracted for proper cleaning and decontamination. 

Cleaning Areas 

Similar to the laundry area, a designated cleaning area must be provided for 

cleaning personal protective equipment (PPE), portable equipment, and any other 

contaminated clothing and equipment. The cleaning areas must have proper ventilation, 

lighting, and drainage connected to a sanitary sewer or a septic system. This area must be 

separate from the areas used for food preparation, eating, sleeping, living areas, and 

personal hygiene. This area must also be separate from the disinfecting area. 

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FACILITY CONSIDERATIONS 

Disinfecting Areas/Facilities 

A fire station should have an area that is designated for disinfecting contaminated 

clothing and equipment. This area should be accessible from the outside of the facility as 

well as through the apparatus bay. The area must meet the requirements established by 

the local and State health departments. It must be equipped with proper lighting and 

ventilation, have floor drains that are connected to a sanitary sewer or septic system, and 

be properly maintained in terms of general housekeeping requirements. 

Disposal Areas

Effective cleaning and disinfecting areas include a method for proper disposal of 

contaminated waste. Disposal shall take place in a properly marked and secured area 

separate from the kitchen, living, personal hygiene, and sleeping areas. Disposal of 

infectious waste must meet State and local laws and regulations pertaining to the 

handling, storage, transportation, and disposal of medical or infectious waste. Proper 

containers must be marked and used for disposal purposes, and not used for the disposal 

of regular waste or trash. 

SUMMARY 

Whether a department is designing a new facility or renovating a current facility, 

the most important factor is infection control. Financial obligations from the governing 

entity will need to be considered in order to bring a facility into compliance with the 

applicable and appropriate health and infection control laws, codes, and standards for fire 

department or EMS facilities. Prevention is much more cost effective than having to pay 

workers’ compensation claims resulting from exposures to an infectious disease. The 

U.S. Fire Administration’s Safety and Health Considerations for the Design of Fire and 

Emergency Medical Services Stations (1997) provides a comprehensive resource for 

other facility design considerations. 

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SECTION 5 

SECTION 5 

ASSESSING EFFECTIVENESS: 

THE EVALUATION PROCESS 

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ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS 

OVERVIEW

Any program is incomplete without a formal evaluation process. Managing any 

program is best described as an ongoing cyclical process (Figure 5-1). 

Figure 5-1 

EVALUATE 

MONITOR MANAGE 

IMPLEMENT 

PLAN 

Thus, although evaluation is the “final” step, it actually leads to a repetition of the 

development cycle. 

Evaluation is a systematic analysis of program activities and results for the 

purpose of determining the program’s overall effectiveness. The evaluation process 

should address two specific aspects: 1) compliance with the performance indicators of the 

existing program, and 2) the attainment of the program goal. Quality monitoring is used 

to determine whether individuals in the organization are complying with established 

protocols/performance standards. In other words, quality monitoring answers the 

question: Are we doing things right? Program evaluation answers the question: Are we 

doing the right things?

Program analysis relies on a systematic analysis of various types of data collected 

over a predetermined period of time. The focus is on identifying measurable changes

that have occurred as a result of the program. Data collected from quality monitoring is 

one source of information used to determine if the program is meeting the overall 

program goal. Review of changes in laws and standards and changes in technology also 

should be used to determine if the program is accomplishing what it should. Analysis of 

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these data should be used to identify what needs to be done to improve program

effectiveness. In effect, this leads back to the planning component. 

ASSESSING EFFECTIVENESS 

In very simple terms, the evaluation phase focuses on measuring the difference 

between what was happening before and what is happening now. In order to compare the 

differences, evaluation criteria/performance indicators must be written in measurable 

terms with an expected outcome stated (compliance level). Performance indicators 

should be reviewed and revised on a regular basis. By analyzing data on a regular basis, 

the organization will be able to revise performance indicators based on compliance, new 

technology, or changing laws/regulations. Performance indicators should be based on 

governmental regulations, such as Occupational Safety and Health Administration 

(OSHA), and national standards, such as National Fire Protection Association (NFPA) 

1500 and NFPA 1581. 

Developing Objectives and Performance Indicators 

Objectives 

Performance indicators are developed from the objectives identified for the 

program. The objectives should be defined during the planning (or revision) phase of the 

program management cycle and should be consistent with the goal of the organization -- 

injury prevention and preventive health care. Objectives should be 

• S – specific 

• M – measurable 

• A – attainable 

• R – realistic 

• T – timely 

Some objectives, when well-defined, also can be used as performance indicators. 

However, other objectives may be too broad to use as performance indicators. For 

example: an organization has documented 40 accidental needlesticks during IV initiation 

(4% of all IV initiations) over the past year. Although the ultimate goal is to reduce 

accidental needlesticks to zero, the organization might begin with an initial goal to reduce 

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accidental needlesticks during IV initiations to less than 2% in the next 6 months. 

Because this is a broad objective, additional indicators must be identified to measure the 

attainment of this objective and analyze the cause. 

Performance Indicators 

Performance indicators are the actions that measure the attainment of the 

objective. They must also be specific, attainable, and realistic. Using the objective of

reducing needlesticks, some performance indicators might include 

• Does not recap needles. 

• Disposes of needles in a sharps container with the needle down immediately 

after use. 

As stated above, objectives must be timely. Taking this example one step further, based 

on technological advancements, the organization might implement a needleless system

for IV administration. In order to evaluate the effectiveness of the new system, new 

performance indicator(s) will need to be developed. One performance indicator might 

be: Uses a needless system for IV initiation/administration. 

Compliance 

Compliance with objective/performance indicators involves using available 

sources of data and information to measure how often personnel comply with the 

performance indicator. In our example, the compliance level for the objective of

decreasing accidental needlesticks during IV initiation is less than 2 percent. In order to 

determine effectiveness, performance indicators are normally written with the expected 

compliance level identified. Going back to the original examples: 

• Does not recap needles 100 percent of the time. 

• Disposes of needles in a sharps container with the needle down immediately after 

use 98 percent of the time. 

• Uses a needleless system for IV initiation/administration 100 percent of the time. 

Careful consideration must be given to setting compliance levels. Since the analysis of 

compliance levels is used to determine the extent to which the objectives have been met, 

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ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS 

if all objective compliance levels are set at 100 percent, effectiveness of the program is 

doomed to failure. 

There are two primary methods for determining appropriate compliance levels. 

The first is benchmarking. Benchmarking uses comparisons based on data from other 

organizations, States, or regions. Benchmarking, in some instances, uses national 

standards. This includes OSHA regulations, NFPA standards, and State law. For 

example, using personal protective equipment (PPE) and following body substance 

isolation techniques 100 percent of the time when there is potential exposure to any body 

fluid is a national standard. This may be another objective of the organization’s infection 

control program. Again this is broad, so performance indicators should be developed that 

address situations requiring just gloves, situations requiring personal respiratory 

protection, situations requiring protective eyewear, etc. When there is no standard or 

accepted compliance level for an objective/performance indicator, the organization must 

determine the compliance level through data collection and analysis. 

INFORMATION MANAGEMENT 

When compliance of performance indicator(s) is not met, an analysis must be 

completed to determine the cause of the problem. Relevant data must be available to 

complete this analysis. The efficient collection and management of data and their 

transformation into useful information are fundamental to successful quality monitoring. 

Local, State, and Federal agencies all have specific requirements and/or guidelines that 

must be included in the infection control program. Therefore, each department will have 

individual forms and checklists to record the required data. 

Data collection also plays a critical role in program evaluation. Baseline data 

collected before implementing a change to the existing program can be compared to later 

data collected at established intervals. This will provide a clear picture of the progress in 

attaining program objectives. The data also can be used to identify training needs. 

Finally, data collection permits effective program management on a day-to-day 

basis by facilitating various administrative requirements. These include 

equipment/supplies inventory management, expenditure monitoring, maintenance of 

employee records, incident analysis, establishing training schedules, etc. 

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ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS 

Selection of Data Elements 

The elements of data collected should meet the needs of those who will use the 

information. The data elements must be linked to the program objectives/performance 

indicators. Determining what data need to be collected should be part of the planning 

process as program objectives are developed, reviewed, and revised. This may involve 

modifying existing data elements. Data and information also must be standardized, 

reliable, rapidly accessible, and timely. 

Data should be standardized. This means that data sets (what is collected), data 

definitions, codes, classifications, and terminology are uniform across departments as 

well as compatible with external databases. 

Reliability refers to data being entered consistently. For example, the element of 

“appropriate protective eye wear worn,” could be interpreted as only face shields by 

some, while others include safety glasses. Reliability hinges on standard definitions of

the data elements, and is affected by the motivation of the data collector and the integrity 

of the storage of the data. Data collection should be automated whenever possible and 

integrated into work processes. There should be ongoing assessment of data quality. In 

addition, all those involved in collecting and entering data should be trained so they are 

knowledgeable about the data being collected and understand how the data are used and 

the benefits to the organization. 

The data also must be timely and rapidly accessible. Data collection systems 

vary from simple paper-based records to complex multicomputer systems. For data to be 

timely and rapidly accessible, the organization must computerize the information 

collected by other means and integrate other computer data into a central database. This 

means the organization must have a person whose primary functions are to keep data upto-date and accurate, conduct analyses, and submit data to State/regional databases. 

Regardless of how relevant the data elements are, performance cannot be 

measured if the analysis program cannot retrieve the needed information. Many 

commercial software databases are available, but organizations must work with vendors 

to customize the software to meet their needs. Software also may be developed at the 

organizational level, if the computer expertise is present. 

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Types of Infection Control Data 

The specific types of data maintained will vary from jurisdiction to jurisdiction, 

depending on applicable laws, standards, and organizational needs. The following are the 

most common types of infection control data maintained by emergency response services. 

Training 

Infection control training (initial and refresher) is necessary to ensure the 

protection of each emergency responder. Documentation of training reduces potential 

departmental liability and may be a legal requirement. Training records should document 

• Date(s) of the training session 

• Subjects covered 

• Name(s) and qualifications of instructor(s) 

• Names and titles of all individuals attending 

• Duration of training 

• Test scores or other indications of satisfactory performance 

It is helpful if the information system also includes the responders’ certifications and the 

expiration dates of those certifications so qualifications can be tracked and training 

records can be compared with established training requirements. In this way, individual 

training needs can be identified, and organizational trends and priorities can be analyzed. 

OSHA requires that training records on infection control be maintained for 3 years from

the date the training occurred. 

Exposures 

All exposures to communicable disease must be documented. Exposure 

documentation ensures compliance with jurisdictional regulations and protection of 

members and their families. It also can be used to identify trends that may indicate the 

need for new training requirements and/or modification of existing protocols. Exposure 

records should include 

• Date of incident 

• Location of incident 

• Incident number 

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• Route of exposure 

• PPE used 

• Type of exposure, if known 

• Member’s name

• Description of member’s duties as they relate to this exposure 

• Social Security Number (required by OSHA) 

• Description of incident and circumstances under which the exposure occurred 

• Notifications made 

• Treatment and follow-up provided 

Figure 5-2 is an example of an exposure form. 

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ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS 

Figure 5-2 

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ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS 

 It is important to remember that all exposure records are confidential. It will be 

necessary to establish passwords in computerized systems to prevent unauthorized access 

to records. Analytical report formats should not include individual names or other 

identifying information unless necessary. Similarly, information from the system should 

not be distributed to persons without a need to know. 

OSHA requires exposure records be retained for the duration of employment plus 

30 years. This may require transfer of the records to a separate system: Microfilm may 

be used. It also should be considered that the programs currently being used to store 

exposure records will be outdated in 30 years, so original records may not be retrievable. 

Personal Health Data 

The department must establish and maintain an accurate personal medical health 

record for each member. The medical record should be up-to-date and include 

• Name of member

• Results of all medical examinations (pre-entry, pre-assignment, 

annual/ongoing, and post-exposure) 

• Medical diagnoses and recommendations 

• Treatment and prescriptions 

• Immunization record, including hepatitis B 

• Follow-up procedures and post-exposure evaluations 

• Member medical complaints and symptoms

• Record of medically caused work restrictions 

Like exposure records, medical records are confidential, and can be released only to 

authorized individuals with the written consent of the member. Medical records should 

not be kept with other personnel records. Protection of member/employee medical 

records and the requirement that medical records be retained for the duration of 

employment plus 30 years is covered in 29 CFR Part 1910.20. 

Work Practices 

The department must record data on work practices at the scene and in the station 

to be able to evaluate whether safety is being maintained. Collection of these data will 

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fulfill applicable legal compliance and quality monitoring requirements. Regular 

observation of employee behavior at emergency incidents and in the station is necessary 

to evaluate compliance with established protocols and work practices. Areas that require 

monitoring include 

• Compliance with infection control protocols (i.e., appropriate use of PPE) 

• Storage facilities (conspicuously marked and secured) 

• Disinfecting areas (marked, contaminants isolated) 

• Disposal areas (marked, containers secured, waste disposal logs up-to-date) 

• Compliance with applicable laws/regulations 

Compliance monitoring can be accomplished by using specific audit forms based 

on jurisdictional requirements. Analysis results should be documented and maintained. 

All deficiencies noted should include recommendations for improvement and follow-up 

re-inspections. 

Equipment and Supplies Inventory

All infection control equipment and supplies must be available. This can be 

accomplished only through an accurate and efficient inventory system. The inventory list 

must identify all items necessary for the program. For each item, the inventory should 

document 

• Cost 

• Minimum on-hand requirement 

• Expiration date 

• Current stock balance 

• Date/Amount ordered 

• Date received 

• Date/Amount issued 

• Organization/Individual receiving the supplies 

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Additional Data Types 

Several additional types of data may contribute to information regarding the 

effectiveness of the infection control program. Employee interviews can be used to 

determine individual knowledge and acceptance of infection control protocols. Postincident analyses or individual debriefing after an emergency response can also help 

identify areas of confusion that can be addressed in counseling and/or training sessions. 

Incident run sheets can help identify unexpected trends within the system. For 

example, an increase in response volume will require increased supplies and equipment. 

This affects inventory supply and the need to re-order. It may also require increases in 

future budget requests. 

 Monitoring compensation claims will help identify trends in injuries and 

exposures. Analysis of these claims can provide direction for possible training, behavior 

modification needs, and/or protocol changes. 

The department also should monitor community health trends to stay current on 

prevalent communicable diseases, potentially dangerous situations, etc. Monitoring 

community trends facilitates a proactive infection control response to unexpected threats. 

For example, if there is an outbreak of meningitis within the community, the department 

could take immediate early action to notify all members and implement more stringent 

infection control procedures. 

Confidentiality 

Maintaining the confidentiality of certain records is necessary for the protection 

of both employees and patients. Each individual’s right to privacy is guaranteed by law 

and each State/municipality has enacted “privacy laws” that regulate information release 

and record retention. 

 All patient-related information is confidential. Each department should have 

standard operating procedures (SOP’s) covering the release of patient information, since 

inadvertent release of confidential information can result in civil liability. Patient 

information should be released only to authorized individuals, and in accordance with 

current guidelines and regulations regarding patient privacy, need for consent, and (if a 

research study) approval of appropriate supervisory bodies. All inquiries and the release 

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of patient information should be documented and stored. The records should include a 

copy of the authorization for release, the name of the individual receiving the 

information, the name of the individual releasing the information, and the dates involved. 

Members’ medical records also are confidential. While exposure records may 

be used to evaluate the effectiveness of the program, the confidentiality of the members 

involved must be maintained. The types and numbers of exposures can be audited, but 

names must not be used. Written procedures should specify who has access to medical 

records and under what circumstances. The process by which medical information is 

collected, stored, retrieved, and released must be thought out carefully. Release of 

medical information should occur only with the written consent of the member. The 

consent form should include 

• Date of written authorization 

• Name and signature of member authorizing release of information 

• Name of individual authorized to receive medical information 

• Description of medical information to be released 

• General description of the purpose for release of medical information 

• Date the written authorization expires 

It is critical that members’ medical records are not disclosed or reported to any 

person within or outside the department except as required by law. The original medical 

records should stay in the department medical file. Only copies of this information 

should be released with proper authorization. 

Computer security must be designed to protect the confidentiality of patient and 

member medical records. This may require the use of passwords to limit access to a 

minimum of individuals. Logs should be maintained to document the release of 

information. Access to the computer or computer terminals must be secured. (This also 

applies to written records in a filing system.) Only authorized personnel should have 

access to the password or secure areas that contain medical records. The issuance of 

authorization, keys, etc., should be recorded and monitored. The department should take 

full advantage of legal resources available for guidance on statutory requirements related 

to confidentiality. 

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PROGRAM REVISION 

Program revision occurs as the result of three primary causes. Changes in 

laws/regulations or technology may require revisions in protocols or equipment related to 

infection control. Program revision may also be necessary when information analysis 

reveals lack of compliance of performance indicators. 

Laws/Regulations 

As stated earlier in this manual, it is critical that the infection control officer stay 

current on the laws/regulations governing infection control practices. Reviewing 

Morbidity Mortality Weekly on a regular basis is an excellent resource for finding 

changes in suggested practices and updating knowledge of infectious/communicable 

diseases. Establishing a relationship with local infection control specialists in hospitals is 

also a resource that should be helpful in maintaining up-to-date information. 

Non-compliance 

When compliance set for a performance indicator is not met, an analysis must be 

completed to determine the cause of the problem. For example, an infection control 

performance objective is that personnel will use body substance isolation techniques 100 

percent of the time when there is potential exposure to any body fluid. Compliance is 

determined to be only 85 percent. A careful analysis might identify one or more of the 

following reasons for the non-compliance, each of which may require action steps at 

different levels of the system. 

Possible reason: Personnel are not following protocol. 

a. Personnel are not familiar with specific infection control protocols. 

b. Personnel do not know which situations require specific PPE (e.g., 

eyewear during intubation) 

c. PPE interferes, or is perceived to interfere with task performance. 

Possible reason: Inadequate supplies of PPE. 

a. Increased call volume depleted supplies. 

b. There is a distribution problem

c. There is a supplier problem. 

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Possible reason: Personnel respond directly to the scene without adequate PPE. 

a. Protocols are inadequate or unclear. 

b. There is an inadequate supply of PPE. 

c. Personnel do not maintain appropriate PPE in personal vehicles. 

From this limited example, it is obvious that analyzing causes of non-compliance 

involves the entire organization and system, including policymakers, line personnel, 

health and safety personnel, and others. 

ACTION PLAN 

Developing the Plan 

Once the analysis is completed, an action plan needs to be developed to correct 

the cause(s) of the problem. The action plan should be specific, with exact steps 

necessary to assure compliance. The first decision that management must make is who 

will be on the team that develops the action plan. In addition to the infection control 

officer, the team should include representatives directly affected by the performance 

indicator, including line personnel. A timeframe for both the completion of the action 

plan and the accomplishment of the actions should be identified. Providing the team with 

a schedule and checkpoints for completion of the plan helps keep them on-task to reach a 

solution in an acceptable timeframe. 

In addition to identifying the specific steps necessary to correct the problem, two 

additional areas should be addressed when developing the action plan. First, obstacles 

that might impede the implementation of the plan should be identified. Examples of 

obstacles include lack of resources or lack of funding. Second, resources needed to carry 

out the plan should be identified. These resources might include equipment, funding, 

and/or training programs. 

Implementing the Plan 

In addition to the obvious necessity of allocating resources, the biggest challenge 

during project implementation will be to maintain credibility and focus, and to maintain 

momentum among team members. 

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• Follow the schedule -- This may seem rather obvious, but often it is not done. 

Efficient use of the schedule will help concentrate efforts and attention where 

they are most needed. It also will help anticipate the next steps. Schedules 

enhance coordination and communication within a team. Everyone should be 

able to identify where they are at any given point, and know others'

responsibilities. 

• Empower team members -- Provide the resources and authority to 

accomplish the task, and allow the team members to do what they do best. 

• Keep others informed -- This is an obvious component, but one that is often 

neglected or ignored during critical periods. Schedule communication 

opportunities, and carry through. 

Monitor the Plan 

Once the plan is implemented, it is critical that the results of the implementation 

be monitored and evaluated to determine results or problems that arise. Monitoring and 

evaluation may take a variety of forms, depending on the actions specified in the plan. 

Methods to collect data to monitor results should be developed during the planning stage. 

It is important that the monitoring methods allow for timely feedback, so any problems 

will be detected early. If problems with the plan are detected during the monitoring 

phase, or if the action plan did not make a difference, it must be revised. Based on the 

problem identified, revision may require re-entering the process cycle at any point.

SUMMARY 

Infection control principles and practices are being updated constantly. 

Therefore, the department’s infection control program must be evaluated regularly and 

revised to ensure continuing effectiveness. Periodic evaluations ensure continued 

compliance with current standards and practices. 

Infection control data collection and analysis are critical for effective program

evaluation, compliance/quality monitoring, and ongoing program management. Detailed 

records must be maintained in the areas of training, exposure, incidents, health, work 

practices, and equipment/supplies inventories. The confidentiality of patient-related 

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information and members’ medical/exposure records must be assured. The department 

should seek a legal review of all program changes prior to implementation, since 

infection control programs deal with medical and legal issues and member safety. 

116 
SECTION 6 

SECTION 6 

SPECIAL SITUATIONS 

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SPECIAL SITUATIONS 

OVERVIEW 

This chapter will cover infection control considerations for two special situations: 

the training environment and practices for protecting the patient. 

THE TRAINING ENVIRONMENT 

Two aspects of training are addressed: training in context and the cleaning and 

disinfecting of equipment. 

Training in Context 

For many years training has reinforced the use of personal protective equipment 

(PPE) when dealing with the potential for exposure to blood or body fluids. There are 

few services left where providers do not don protective gloves when dealing with 

patients. However, the same cannot be said about the use of eyewear, masks, and 

gowns. 

Training programs should consistently stress the use of appropriate PPE in 

lectures and discussions. Training programs also should reinforce using the appropriate 

PPE needed in “hands on” practice stations. Testing stations for the National Registry 

Examination (both basic and advanced levels) require the provider to use body substance 

isolation (BSI). Although this concept usually is reinforced verbally, frequently it is 

accepted as being met when the student demonstrates the donning of gloves only. 

It is a well-known educational fact that the way we learn a process/skill in the 

training environment is the way we tend to carry that process out in real life. A second 

educational fact is that it is very difficult to change the steps of a work process/skill from

the way it was initially learned. When the training environment allows students to don 

only gloves as a demonstration of the use of PPE, this practice frequently is carried into 

the real world of patient care. 

Training programs can increase compliance with the use of appropriate BSI by 

developing a variety of “hands on” scenarios that require providers to don PPE in 

addition to gloves. Such scenarios might include an airway management case that 

requires protective eyewear and a mask, or the assessment of a potential tuberculosis 

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SPECIAL SITUATIONS 

patient that requires the use of respiratory protection that meets Occupational Safety and 

Health Administration (OSHA) standards. If providers practice skills using all the PPE 

dictated by the situation, they are far more likely to use all the equipment in the job 

environment. 

Those responsible for planning and conducting training should assess the need for 

training in context, provide supplies of PPE adequate to allow all attendees to complete 

the training exercises using the appropriate PPE, and notify attendees to bring any 

personally fitted PPE needed with them to training sessions. 

Cleaning Equipment 

Risk of disease transmission using manikins is extremely low. According to the 

American Heart Association, as of March 2000 there were no reports of infection 

associated with direct contact with manikins during CPR training.6

 

Since there is some risk of disease transmission, manikin surfaces should be 

cleaned and disinfected after each use. Cleaning means washing the equipment with soap 

and water. Disinfecting involves the use of a disinfectant to kill many of the 

microorganisms that may be on the object. There are many types of manikins, so 

cleaning and disinfecting should follow the specific manufacturer’s guidelines. Internal 

parts such as artificial lungs and valve mechanisms should be cleaned thoroughly 

between users. 

The human immunodeficiency virus (HIV) is inactivated in less than 10 minutes 

at room temperature by a number of commercial disinfectants. An equally effective and 

less expensive alternative to commercial disinfectants is a bleach solution. One part 

bleach to 100 parts water (1:100, approximately 2 cups/gallon) should be effective for 

training equipment, as long as the equipment is first washed with warm, soapy water and 

 6 American Heart Association. (2000). Guidelines for cardiopulmonary resuscitation and 

emergency cardiovascular care; Supplement to Circulation; 12(8). 

120 
SPECIAL SITUATIONS 

rinsed with clean water. Follow manufacturers’ instructions for commercial 

disinfectants. 

PROTECTING THE PATIENT 

Guidelines for job functions for health-care workers infected with HIV or 

Hepatitis B virus (HBV) are addressed in Recommendations for Preventing Transmission 

of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During ExposureProne Invasive Procedures (MMWR Vol. 40, No. RR-08, July 12, 1991) and Guidelines 

for the Management of Occupational Exposures to HBV, HCV and HIV and 

Recommendations for Postexposure Prophylaxis (MMWR, May 15, 2001). These 

recommendations are summarized in Chapter 2 of this Guide. The major focus of

infected workers providing care revolves around invasive procedures that might result in 

exposing the patient to the virus. Although the recommendations are made for hospital 

workers, intravenous initiation often occurs in confined spaces or under conditions of 

poor visibility in the out-of-hospital area. Therefore, this is a legitimate concern in 

emergency services. 

The work status of an infected worker also may be a legal issue under the 

Americans with Disability Act (ADA). Some contagious diseases, including HIV 

infection and tuberculosis (TB), are considered disabilities under the ADA. Relieving an 

“otherwise qualified” employee with a communicable disease must be supported by 

objective evidence of risk, and reasonable accommodation to eliminate that risk must 

have been attempted. 

Health-care workers who are infected with HIV or HBV should receive 

counseling from an expert review panel, including the department physician and the 

employee’s personal physician and receive advice regarding under what circumstances, if 

any, they may perform invasive procedures. If these workers are allowed to continue to 

perform invasive procedures, there may be an obligation to notify patients of their 

positive HIV/HBV status before the procedure is initiated. 

If counseling results in the prohibition of invasive procedures, the worker should 

be provided opportunities to continue appropriate patient care activities whenever 

possible. If the worker is removed from patient care due to strong risk, career counseling 

121 
SPECIAL SITUATIONS 

and job retraining should be available to allow continued employment in another 

appropriate area. If the worker’s practices are modified because of HBV infection, 

he/she should be reevaluated periodically to determine whether the seropositive status 

changes due to resolution of infection or as a result of treatment 

SUMMARY 

The training environment and the infected worker are two special situations that 

must be considered in the department’s overall infection control program. Infection 

control practices in the training environment should reflect the infection control practices 

required in the field. To reinforce appropriate infection control practices, training 

programs should develop a variety of scenarios that require the use of all PPE. Practicing 

with appropriate PPE will increase the compliance of using that equipment when needed 

in the actual job environment. Although there has been no documented transmission of 

infection from manikins, training programs must remain vigilant in cleaning and 

disinfecting the equipment used in an educational setting by following the manufacturer’s 

suggested guidelines. 

Workers with HIV and tuberculosis are protected under ADA. The scope of 

practice for workers with HIV and HBV relative to invasive procedures is addressed in 

the Center for Disease Control and Prevention’s (CDC) Recommendations for Preventing 

Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients 

During Exposure-Prone Invasive Procedures and Guidelines for the Management of 

Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure 

Prophylaxis (MMWR, May 15, 2001). Restricting the scope of practice of an infected 

worker should be preceded by counsel from an expert panel that includes the fire 

department physician and the member’s personal physician. If practice is restricted, the 

worker should be allowed to continue appropriate patient care activities whenever 

possible or provided job retraining to allow continued employment in another appropriate 

area. If the worker is HBV positive, he/she should be reevaluated periodically to 

determine whether the positive status changes due to resolution of infection or as a result 

of treatment 

122 
 BIBLIOGRAPHY 

BIBLIOGRAPHY

123 
 BIBLIOGRAPHY 

BIBLIOGRAPHY

Barillo, D. (1997). Infection control In Pons, P. & Cason, D. (Eds.). Paramedic Field 

Care (131-144). American College of Emergency Physicians St. Louis: Mosby 

YearBook. 

Bolyard, E.A., Tablan, O.C., Williams W.W., Pearson, M., Shapiro, C.N., Deitchman, 

S.D. & Hospital Infection Control Practices Advisory Committee. (1998). Guidelines for 

infection control in health care personnel. American Journal of Infection Control 26; 289-

354 and Infection Control and Hospital Epidemiology 19; 407-463. 

Dickinson E. (1999). Infection control and body substance isolation. Fire Service 

Emergency Care (35-50). Upper Saddle River, NJ: Prentice-Hall, Inc. 

Mistovich J., Hafen, B., & Karren, K. (2000) Ambulance operations. Prehospital 

Emergency Care (810-830). Upper Saddle River, NJ: Prentice-Hall, Inc. 

National Fire Academy. (1999). Student Manual: Advanced leadership issues in EMS. 

Emmitsburg, MD: NFA. 

 . (1992). Student Manual: Infection control for emergency response personnel: 

The supervisor’s role. Emmitsburg, MD: NFA. 

 . (1998). Student Manual: Management of emergency medical services. 

Emmitsburg, MD: NFA. 

National Fire Protection Association. (1997). NFPA 1500: Standard on fire department 

occupational safety and health program. Quincy, MA: NFPA. 

 . (1997b). NFPA 1521: Standard on fire department safety officer. Quincy, MA: 

NFPA. 

 . (2000). NFPA 1581: Standard on fire department infection control program. 

Quincy, MA: NFPA. 

 . (2000b). NFPA 1582: Standard on medical requirements for fire fighters and 

information for fire department physicians. Quincy, MA: NFPA. 

National Highway and Transportation Safety Administration. (1997). A leadership guide 

to quality improvement for emergency medical services (EMS) systems. 

U.S. Department of Health and Human Services, Centers for Disease Control. (1994). 

Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care 

facilities. Morbidity Mortality Weekly Report. Vol. 43, No. RR-13. 

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 . (1989). Guidelines for prevention of transmission of human immunodeficiency 

virus and hepatitis B Virus to health care and public safety workers. Morbidity Mortality 

Weekly Report. Vol. 38, No.2-6. 

 . (1997). Immunization of health-care workers: Recommendations of the advisory 

committee on immunization practices (ACIP) and the hospital infection control practices 

advisory committee (HICPAC). Morbidity Mortality Weekly Report. Vol. 46, No. RR-18. 

 . (1998). Public health service guidelines for the management of health-care 

worker exposures to HIV and recommendations for post exposure prophylaxis. Morbidity 

Mortality Weekly Report. Vol. 47, No. RR-7. 

 . (1991). Recommendations for preventing transmission of human 

immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive 

procedures. Morbidity Mortality Weekly Report. Vol. 40, No. RR-08. 

 . (1998). Recommendations for prevention and control of hepatitis C virus (HCV) 

infection and HCV-related chronic disease. Morbidity Mortality Weekly Report. Vol. 47, 

No. 19. 

 . (1999). Preventing occupational HIV transmission to health care workers. 

 . (2000). Recommendations for prevention and control of mennigococcal disease. 

Morbidity Mortality Weekly Report. Vol. 49, No. RR-07. 

 . (1987). Recommendations for prevention of HIV transmission in health-care 

settings. Morbidity Mortality Weekly Report. Vol. 36 No.2 

 . (2000b). Updated U.S. Public Health Service guidelines for the management for 

occupational exposures to HBV, HCV, and HIV and recommendations for postexposure 

prophylaxis. Morbidity Mortality Weekly Report. Vol. 50, No. 11. 

 

 . (1988). Universal precautions for prevention of transmission of human 

immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care 

settings. Morbidity Mortality Weekly Report. Vol. 37, No. 24. 

 . National Center for HIV, STD, and TB Prevention. Reported tuberculosis in the 

United States, 1999. http://www.cdc.gov/nchstp/tb/surv/surv99/surv99.htm.

 . (1999). National Institute for Occupational Safety and Health. Preventing 

needlestick injuries in health care settings, Pub. No.2000-108. 

U.S. Department of Labor, Occupational Safety and Health Administration. (1991). 

Occupational exposure to bloodborne pathogens: Final rule (29 CFR Part 1910.1030). 

Washington, DC: Federal Register. Vol. 56, No. 235. 

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 . (1997). Safer needle devices: Protecting health care workers. Washington, DC. 

 . (1999). Enforcement procedures for the occupational exposure to bloodborne 

pathogens (CPL 2-2.44D). Washington, DC. 

U.S. Environmental Protection Agency, Office of Solid Waste. (1986). EPA guide for 

infectious waste management. Washington, DC. 

U.S. Fire Administration. (1999). Developing effective standard operating procedures for 

fire and EMS departments. Federal Emergency Management Agency: Washington, D.C. 

 . (1992). Guide to developing and managing an emergency service infection 

control program. Federal Emergency Management Agency: Washington, DC. 

 . (1997). Safety and health considerations for the design of fire and emergency 

medical services stations. Federal Emergency Management Agency: Washington, DC. 

127 
 APPENDICES 

APPENDICES 

A. Glossary of Common Terms 

B. Laws, Standards, and Guidelines

 C. Sources of Additional Information 

129 
APPENDIX A 

APPENDIX A 

GLOSSARY OF COMMON TERMS

131 
 APPENDIX A 

GLOSSARY OF COMMON TERMS 

AIDS: Acquired Immune Deficiency Syndrome, a communicable disease caused by 

Human Immunodeficiency Virus (HIV). 

Advanced Life Support (ALS): Emergency medical treatment at an advanced level, 

usually provided by paramedics, and including use of drugs, cardiac monitoring and 

intervention, and intravenous fluids. 

Airborne Pathogen: Pathologic microorganisms spread by droplets expelled into the 

air or aerosol, typically through a productive cough or sneeze. 

Antibody: A component of the immune system which eliminates or counteracts a 

foreign substance (antigen) in the body. 

Antigen: A foreign substance which stimulates the production of antibodies in the 

immune system. 

ARC (AIDS-Related Complex): An outdated term used to describe symptoms of HIV 

infection in patients who have not developed AIDS. These include fatigue, diarrhea, 

night sweats, and enlarged lymph nodes. ARC is not included in the current CDC 

classification of HIV infection. 

Bacteria: A type of living microorganism that can produce disease in a suitable host. 

Bacteria can self-reproduce, and some forms may produce toxins harmful to their host. 

Basic Life Support (BLS): “Emergency medical treatment at a level authorized to be 

performed by emergency medical technicians as defined by the medical authority having 

jurisdiction” (NFPA 1500). Generally refers to treatment provided at EMT-B levels. 

Biohazard: A risk of exposure to harmful bacteria, viruses, or other dangerous 

biological agents 

Bloodborne Pathogen: Pathologic microorganisms that are present in human blood 

and that can cause disease in humans. (OSHA) Note: the term “blood” includes blood, 

blood components, and products made from human blood. 

Body Fluids: “Fluids that have been recognized by the CDC as directly linked to the 

transmission of HIV and/or HBV and/or to which Universal Precautions apply: blood, 

semen, blood products, vaginal secretions, cerebrospinal fluid, synovial fluid, pericardial 

fluid, amniotic fluid, and concentrated HIV or HBV viruses.” (OSHA) 

133 
 APPENDIX A 

Body Substance Isolation (BSI): An infection control strategy that considers all 

body substances potentially infectious. This protective measure is accomplished through 

barrier protection using personal protective equipment (gloves, masks, protective 

eyewear, gowns, and resuscitation devices, as appropriate) to prevent personal contact 

with any body fluids or other potentially infectious material. 

CDC (Centers for Disease Control and Prevention): A branch of the Department 

of Health and Human Services, Public Health Service, that serves as the national focus 

for developing and applying disease prevention and control, environmental health, and 

health promotion and education activities designed to improve the health of the people of

the United States. 

Chickenpox (Varicella): A vaccine-preventable, highly communicable disease caused 

by a herpes virus resulting in skin vesicles. Commonly occurs in childhood. 

CISD (Critical Incident Stress Debriefing): Stress reduction processes designed to 

address the special needs of emergency response personnel in dealing with situations 

which cause strong emotional reactions or interfere with the ability to function. 

Cleaning: The physical removal of dirt and debris, generally accomplished with soap 

and water and physical scrubbing. (NFPA 1581) 

Communicable (Contagious) Disease: A disease that can be transmitted from one 

person to another. 

Contamination: Soiling or pollution, as by the introduction of organisms into a wound 

or onto equipment. 

Debilitating Illness or Injury: “A condition that temporarily or permanently prevents 

a member of the fire department from engaging in normal duties and activities as a result 

of illness or injury.” (NFPA 1500) 

Decontamination: The use of physical or chemical means to remove, inactivate, or 

destroy bloodborne, airborne, or foodborne pathogens on a surface or item to the point 

they are not longer capable of transmitting infectious particles. (NFPA 1581) 

Disease: An alteration of health, with a characteristic set of symptoms, which may 

affect the entire body or specific organs. 

Contagious: Infectious disease that can be transmitted from one person to 

another from either direct or indirect contact. 

Infectious: Disease due to a pathogenic microorganism such as a bacteria, 

virus, or fungus. 

 

134 
 APPENDIX A 

Disease Transmission: 

 

Direct: Communicable disease is transmitted from one person to another due to 

direct contact with infected blood, body fluids, or other infectious material. 

Indirect: Communicable disease is transmitted from one person to another 

without direct contact. 

Infectious: An illness or disease resulting from invasion of a host by diseaseproducing organisms such as bacteria, viruses, fungi, or parasites. 

Disinfection: “A procedure which inactivates virtually all recognized pathogenic 

microorganisms, but not necessarily all microbial forms (ex. Bacterial endospores) or 

inanimate objects.” (OSHA) 

ELISA: Enzyme-linked immunosorbent assay. A test used to detect antibodies to the 

AIDS virus, indicating infection. For accuracy, a positive ELISA test is always repeated. 

If still positive, a Western Blot test is then performed to confirm the diagnosis. 

Emergency Medical Care: The provision of treatment to patients, including first aid, 

cardiopulmonary resuscitation, basic life support, advanced life support a, and other 

medical procedures that occur prior to arrival at a hospital or other health-care facility. 

(NFPA 1581) 

Emergency Medical Operations: Delivery of emergency medical care and 

transportation prior to arrival at a hospital or other health care facility. (NFPA 1581) 

EMS (Emergency Medical Services): A group, department, or agency that is 

trained and equipped to respond in an organized manner to any emergency situation 

where there is the potential need for the delivery of prehospital emergency medical care 

and/or transportation. EMS can be provided by fire department, private, third service, or 

hospital-based systems or any combination thereof. 

Enteric Precautions: A system of precautions to prevent transmission of disease by 

the oral/fecal route. 

Etiologic Agent: The agent that is the cause or origin of a disease. 

Exposure: Eye, mouth, other mucous membrane, non-related skin, or parenteral 

contact with blood, other body fluids, or other potentially infectious material. 

Parenteral: “Exposure which occurs through a break in the skin barrier.” 

(OSHA) Includes injections, needle sticks, human bites, and cuts contaminated 

with blood. 

135 
 APPENDIX A 

First Responder: Personnel who arrive first on the scene at emergency incidents and 

have the responsibility to act. Includes fire, police, EMS, and other public safety 

workers. 

Fluid Resistant Clothing: Clothing designed and constructed to provide a barrier 

against accidental contact with body fluids. 

Fungus: A group of microorganisms including molds and yeasts, similar to the cellular 

structure of plants. Some fungi can cause disease. 

German Measles: See Rubella. 

Gloves, Emergency Medical: Single-use, patient examination gloves that are 

designed to provide a barrier against body fluids meeting. (NFPA 1581) 

Gonorrhea: A sexually transmitted disease caused by the bacteria Neisseria gonorrhea. 

Health-Care Worker: “An employee of a health care facility including, but not limited 

to, nurses, physicians, dentists, and other dental workers, optometrists, podiatrists, 

chiropractors, laboratory and blood bank technologists and technician, research 

laboratory scientists, phlebotomists, dialysis personnel, paramedics, emergency medical 

technicians, medical examiners, morticians, housekeepers, laundry workers, and others 

whose work may involve direct contact with body fluids from living individuals or 

corpses.” (OSHA, bold added.) 

Health Database: “A compilation of records and data relating to the health experience 

of a group of individuals, maintained in such a manner that it is retrievable for study and 

analysis over a period of time.” (NFPA 1581) 

Health Promotion: “Preventive health activities that identify real and potential risks in 

the work environment, and that inform, motivate, and otherwise help people to adopt and 

maintain healthy practices and lifestyles.” (NFPA 1500) 

Health and Safety Officer: “The member of the fire department assigned and 

authorized by the fire chief as the manager of the safety and health program and who 

performs the duties and responsibilities specified in NFPA 1581.” (NFPA 1581) 

Hepatitis: Inflammation or swelling of the liver. Hepatitis can be caused by certain 

drugs, toxins, or infectious agents, including viruses. Hepatitis caused by viruses include 

A,B, C, D, E, F G, and other, as yet unclassified, types. 

Hepatitis A (Infectious): Viral infection normally spread by fecal 

contamination. 

136 
 APPENDIX A 

Hepatitis B (HBV, Serum): Viral infection spread through blood contact, and 

also as a sexually transmitted disease. Infection may result in chronic hepatitis, 

liver cancer, cirrhosis of the liver, or death. 

Hepatitis C (HCV): Viral infection spread through blood contact. Currently, no 

prophylaxis is available. 

Hepatitis D (HDV, Delta): Viral infection occurring in people with present or 

past HBV infection. A complication of HBV infection and can increase the 

severity of HBV infection. 

Hepatitis E: Viral infection spread by the fecal-oral route. 

Hepatitis F: Viral infection with mode of transmission unknown, but may be 

bloodborne. 

Hepatitis G: Viral infection spread through blood contact. 

Herpes: A family of similar viruses which can cause different diseases, including 

chickenpox, zoster, “cold sores,” and genital herpes type II. 

Zoster (Shingles): A painful skin rash caused by recurrence of a past case of 

chickenpox. Herpes zoster is not typically spread person-to-person, but persons 

who have not had chickenpox previously can contract chickenpox after exposure 

to a patient with zoster. 

HIV Infection (HIV Positive): A person who has tested positive for HIV antibodies on 

two ELISA tests, confirmed with Western Blot testing. HIV-infected patients can spread 

the virus through blood and body fluids. 

Host: The person who harbors or nourishes a disease-producing organism. 

Human Immunodeficiency Virus: The causative agent of AIDS. HIV type 1 causes 

most cases of AIDS. A second virus, HIV-2 is a less common cause of the disease. 

Iatrogenic: A complication, injury, or disease state resulting from medical treatment. 

Immediately Dangerous to Life or Health (IDLH): “Any atmosphere that poses an 

immediate hazard to life or produces immediate irreversible debilitating effects on 

health.” (NFPA 1500). 

Immunization: The process of rendering a person immune, or highly resistant to a 

disease. 

Incident Commander: “The person in overall command of an emergency incident.” 

(NFPA 1500) 

137 
 APPENDIX A 

Incident Management System (IMS): “An organized system of roles, 

responsibilities, and standard operating procedures used to manage emergency 

operations” (NFPA 1500) Such system often is referred to as an Incident Command 

System. 

Incubation Period: The time from exposure to the disease until the first appearance of 

symptoms.

Infection: Growth of pathogenic organisms in the tissues of a host, with or without 

detectable signs of injury. 

Infection Control Officer: “The person within the fire department who is responsible 

for managing the department infection control program and for coordinating efforts 

surrounding the investigation of an exposure.” (NFPA 1581) 

Infection Control Practitioner: A medical professional with a specialty interest in 

infection control. 

Infection Control Program: “The establishment’s oral or written policy and 

implementation of procedures relating to the control of infectious disease hazards where 

employees may be exposed to direct contact with body fluids.” (OSHA) 

Infectious: Capable of causing infection in a suitable host. 

Infectious Waste: “Blood and blood products, pathological wastes, microbiological 

wastes, and contaminated sharps.” (MMWR) 

Joint Advisory Notice: A list of recommendations developed by the Department of 

Labor/Department of Health and Human Services to assist employers in implementing 

the Centers for Disease Control and Prevention guidelines. 

Leakproof Bag: A bag that is sufficiently sturdy to prevent tearing or breaking and can 

be sealed securely to prevent leakage. Such bags are red in color or display the universal 

biohazard symbol. (NFPA 1581) 

 

Measles: A vaccine-preventable viral communicable disease causing a skin rash. 

Usually occurs in childhood. 

Member: “A person involved in performing the duties and responsibilities of a fire 

department, under the auspices of the organization. A member can be full-time, parttime, paid, or unpaid, can occupy any position or rank within the fire department, and 

might or might not engage in emergency operations.” (NFPA 1581) 

Member Assistance Program: “A generic term used to describe the various 

methods used in the workplace for the control of alcohol and other substance abuse, 

stress, and personal problems that adversely affect job performance.” (NFPA 1500) 

138 
 APPENDIX A 

Meningitis: An infection of the meninges (layers covering the brain and spinal cord). 

May be caused by a bacteria or virus; considered a communicable disease. 

Microorganism: A living organism, usually visible only with a microscope, including 

bacteria, viruses, fungi, and parasites. 

Morbidity and Mortality Weekly Report (MMWR): A weekly publication from the 

Centers for Disease Control and Prevention presenting up-to-date information on 

communicable diseases. 

Mucous Membrane: The lining of the nose, mouth, eyes, vagina, and rectum. 

Mucous membranes are not as durable as other skin; contact of infected body fluids with 

intact mucous membranes may transmit disease. 

Mumps: A vaccine-preventable virus resulting in inflamed and swollen parotid glands. 

Usually occurring in childhood. 

Nosocomial: Originating in the hospital. 

Occupational: Related to the performance of duties and responsibilities of the job. 

Exposure: “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.” (OSHA) This definition excludes 

incidental exposures that may take place on the job, that are neither reasonable or 

routinely expected, and that the worker is not required to incur in the normal 

course of employment. 

Illness: “An illness or disease contracted through or aggravated by the 

performance of the duties, responsibilities, and functions of a fire department 

member.” (NFPA 1500) 

 Injury: “An injury sustained during the performance of the duties, 

responsibilities, and functions of a fire department member.” (NFPA 1500). 

Pathogen: A microorganism that can cause disease. Pathogens can be bacteria, viruses, 

fungi, or parasites. 

Personal Protective Equipment (PPE): “Specialized clothing or equipment worn 

by an employee for protection from 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.” (OSHA) 

Phlebotomist: Any health care worker who draws blood samples. (OSHA) 

139 
 APPENDIX A 

Pneumocyctis Pneumonia: A type of pneumonia caused by a parasite, seen in 

patients with impaired immune systems. 

Purified Protein Derivative (PPD): A skin test for exposure to tuberculosis. 

Recombinant Vaccine: A vaccine produced by genetic manipulation (gene splicing), 

usually in yeast. 

RPR: A blood test for syphilis. 

Rubella: A vaccine-preventable viral disease. Rubella infection during pregnancy can 

cause birth defects. 

Sexually Transmitted Disease (STD): A disease spread through sexual contact or 

activities. HIV and HBV are both bloodborne and sexually transmitted diseases. 

Seroconversion: A change in the status of one’s serum test. For example, someone 

initially tests negative for HIV, then tests positive at a later date. 

Sharps: “Any object that can penetrate the skin including, but not limited to needles, 

lancets, scalpels, and broken capillary tubes.” (OSHA) 

Sharps Container: “Container that is closable, puncture-resistant, disposable, and 

leakproof on the sides and bottom; red in color or displays the universal biohazard 

symbol; and designed to store sharp objects after use.” (NFPA 1581) 

Standard Precautions: “Synthesize the major features of universal precautions and 

body substance isolation and applies them to all patients receiving care in the hospital. 

Apply to blood, all body fluids except sweat regardless of whether or not they contain 

visible blood, non-intact skin, and mucous membranes.” (CDC) 

Sterilization: “The use of a physical or chemical procedure to destroy all microbial life, 

including highly resistant bacterial endospores.” (OSHA) 

Syphilis: A sexually transmitted infectious disease. Syphilis is uncommonly 

transmitted through blood exposure or transfusion. 

Tuberculocidal: Capable of killing tuberculosis bacteria. Used as a guideline for 

effectiveness of disinfecting/sterilizing agents. 

Tuberculosis (TB): A communicable disease caused by the bacteria Mycobacterium 

tuberculosis, usually affecting the lungs. 

140 
 APPENDIX A 

Universal Precautions: Infection control strategy developed by the CDC for hospital 

workers. Universal precautions are based on the concept that blood and certain body 

fluids (any body fluids containing visible blood, semen, vaginal secretions, tissues, 

cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, 

and amniotic fluid) of all patients should be considered potentially infectious for HIV, 

HBV, and other bloodborne pathogens. 

Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses or 

rickettsiae), administered to prevent or reduce the chance of contracting infectious 

diseases. 

VDRL: Blood test for syphilis. Stands for Venereal Disease Research Laboratory, where 

the test was designed. 

Venereal: Due to or propagated by sexual contact. 

Virulence: The disease-evoking power of a microorganism in a given host. 

Virus: A microorganism usually only visible with the electron microscope. Normally 

reside within other living (host) cells and cannot reproduce outside a living cell. 

Western Blot: A test for HIV, used to confirm a positive ELISA test. More expensive 

and time consuming that the ELISA, but more specific. Diagnosis of HIV infection 

requires two positive ELISA tests, confirmed with a positive Western Blot test. 

Whitlow: A fingertip infection commonly caused by herpes virus. Spread by contact 

with respiratory secretions. 

Window Phase: The time from exposure to the disease to positive testing. 

141 
APPENDIX B 

APPENDIX B 

LAWS, REGULATIONS, AND 

STANDARDS 

1. Health Care Worker Needlestick Prevention Act (PL 106-430). 

 2. Occupational Exposure to Bloodborne Pathogens: Final Rule. (OSHA 29 

CFR Part 1910.1030). 

3. Occupational Exposure to Bloodborne Pathogens: Needlesticks and 

Other Sharps Injuries: Final Rule. (OSHA 29 CFS Part 1910). 

 

4. Updated U.S. Public Health Service. Guidelines for the Management of 

Occupational Exposures to HBV, HCV, and HIV and Recommendations 

for Postexposure Prophylaxis (Morbidity and Mortality Weekly, June 29, 

2001 / 50(RR-11); 1-42.

 

143 
 APPENDIX B-1 

APPENDIX B-1 

Health Care Worker Needlestick Prevention Act (PL 106-430) 

To require changes in the bloodborne pathogens standard in effect under the 

Occupational Safety and Health Act of 1970. 

Be it enacted by the Senate and House of Representatives of the United States of America 

in Congress assembled, 

SECTION 1. SHORT TITLE. 

This Act may be cited as the “Needlestick Safety and Prevention Act”. 

SEC. 2. FINDINGS. 

The Congress finds the following: 

 (1) Numerous workers who are occupationally exposed to bloodborne pathogens 

have contracted fatal and other serious viruses and diseases, including the human 

immunodeficiency virus (HIV), hepatitis B, and hepatitis C from exposure to blood and 

other potentially infectious materials in their workplace. 

 (2) In 1991 the Occupational Safety and Health Administration issued a standard 

regulating occupational exposure to bloodborne pathogens, including the human 

immunodeficiency virus, (HIV), the hepatitis B virus (HBV), and the hepatitis C virus 

(HCV). 

 (3) Compliance with the bloodborne pathogens standard has significantly reduced 

the risk that workers will contract a bloodborne disease in the course of their work. 

 (4) Nevertheless, occupational exposure to bloodborne pathogens from accidental 

sharps injuries in health care settings continues to be a serious problem. In March 2000, 

the Centers for Disease Control and Prevention estimated that more than 380,000 

percutaneous injuries from contaminated sharps occur annually among health care 

workers in United States hospital settings. Estimates for all health care settings are that 

600,000 to 800,000 needlestick and other percutaneous injuries occur among health care 

workers annually. Such injuries can involve needles or other sharps contaminated with 

bloodborne pathogens, such as HIV, HBV, or HCV. 

 (5) Since publication of the bloodborne pathogens standard in 1991 there has been 

a substantial increase in the number and assortment of effective engineering controls 

available to employers. There is now a large body of research and data concerning the 

effectiveness of newer engineering controls, including safer medical devices. 

 (6) 396 interested parties responded to a Request for Information (in this section 

referred to as the “RFI”) conducted by the Occupational Safety and Health 

Administration in 1998 on engineering and work practice controls used to eliminate or 

minimize the risk of occupational exposure to bloodborne pathogens due to percutaneous 

injuries from contaminated sharps. Comments were provided by health care facilities, 

groups representing healthcare workers, researchers, educational institutions, professional 

and industry associations, and manufacturers of medical devices. 

145 
 APPENDIX B-1 

 (7) Numerous studies have demonstrated that the use of safer medical devices, 

such as needleless systems and sharps with engineered sharps injury protections, when 

they are part of an overall bloodborne pathogens risk-reduction program, can be 

extremely effective in reducing accidental sharps injuries. 

 (8) In March 2000, the Centers for Disease Control and Prevention estimated that, 

depending on the type of device used and the procedure involved, 62 to 88 percent of 

sharps injuries can potentially be prevented by the use of safer medical devices. 

 (9) The OSHA 200 Log, as it is currently maintained, does not sufficiently reflect 

injuries that may involve exposure to bloodborne pathogens in healthcare facilities. More 

than 98 percent of healthcare facilities responding to the RFI have adopted surveillance 

systems in addition to the OSHA 200 Log. Information gathered through these 

surveillance systems is commonly used for hazard identification and evaluation of 

program and device effectiveness. 

(10) Training and education in the use of safer medical devices and safer work 

practices are significant elements in the prevention of percutaneous exposure incidents. 

Staff involvement in the device selection and evaluation process is also an important 

element to achieving a reduction in sharps injuries, particularly as new safer devices are 

introduced into the work setting. 

 (11) Modification of the bloodborne pathogens standard is appropriate to set forth 

in greater detail its requirement that employers identify, evaluate, and make use of 

effective safer medical devices. 

SEC. 3. BLOODBORNE PATHOGENS STANDARD. 

 The bloodborne pathogens standard published at 29 CFR 1910.1030 shall be revised as 

follows: 

 (1) The definition of “Engineering Controls” (at 29 CFR 1910.1030(b)) shall 

include as additional examples of controls the following: ``safer medical devices, such as 

sharps with engineered sharps injury protections and needleless systems''.

 (2) The term “Sharps with Engineered Sharps Injury Protections” shall be added 

to the definitions (at 29 CFR 1910.1030(b)) and defined as ``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''.

(3) The term “Needleless Systems” shall be added to the definitions (at 29 CFR 

1910.1030(b)) and defined as “a device that does not use needles for: (A) the collection 

of bodily fluids or withdrawal of body fluids after initial venous or arterial access is 

established; (B) the administration of medication or fluids; or (C) any other procedure 

involving the potential for occupational exposure to bloodborne pathogens due to 

percutaneous injuries from contaminated sharps”. 

 (4) In addition to the existing requirements concerning exposure control plans (29 

CFR 1910.1030(c)(1)(iv)), the review and update of such plans shall be required to also-- 

 (A) “reflect changes in technology that eliminate or reduce exposure to 

bloodborne pathogens”; and 

146 
 APPENDIX B-1 

 (B) “document annually consideration and implementation of appropriate 

commercially available and effective safer medical devices designed to eliminate or 

minimize occupational exposure”. 

 (5) The following additional recordkeeping requirement shall be added to the 

bloodborne pathogens standard at 29 CFR 1910.1030(h): “The employer shall establish 

and maintain a sharps injury log for the recording of percutaneous injuries from

contaminated sharps. The information in the sharps injury log shall be recorded and 

maintained in such manner as to protect the confidentiality of the injured employee. The 

sharps injury log shall contain, at a minimum-- 

 (A) the type and brand of device involved in the incident, 

 (B) the department or work area where the exposure incident occurred, and 

 (C) an explanation of how the incident occurred”. 

The requirement for such sharps injury log shall not apply to any employer who is not 

required to maintain a log of occupational injuries and illnesses under 29 CFR 1904 and 

the sharps injury log shall be maintained for the period required by 29 CFR 1904.6. 

 (6) The following new section shall be added to the bloodborne pathogens 

standard: “An employer, who is required to establish an Exposure Control Plan shall 

solicit input from non-managerial employees responsible for direct patient care who are 

potentially exposed to injuries from contaminated sharps in the identification, evaluation, 

and selection of effective engineering and work practice controls and shall document the 

solicitation in the Exposure Control Plan”. 

SEC. 4. EFFECT OF MODIFICATIONS. 

The modifications under section 3 shall be in force until superseded in whole or in part 

by regulations promulgated by the Secretary of Labor under section 6(b) of the 

Occupational Safety and Health Act of 1970 (29 U.S.C. 655(b)) and shall be enforced in 

the same manner and to the same extent as any rule or regulation promulgated under 

section 6(b). 

SEC. 5. PROCEDURE AND EFFECTIVE DATE. 

 (a) Procedure --The modifications of the bloodborne pathogens standard prescribed by 

section 3 shall take effect without regard to the procedural requirements applicable to 

regulations promulgated under section 6(b) of the Occupational Safety and Health Act of 

1970 (29 U.S.C. 655(b)) or the procedural requirements of chapter 5 of title 5, United 

States Code. 

 (b) Effective Date --The modifications to the bloodborne pathogens standard required 

by section 3 shall-- 

 (1) within 6 months of the date of the enactment of this Act, be made and 

published in the Federal Register by the Secretary of Labor acting through the 

Occupational Safety and Health Administration; and 

 (2) at the end of 90 days after such publication, take effect. 

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 APPENDIX B-2 

APPENDIX B-2 

DEPARTMENT OF LABOR, OCCUPATIONAL SAFETY and HEALTH 

ADMINISTRATION 29 CFR part 1910.1030, SubPart: Z: Occupational 

Exposure to Bloodborne Pathogens (Final Rule)

(a) Scope and Application. This section applies to all occupational exposure to blood or 

other potentially infectious materials as defined by paragraph (b) of this section. 

(b) Definitions. For purposes of this section, the following shall apply: 

Assistant Secretary means the Assistant Secretary of Labor for Occupational Safety and 

Health, or designated representative. 

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). 

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 item 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. 

Director means the Director of the National Institute for Occupational Safety and Health, 

U.S. Department of Health and Human Services, or designated representative. 

Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing 

needles) that isolate or remove the bloodborne pathogens hazard from the workplace. 

149 
 APPENDIX B-2 

Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, 

or parenteral contact with blood or other potentially infectious materials that results from

the performance of an employee's duties. 

Handwashing Facilities means a facility providing an adequate supply of running potable 

water, soap and single use towels or hot air drying machines. 

Licensed Healthcare Professional is a person whose legally permitted scope of practice 

allows him or her to independently perform the activities required by paragraph (f) 

Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up. 

HBV means hepatitis B virus. 

HIV means human immunodeficiency virus. 

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 

visibly 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 or HBV. 

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. 

Production Facility means a facility engaged in industrial-scale, large-volume or high 

concentration production of HIV or HBV. 

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. 

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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. 

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 patients; clients in institutions for the 

developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; 

residents of hospices and nursing homes; human remains; and individuals who donate or 

sell blood or blood components. 

Sterilize means the use of a physical or chemical procedure to destroy all microbial life 

including highly resistant bacterial endospores. 

Universal Precautions is 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 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 twohanded technique). 

(c) Exposure Control. 

(c)(1) Exposure Control Plan. 

(c)(1)(i) Each employer having an employee(s) with occupational exposure as defined by 

paragraph (b) of this section shall establish a written Exposure Control Plan designed to 

eliminate or minimize employee exposure. 

(c)(1)(ii) The Exposure Control Plan shall contain at least the following elements: 

(c)(1)(ii)(A) The exposure determination required by paragraph (c)(2), 

(c)(1)(ii)(B) The schedule and method of implementation for paragraphs (d) Methods of 

Compliance, (e) HIV and HBV Research Laboratories and Production Facilities, (f) 

Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up, (g) 

Communication of Hazards to Employees, and (h) Recordkeeping, of this standard, and 

(c)(1)(ii)(C) The procedure for the evaluation of circumstances surrounding exposure 

incidents as required by paragraph (f)(3)(i) of this standard. 

(c)(1)(iii) Each employer shall ensure that a copy of the Exposure Control Plan is 

accessible to employees in accordance with 29 CFR 1910.1020(e). 

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 APPENDIX B-2 

(c)(1)(iv) The Exposure Control Plan shall be reviewed and updated at least annually and 

whenever necessary to reflect new or modified tasks and procedures which affect 

occupational exposure and to reflect new or revised employee positions with 

occupational exposure. 

(c)(1)(v) The Exposure Control Plan shall be made available to the Assistant Secretary 

and the Director upon request for examination and copying. 

(c)(2) Exposure Determination.

(c)(2)(i) Each employer who has an employee(s) with occupational exposure as defined 

by paragraph (b) of this section shall prepare an exposure determination. This exposure 

determination shall contain the following: 

(c)(2)(i)(A) A list of all job classifications in which all employees in those job 

classifications have occupational exposure; 

 (c)(2)(i)(B) A list of job classifications in which some employees have occupational 

exposure, and 

(c)(2)(i)(C) 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 paragraph (c)(2)(i)(B) of 

this standard. 

(c)(2)(ii) This exposure determination shall be made without regard to the use of personal 

protective equipment. 

(d) Methods of Compliance. 

(d)(1) General. Universal precautions shall be observed to prevent contact with blood or 

other potentially infectious materials. Under circumstances in which differentiation 

between body fluid types is difficult or impossible, all body fluids shall be considered 

potentially infectious materials. 

(d)(2) Engineering and Work Practice Controls. 

(d)(2)(i) Engineering and work practice controls shall be used to eliminate or minimize 

employee exposure. Where occupational exposure remains after institution of these 

controls, personal protective equipment shall also be used. 

(d)(2)(ii) Engineering controls shall be examined and maintained or replaced on a regular 

schedule to ensure their effectiveness. 

(d)(2)(iii) Employers shall provide handwashing facilities which are readily accessible to 

employees. 

152 
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(d)(2)(iv) When provision of handwashing facilities is not feasible, the employer shall 

provide either an appropriate antiseptic hand cleanser in conjunction with clean 

cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes 

are used, hands shall be washed with soap and running water as soon as feasible. 

(d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon 

as feasible after removal of gloves or other personal protective equipment. 

(d)(2)(vi) Employers shall ensure that employees wash 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 other potentially infectious 

materials.

(d)(2)(vii) Contaminated needles and other contaminated sharps shall not be bent, 

recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) 

below. Shearing or breaking of contaminated needles is prohibited. 

(d)(2)(vii)(A) Contaminated needles and other contaminated sharps shall not be bent, 

recapped or removed unless the employer can demonstrate that no alternative is feasible 

or that such action is required by a specific medical or dental procedure. 

(d)(2)(vii)(B) Such bending, recapping or needle removal must be accomplished through 

the use of a mechanical device or a one-handed technique. 

(d)(2)(viii) Immediately or as soon as possible after use, contaminated reusable sharps 

shall be placed in appropriate containers until properly reprocessed. These containers 

shall be: 

(d)(2)(viii)(A) puncture resistant; 

(d)(2)(viii)(B) labeled or color-coded in accordance with this standard; 

(d)(2)(viii)(C) leakproof on the sides and bottom; and 

(d)(2)(viii)(D) in accordance with the requirements set forth in paragraph(d)(4)(ii)(E) for 

reusable sharps. 

(d)(2)(ix) 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. 

(d)(2)(x) Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or 

on countertops or benchtops where blood or other potentially infectious materials are 

present. 

153 
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(d)(2)(xi) All procedures involving blood or other potentially infectious materials shall be 

performed in such a manner as to minimize splashing, spraying, spattering, and 

generation of droplets of these substances. 

(d)(2)(xii) Mouth pipetting/suctioning of blood or other potentially infectious materials is 

prohibited. 

(d)(2)(xiii) Specimens of blood or other potentially infectious materials shall be placed in 

a container which prevents leakage during collection, handling, processing, storage, 

transport, or shipping. 

(d)(2)(xiii)(A) The container for storage, transport, or shipping shall be labeled or colorcoded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or 

shipped. When a facility utilizes Universal Precautions in the handling of all specimens, 

the labeling/color-coding of specimens is not necessary provided containers are 

recognizable as containing specimens. This exemption only applies while such 

specimens/containers remain within the facility. Labeling or color-coding in accordance 

with paragraph (g)(1)(i) is required when such specimens/containers leave the facility. 

(d)(2)(xiii)(B) If outside contamination of the primary container occurs, the primary 

container shall be placed within a second container which prevents leakage during 

handling, processing, storage, transport, or shipping and is labeled or color-coded 

according to the requirements of this standard. 

(d)(2)(xiii)(C) If the specimen could puncture the primary container, the primary 

container shall be placed within a secondary container which is puncture-resistant in 

addition to the above characteristics. 

(d)(2)(xiv) 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 the employer can demonstrate that decontamination 

of such equipment or portions of such equipment is not feasible. 

(d)(2)(xiv)(A) A readily observable label in accordance with paragraph (g)(1)(i)(H) shall 

be attached to the equipment stating which portions remain contaminated. 

(d)(2)(xiv)(B) The employer shall ensure that this information is conveyed to all affected 

employees, the servicing representative, and/or the manufacturer, as appropriate, prior to 

handling, servicing, or shipping so that appropriate precautions will be taken. 

(d)(3) Personal Protective Equipment. 

(d)(3)(i) Provision. When there is occupational exposure, the employer shall provide, at 

no cost to the employee, appropriate personal protective equipment such as, but not 

limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and 

mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal 

154 
 APPENDIX B-2 

protective equipment will be considered "appropriate" only if it does not permit blood or 

other potentially infectious materials to pass through to or reach the employee's work 

clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes 

under normal conditions of use and for the duration of time which the protective 

equipment will be used. 

(d)(3)(ii) Use. The employer shall ensure that the employee uses appropriate personal 

protective equipment unless the employer shows that the employee temporarily and 

briefly declined to use personal protective equipment when, under rare and extraordinary 

circumstances, it was the employee's professional judgment that in the specific instance 

its use would have prevented the delivery of health care or public safety services or 

would have posed an increased hazard to the safety of the worker or co-worker. When the 

employee makes this judgement, the circumstances shall be investigated and documented 

in order to determine whether changes can be instituted to prevent such occurrences in 

the future. 

(d)(3)(iii) Accessibility. The employer shall ensure that appropriate personal protective 

equipment in the appropriate sizes is readily accessible at the worksite or is issued to 

employees. 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. 

(d)(3)(iv) Cleaning, Laundering, and Disposal. The employer shall clean, launder, and 

dispose of personal protective equipment required by paragraphs (d) and (e) of this 

standard, at no cost to the employee. 

(d)(3)(v) Repair and Replacement. The employer shall repair or replace personal 

protective equipment as needed to maintain its effectiveness, at no cost to the employee. 

(d)(3)(vi) If a garment(s) is penetrated by blood or other potentially infectious materials, 

the garment(s) shall be removed immediately or as soon as feasible. 

(d)(3)(vii) All personal protective equipment shall be removed prior to leaving the work 

area. 

(d)(3)(viii) When personal protective equipment is removed it shall be placed in an 

appropriately designated area or container for storage, washing, decontamination or 

disposal. 

(d)(3)(ix) Gloves. Gloves shall be worn when it can be reasonably anticipated that the 

employee may have hand contact with blood, other potentially infectious materials, 

mucous membranes, and non-intact skin; when performing vascular access procedures 

except as specified in paragraph (d)(3)(ix)(D); and when handling or touching 

contaminated items or surfaces. 

155 
 APPENDIX B-2 

(d)(3)(ix)(A) 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, 

punctured, or when their ability to function as a barrier is compromised. 

(d)(3)(ix)(B) Disposable (single use) gloves shall not be washed or decontaminated for 

re-use. 

(d)(3)(ix)(C) Utility gloves may be decontaminated for re-use if the integrity of the glove 

is not compromised. However, they must be discarded if they are cracked, peeling, torn, 

punctured, or exhibit other signs of deterioration or when their ability to function as a 

barrier is compromised. 

(d)(3)(ix)(D) If an employer in a volunteer blood donation center judges that routine 

gloving for all phlebotomies is not necessary then the employer shall: 

(d)(3)(ix)(D)(1) Periodically reevaluate this policy; 

(d)(3)(ix)(D)(2) Make gloves available to all employees who wish to use them for 

phlebotomy; 

(d)(3)(ix)(D)(3) Not discourage the use of gloves for phlebotomy; and 

(d)(3)(ix)(D)(4) Require that gloves be used for phlebotomy in the following 

circumstances: 

[i] When the employee has cuts, scratches, or other breaks in his or her skin; 

[ii] When the employee judges that hand contamination with blood may occur, for 

example, when performing phlebotomy on an uncooperative source individual; and 

[iii] When the employee is receiving training in phlebotomy. 

(d)(3)(x) Masks, Eye Protection, and Face Shields. Masks in combination with eye 

protection devices, such as goggles or glasses with solid side shields, or chin-length face 

shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other 

potentially infectious materials may be generated and eye, nose, or mouth contamination 

can be reasonably anticipated. 

(d)(3)(xi) Gowns, Aprons, and Other Protective Body Clothing. Appropriate protective 

clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar 

outer garments shall be worn in occupational exposure situations. The type and 

characteristics will depend upon the task and degree of exposure anticipated. 

(d)(3)(xii) Surgical caps or hoods and/or shoe covers or boots shall be worn in instances 

when gross contamination can reasonably be anticipated (e.g., autopsies, orthopaedic 

surgery). 

156 
 APPENDIX B-2 

(d)(4) Housekeeping. 

(d)(4)(i) General. Employers shall ensure that the worksite is maintained in a clean and 

sanitary condition. The employer shall determine and implement an appropriate written 

schedule for cleaning and method of decontamination based upon the location within the 

facility, type of surface to be cleaned, type of soil present, and tasks or procedures being 

performed in the area. 

(d)(4)(ii) All equipment and environmental and working surfaces shall be cleaned and 

decontaminated after contact with blood or other potentially infectious materials. 

(d)(4)(ii)(A) Contaminated work surfaces shall be decontaminated with an appropriate 

disinfectant after completion of procedures; immediately or as soon as feasible when 

surfaces are overtly contaminated or after any spill of blood or other potentially 

infectious materials; and at the end of the work shift if the surface may have become

contaminated since the last cleaning. 

(d)(4)(ii)(B) Protective coverings, such as plastic wrap, aluminum foil, or imperviouslybacked absorbent paper used to cover equipment and environmental surfaces, shall be 

removed and replaced as soon as feasible when they become overtly contaminated or at 

the end of the workshift if they may have become contaminated during the shift. 

(d)(4)(ii)(C) 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 upon visible 

contamination. 

(d)(4)(ii)(D) Broken glassware which may be contaminated shall not be picked up 

directly with the hands. It shall be cleaned up using mechanical means, such as a brush 

and dust pan, tongs, or forceps. 

(d)(4)(ii)(E) Reusable sharps that are contaminated with blood or other potentially 

infectious materials 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. 

(d)(4)(iii) Regulated Waste. 

(d)(4)(iii)(A) Contaminated Sharps Discarding and Containment. 

(d)(4)(iii)(A)(1) Contaminated sharps shall be discarded immediately or as soon as 

feasible in containers that are: 

[a] Closable;

[b] Puncture resistant; 

157 
 APPENDIX B-2 

[c] Leakproof on sides and bottom; and 

[d] Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard. 

(d)(4)(iii)(A)(2) During use, containers for contaminated sharps shall be: 

[a] 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 (e.g., laundries); 

[b] Maintained upright throughout use; and 

[c] Replaced routinely and not be allowed to overfill. 

(d)(4)(iii)(A)(3) When moving containers of contaminated sharps from the area of use, 

the containers shall be: 

[a] Closed immediately prior to removal or replacement to prevent spillage or protrusion 

of contents during handling, storage, transport, or shipping; 

[b] Placed in a secondary container if leakage is possible. The second container shall be: 

[i] Closable;

[ii] Constructed to contain all contents and prevent leakage during handling, storage, 

transport, or shipping; and 

[iii] Labeled or color-coded according to paragraph (g)(1)(i) of this standard. 

(d)(4)(iii)(A)(4) Reusable containers shall not be opened, emptied, or cleaned manually 

or in any other manner which would expose employees to the risk of percutaneous injury. 

(d)(4)(iii)(B) Other Regulated Waste Containment. 

(d)(4)(iii)(B)(1) Regulated waste shall be placed in containers which are: 

[a] Closable;

[b] Constructed to contain all contents and prevent leakage of fluids during handling, 

storage, transport or shipping; 

[c] Labeled or color-coded in accordance with paragraph (g)(1)(i) this standard; and 

[d] Closed prior to removal to prevent spillage or protrusion of contents during handling, 

storage, transport, or shipping. 

158 
 APPENDIX B-2 

(d)(4)(iii)(B)(2) If outside contamination of the regulated waste container occurs, it shall 

be placed in a second container. The second container shall be: 

[a] Closable;

[b] Constructed to contain all contents and prevent leakage of fluids during handling, 

storage, transport or shipping; 

[c] Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard; and 

[d] Closed prior to removal to prevent spillage or protrusion of contents during handling, 

storage, transport, or shipping. 

(d)(4)(iii)(C) Disposal of all regulated waste shall be in accordance with applicable 

regulations of the United States, States and Territories, and political subdivisions of 

States and Territories. 

(d)(4)(iv) Laundry. 

(d)(4)(iv)(A) Contaminated laundry shall be handled as little as possible with a minimum

of agitation. 

(d)(4)(iv)(A)(1) Contaminated laundry shall be bagged or containerized at the location 

where it was used and shall not be sorted or rinsed in the location of use. 

(d)(4)(iv)(A)(2) Contaminated laundry shall be placed and transported in bags or 

containers labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard. 

When a facility utilizes Universal Precautions in the handling of all soiled laundry, 

alternative labeling or color-coding is sufficient if it permits all employees to recognize 

the containers as requiring compliance with Universal Precautions. 

(d)(4)(iv)(A)(3) Whenever contaminated laundry is wet and presents a reasonable 

likelihood of soak-through of or leakage from the bag or container, the laundry shall be 

placed and transported in bags or containers which prevent soak-through and/or leakage 

of fluids to the exterior. 

(d)(4)(iv)(B) The employer shall ensure that employees who have contact with 

contaminated laundry wear protective gloves and other appropriate personal protective 

equipment. 

(d)(4)(iv)(C) When a facility ships contaminated laundry off-site to a second facility 

which does not utilize Universal Precautions in the handling of all laundry, the facility 

generating the contaminated laundry must place such laundry in bags or containers which 

are labeled or color-coded in accordance with paragraph (g)(1)(i). 

(e) HIV and HBV Research Laboratories and Production Facilities. 

159 
 APPENDIX B-2 

(e)(1) This paragraph applies to research laboratories and production facilities engaged in 

the culture, production, concentration, experimentation, and manipulation of HIV and 

HBV. It does not apply to clinical or diagnostic laboratories engaged solely in the 

analysis of blood, tissues, or organs. These requirements apply in addition to the other 

requirements of the standard. 

(e)(2) Research laboratories and production facilities shall meet the following criteria: 

(e)(2)(i) Standard Microbiological Practices. All regulated waste shall either be 

incinerated or decontaminated by a method such as autoclaving known to effectively 

destroy bloodborne pathogens. 

(e)(2)(ii) Special Practices 

(e)(2)(ii)(A) Laboratory doors shall be kept closed when work involving HIV or HBV is 

in progress. 

(e)(2)(ii)(B) Contaminated materials that are to be decontaminated at a site away from the 

work area shall be placed in a durable, leakproof, labeled or color-coded container that is 

closed before being removed from the work area. 

(e)(2)(ii)(C) Access to the work area shall be limited to authorized persons. Written 

policies and procedures shall be established whereby only persons who have been 

advised of the potential biohazard, who meet any specific entry requirements, and who 

comply with all entry and exit procedures shall be allowed to enter the work areas and 

animal rooms. 

(e)(2)(ii)(D) When other potentially infectious materials or infected animals are present 

in the work area or containment module, a hazard warning sign incorporating the 

universal biohazard symbol shall be posted on all access doors. The hazard warning sign 

shall comply with paragraph (g)(1)(ii) of this standard. 

(e)(2)(ii)(E) All activities involving other potentially infectious materials shall be 

conducted in biological safety cabinets or other physical-containment devices within the 

containment module. No work with these other potentially infectious materials shall be 

conducted on the open bench. 

(e)(2)(ii)(F) Laboratory coats, gowns, smocks, uniforms, or other appropriate protective 

clothing shall be used in the work area and animal rooms. Protective clothing shall not be 

worn outside of the work area and shall be decontaminated before being laundered. 

(e)(2)(ii)(G) Special care shall be taken to avoid skin contact with other potentially 

infectious materials. Gloves shall be worn when handling infected animals and when 

making hand contact with other potentially infectious materials is unavoidable. 

160 
 APPENDIX B-2 

(e)(2)(ii)(H) Before disposal all waste from work areas and from animal rooms shall 

either be incinerated or decontaminated by a method such as autoclaving known to 

effectively destroy bloodborne pathogens. 

(e)(2)(ii)(I) Vacuum lines shall be protected with liquid disinfectant traps and highefficiency particulate air (HEPA) filters or filters of equivalent or superior efficiency and 

which are checked routinely and maintained or replaced as necessary. 

(e)(2)(ii)(J) Hypodermic needles and syringes shall be used only for parenteral injection 

and aspiration of fluids from laboratory animals and diaphragm bottles. Only needlelocking syringes or disposable syringe-needle units (i.e., the needle is integral to the 

syringe) shall be used for the injection or aspiration of other potentially infectious 

materials. Extreme caution shall be used when handling needles and syringes. A needle 

shall not be bent, sheared, replaced in the sheath or guard, or removed from the syringe 

following use. The needle and syringe shall be promptly placed in a puncture-resistant 

container and autoclaved or decontaminated before reuse or disposal. 

(e)(2)(ii)(K) All spills shall be immediately contained and cleaned up by appropriate 

professional staff or others properly trained and equipped to work with potentially 

concentrated infectious materials. 

(e)(2)(ii)(L) A spill or accident that results in an exposure incident shall be immediately 

reported to the laboratory director or other responsible person. 

(e)(2)(ii)(M) A biosafety manual shall be prepared or adopted and periodically reviewed 

and updated at least annually or more often if necessary. Personnel shall be advised of 

potential hazards, shall be required to read instructions on practices and procedures, and 

shall be required to follow them. 

(e)(2)(iii) Containment Equipment. 

(e)(2)(iii)(A) Certified biological safety cabinets (Class I, II, or III) or other appropriate 

combinations of personal protection or physical containment devices, such as special 

protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotors, and 

containment caging for animals, shall be used for all activities with other potentially 

infectious materials that pose a threat of exposure to droplets, splashes, spills, or aerosols. 

(e)(2)(iii)(B) Biological safety cabinets shall be certified when installed, whenever they 

are moved and at least annually. 

(e)(3) HIV and HBV research laboratories shall meet the following criteria: 

(e)(3)(i) Each laboratory shall contain a facility for hand washing and an eye wash 

facility which is readily available within the work area. 

(e)(3)(ii) An autoclave for decontamination of regulated waste shall be available. 

161 
 APPENDIX B-2 

(e)(4) HIV and HBV production facilities shall meet the following criteria: 

(e)(4)(i) The work areas shall be separated from areas that are open to unrestricted traffic 

flow within the building. Passage through two sets of doors shall be the basic requirement 

for entry into the work area from access corridors or other contiguous areas. Physical 

separation of the high-containment work area from access corridors or other areas or 

activities may also be provided by a double-doored clothes-change room (showers may 

be included), airlock, or other access facility that requires passing through two sets of 

doors before entering the work area. 

(e)(4)(ii) The surfaces of doors, walls, floors and ceilings in the work area shall be water 

resistant so that they can be easily cleaned. Penetrations in these surfaces shall be sealed 

or capable of being sealed to facilitate decontamination. 

(e)(4)(iii) Each work area shall contain a sink for washing hands and a readily available 

eye wash facility. The sink shall be foot, elbow, or automatically operated and shall be 

located near the exit door of the work area. 

(e)(4)(iv) Access doors to the work area or containment module shall be self-closing. 

(e)(4)(v) An autoclave for decontamination of regulated waste shall be available within or 

as near as possible to the work area. 

(e)(4)(vi) A ducted exhaust-air ventilation system shall be provided. This system shall 

create directional airflow that draws air into the work area through the entry area. The 

exhaust air shall not be recirculated to any other area of the building, shall be discharged 

to the outside, and shall be dispersed away from occupied areas and air intakes. The 

proper direction of the airflow shall be verified (i.e., into the work area). 

(e)(5) Training Requirements. Additional training requirements for employees in HIV 

and HBV research laboratories and HIV and HBV production facilities are specified in 

paragraph (g)(2)(ix). 

(f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up. 

(f)(1) General. 

(f)(1)(i) The employer shall make available the hepatitis B vaccine and vaccination series 

to all employees who have occupational exposure, and post-exposure evaluation and 

follow-up to all employees who have had an exposure incident. 

(f)(1)(ii) The employer shall ensure that all medical evaluations and procedures including 

the hepatitis B vaccine and vaccination series and post-exposure evaluation and followup, including prophylaxis, are: 

(f)(1)(ii)(A) Made available at no cost to the employee; 

162 
 APPENDIX B-2 

(f)(1)(ii)(B) Made available to the employee at a reasonable time and place; 

(f)(1)(ii)(C) Performed by or under the supervision of a licensed physician or by or under 

the supervision of another licensed healthcare professional; and 

(f)(1)(ii)(D) Provided according to recommendations of the U.S. Public Health Service 

current at the time these evaluations and procedures take place, except as specified by 

this paragraph (f). 

(f)(1)(iii) The employer shall ensure that all laboratory tests are conducted by an 

accredited laboratory at no cost to the employee. 

(f)(2) Hepatitis B Vaccination. 

(f)(2)(i) Hepatitis B vaccination shall be made available after the employee has received 

the training required in paragraph (g)(2)(vii)(I) and within 10 working days of initial 

assignment to all employees who have occupational exposure unless the employee has 

previously received the complete hepatitis B vaccination series, antibody testing has 

revealed that the employee is immune, or the vaccine is contraindicated for medical 

reasons. 

(f)(2)(ii) The employer shall not make participation in a prescreening program a 

prerequisite for receiving hepatitis B vaccination. 

(f)(2)(iii) If the employee initially declines hepatitis B vaccination but at a later date 

while still covered under the standard decides to accept the vaccination, the employer 

shall make available hepatitis B vaccination at that time. 

(f)(2)(iv) The employer shall assure that employees who decline to accept hepatitis B 

vaccination offered by the employer sign the statement in Appendix A. 

(f)(2)(v) 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 in 

accordance with section (f)(1)(ii). 

(f)(3) Post-exposure Evaluation and Follow-up. Following a report of an exposure 

incident, the employer shall make immediately available to the exposed employee a 

confidential medical evaluation and follow-up, including at least the following elements: 

(f)(3)(i) Documentation of the route(s) of exposure, and the circumstances under which 

the exposure incident occurred; 

(f)(3)(ii) Identification and documentation of the source individual, unless the employer 

can establish that identification is infeasible or prohibited by state or local law; 

163 
 APPENDIX B-2 

(f)(3)(ii)(A) The source individual's blood shall be tested as soon as feasible and after 

consent is obtained in order to determine HBV 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. 

(f)(3)(ii)(B) When the source individual is already known to be infected with HBV or 

HIV, testing for the source individual's known HBV or HIV status need not be repeated. 

(f)(3)(ii)(C) Results of the source individual's testing shall be made available 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. 

(f)(3)(iii) Collection and testing of blood for HBV and HIV serological status; 

(f)(3)(iii)(A) The exposed employee's blood shall be collected as soon as feasible and 

tested after consent is obtained. 

(f)(3)(iii)(B) 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. 

(f)(3)(iv) Post-exposure prophylaxis, when medically indicated, as recommended by the 

U.S. Public Health Service; 

(f)(3)(v) Counseling; and 

(f)(3)(vi) Evaluation of reported illnesses. 

(f)(4) Information Provided to the Healthcare Professional. 

(f)(4)(i) The employer shall ensure that the healthcare professional responsible for the 

employee's Hepatitis B vaccination is provided a copy of this regulation. 

(f)(4)(ii) The employer shall ensure that the healthcare professional evaluating an 

employee after an exposure incident is provided the following information: 

(f)(4)(ii)(A) A copy of this regulation; 

(f)(4)(ii)(B) A description of the exposed employee's duties as they relate to the exposure 

incident; 

(f)(4)(ii)(C) Documentation of the route(s) of exposure and circumstances under which 

exposure occurred; 

164 
 APPENDIX B-2 

(f)(4)(ii)(D) Results of the source individual's blood testing, if available; and 

(f)(4)(ii)(E) All medical records relevant to the appropriate treatment of the employee 

including vaccination status which are the employer's responsibility to maintain. 

(f)(5) Healthcare Professional's Written Opinion. The employer shall obtain and provide 

the employee with a copy of the evaluating healthcare professional's written opinion 

within 15 days of the completion of the evaluation. 

(f)(5)(i) The healthcare professional's written opinion for Hepatitis B vaccination shall be 

limited to whether Hepatitis B vaccination is indicated for an employee, and if the 

employee has received such vaccination. 

(f)(5)(ii) The healthcare professional's written opinion for post-exposure evaluation and 

follow-up shall be limited to the following information: 

(f)(5)(ii)(A) That the employee has been informed of the results of the evaluation; and 

(f)(5)(ii)(B) That the employee has been told about any medical conditions resulting from

exposure to blood or other potentially infectious materials which require further 

evaluation or treatment. 

(f)(5)(iii) All other findings or diagnoses shall remain confidential and shall not be 

included in the written report. 

(f)(6) Medical Recordkeeping. Medical records required by this standard shall be 

maintained in accordance with paragraph (h)(1) of this section. 

(g) Communication of Hazards to Employees. 

(g)(1) Labels and Signs. 

(g)(1)(i) Labels. 

(g)(1)(i)(A) Warning labels shall be affixed to containers of regulated waste, refrigerators 

and freezers containing blood or other potentially infectious material; and other 

containers used to store, transport or ship blood or other potentially infectious materials, 

except as provided in paragraph (g)(1)(i)(E), (F) and (G). 

(g)(1)(i)(B) Labels required by this section shall include the following legend: 

 BIOHAZARD 

165 
 APPENDIX B-2 

(g)(1)(i)(C) These labels shall be fluorescent orange or orange-red or predominantly so, 

with lettering and symbols in a contrasting color. 

(g)(1)(i)(D) Labels shall be affixed as close as feasible to the container by string, wire, 

adhesive, or other method that prevents their loss or unintentional removal. 

(g)(1)(i)(E) Red bags or red containers may be substituted for labels. 

(g)(1)(i)(F) Containers of blood, blood components, or blood products that are labeled as 

to their contents and have been released for transfusion or other clinical use are exempted 

from the labeling requirements of paragraph (g). 

(g)(1)(i)(G) Individual containers of blood or other potentially infectious materials that 

are placed in a labeled container during storage, transport, shipment or disposal are 

exempted from the labeling requirement. 

(g)(1)(i)(H) Labels required for contaminated equipment shall be in accordance with this 

paragraph and shall also state which portions of the equipment remain contaminated. 

(g)(1)(i)(I) Regulated waste that has been decontaminated need not be labeled or colorcoded. 

(g)(1)(ii) Signs. 

(g)(1)(ii)(A) The employer shall post signs at the entrance to work areas specified in 

paragraph (e), HIV and HBV Research Laboratory and Production Facilities, which shall 

bear the following legend: 

 BIOHAZARD 

(Name of the Infectious Agent) 

(Special requirements for entering the area) 

(Name, telephone number of the laboratory director or other 

 responsible person.) 

(g)(1)(ii)(B) These signs shall be fluorescent orange-red or predominantly so, with 

lettering and symbols in a contrasting color. 

(g)(2) Information and Training. 

166 
 APPENDIX B-2 

(g)(2)(i) Employers shall ensure that all employees with occupational exposure 

participate in a training program which must be provided at no cost to the employee and 

during working hours. 

(g)(2)(ii) Training shall be provided as follows: 

(g)(2)(ii)(A) At the time of initial assignment to tasks where occupational exposure may 

take place; 

(g)(2)(ii)(B) Within 90 days after the effective date of the standard; and 

(g)(2)(ii)(C) At least annually thereafter. 

(g)(2)(iii) For employees who have received training on bloodborne pathogens in the year 

preceding the effective date of the standard, only training with respect to the provisions 

of the standard which were not included need be provided. 

(g)(2)(iv) Annual training for all employees shall be provided within one year of their 

previous training. 

(g)(2)(v) Employers shall provide additional training when changes such as modification 

of tasks or procedures or institution of new tasks or procedures affect the employee's 

occupational exposure. The additional training may be limited to addressing the new 

exposures created. 

(g)(2)(vi) Material appropriate in content and vocabulary to educational level, literacy, 

and language of employees shall be used. 

(g)(2)(vii) The training program shall contain at a minimum the following elements: 

(g)(2)(vii)(A) An accessible copy of the regulatory text of this standard and an 

explanation of its contents; 

(g)(2)(vii)(B) A general explanation of the epidemiology and symptoms of bloodborne 

diseases; 

(g)(2)(vii)(C) An explanation of the modes of transmission of bloodborne pathogens; 

(g)(2)(vii)(D) An explanation of the employer's exposure control plan and the means by 

which the employee can obtain a copy of the written plan; 

(g)(2)(vii)(E) An explanation of the appropriate methods for recognizing tasks and other 

activities that may involve exposure to blood and other potentially infectious materials; 

167 
 APPENDIX B-2 

(g)(2)(vii)(F) An explanation of the use and limitations of methods that will prevent or 

reduce exposure including appropriate engineering controls, work practices, and personal 

protective equipment; 

(g)(2)(vii)(G) Information on the types, proper use, location, removal, handling, 

decontamination and disposal of personal protective equipment; 

(g)(2)(vii)(H) An explanation of the basis for selection of personal protective equipment; 

(g)(2)(vii)(I) Information on the hepatitis B vaccine, including information on its 

efficacy, safety, method of administration, the benefits of being vaccinated, and that the 

vaccine and vaccination will be offered free of charge; 

(g)(2)(vii)(J) Information on the appropriate actions to take and persons to contact in an 

emergency involving blood or other potentially infectious materials; 

(g)(2)(vii)(K) An explanation of the procedure to follow if an exposure incident occurs, 

including the method of reporting the incident and the medical follow-up that will be 

made available; 

(g)(2)(vii)(L) Information on the post-exposure evaluation and follow-up that the 

employer is required to provide for the employee following an exposure incident; 

(g)(2)(vii)(M) An explanation of the signs and labels and/or color coding required by 

paragraph (g)(1); and 

(g)(2)(vii)(N) An opportunity for interactive questions and answers with the person 

conducting the training session. 

(g)(2)(viii) The person conducting the training shall be knowledgeable in the subject 

matter covered by the elements contained in the training program as it relates to the 

workplace that the training will address. 

(g)(2)(ix) Additional Initial Training for Employees in HIV and HBV Laboratories and 

Production Facilities. Employees in HIV or HBV research laboratories and HIV or HBV 

production facilities shall receive the following initial training in addition to the above 

training requirements. 

(g)(2)(ix)(A) The employer shall assure that employees demonstrate proficiency in 

standard microbiological practices and techniques and in the practices and operations 

specific to the facility before being allowed to work with HIV or HBV. 

(g)(2)(ix)(B) The employer shall assure that employees have prior experience in the 

handling of human pathogens or tissue cultures before working with HIV or HBV. 

168 
 APPENDIX B-2 

(g)(2)(ix)(C) The employer shall provide a training program to employees who have no 

prior experience in handling human pathogens. Initial work activities shall not include the 

handling of infectious agents. A progression of work activities shall be assigned as 

techniques are learned and proficiency is developed. The employer shall assure that 

employees participate in work activities involving infectious agents only after proficiency 

has been demonstrated. 

(h) Recordkeeping. 

(h)(1) Medical Records. 

(h)(1)(i) The employer shall establish and maintain an accurate record for each employee 

with occupational exposure, in accordance with 29 CFR 1910.1020. 

(h)(1)(ii) This record shall include: 

(h)(1)(ii)(A) The name and social security number of the employee; 

(h)(1)(ii)(B) 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 as required by paragraph (f)(2); 

(h)(1)(ii)(C) A copy of all results of examinations, medical testing, and follow-up 

procedures as required by paragraph (f)(3); 

(h)(1)(ii)(D) The employer's copy of the healthcare professional's written opinion as 

required by paragraph (f)(5); and 

(h)(1)(ii)(E) A copy of the information provided to the healthcare professional as 

required by paragraphs (f)(4)(ii)(B)(C) and (D). 

(h)(1)(iii) Confidentiality. The employer shall ensure that employee medical records 

required by paragraph (h)(1) are: 

(h)(1)(iii)(A) Kept confidential; and 

(h)(1)(iii)(B) Not disclosed or reported without the employee's express written consent to 

any person within or outside the workplace except as required by this section or as may 

be required by law. 

(h)(1)(iv) The employer shall maintain the records required by paragraph (h) for at least 

the duration of employment plus 30 years in accordance with 29 CFR 1910.1020. 

(h)(2) Training Records. 

(h)(2)(i) Training records shall include the following information: 

169 
 APPENDIX B-2 

(h)(2)(i)(A) The dates of the training sessions; 

(h)(2)(i)(B) The contents or a summary of the training sessions; 

(h)(2)(i)(C) The names and qualifications of persons conducting the training; and 

(h)(2)(i)(D) The names and job titles of all persons attending the training sessions. 

(h)(2)(ii) Training records shall be maintained for 3 years from the date on which the 

training occurred. 

(h)(3) Availability. 

(h)(3)(i) The employer shall ensure that all records required to be maintained by this 

section shall be made available upon request to the Assistant Secretary and the Director 

for examination and copying. 

(h)(3)(ii) Employee training records required by this paragraph shall be provided upon 

request for examination and copying to employees, to employee representatives, to the 

Director, and to the Assistant Secretary. 

(h)(3)(iii) Employee medical records required by this paragraph shall be provided upon 

request for examination and copying to the subject employee, to anyone having written 

consent of the subject employee, to the Director, and to the Assistant Secretary in 

accordance with 29 CFR 1910.1020. 

(h)(4) Transfer of Records. 

(h)(4)(i) The employer shall comply with the requirements involving transfer of records 

set forth in 29 CFR 1910.1020(h). 

(h)(4)(ii) If the employer ceases to do business and there is no successor employer to 

receive and retain the records for the prescribed period, the employer shall notify the 

Director, at least three months prior to their disposal and transmit them to the Director, if

required by the Director to do so, within that three month period. 

(i) Dates. 

(i)(1) Effective Date. The standard shall become effective on March 6, 1992. 

(i)(2) The Exposure Control Plan required by paragraph (c) of this section shall be 

completed on or before May 5, 1992. 

(i)(3) Paragraph (g)(2) Information and Training and (h) Recordkeeping shall take effect 

on or before June 4, 1992. 

170 
 APPENDIX B-2 

(i)(4) Paragraphs (d)(2) Engineering and Work Practice Controls, (d)(3) Personal 

Protective Equipment, (d)(4) Housekeeping, (e) HIV and HBV Research Laboratories 

and Production Facilities, (f) Hepatitis B Vaccination and Post-Exposure Evaluation and 

Follow-up, and (g)(1) Labels and Signs, shall take effect July 6, 1992. 

[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, 

July 1, 1992; 61 FR 5507, Feb. 13, 1996] 

(NOTE) 

Hazardous Waste Operations and Emergency Response Standard 

The Hazardous Waste Operations and Emergency Response (HAZWOPER) Standard (29 

CFR 1910.120) covers three groups of employees: workers at uncontrolled hazardous 

waste remediation sites; workers at Resource Conservation Recovery Act (RCRA) 

permitted hazardous waste treatment, storage, and disposal facilities; and those workers 

expected to respond to emergencies caused by the uncontrolled release of hazardous 

substances. 

The definition of hazardous substance includes any biological agent or infectious material 

which may cause disease or death. There are three potential scenarios where the 

bloodborne and hazardous waste operations and emergency response standard may 

interface. These scenarios include: workers involved in cleanup operations at hazardous 

waste sites involving regulated waste; workers at RCRA permitted incinerators that burn 

infectious waste; and workers responding to an emergency caused by the uncontrolled 

release of regulated waste (e.g., a transportation accident). 

Employers of employees engaged in these three activities must comply with the 

requirements in 29 CFR 1910.120 as well as the Bloodborne Pathogens Standard. If there 

is a conflict or overlap, the provision that is more protective of employee health and 

safety applies. 

171 
 APPENDIX B-3 

APPENDIX B-3 

DEPARTMENT OF LABOR, OCCUPATIONAL SAFETY and HEALTH 

ADMINISTRATION 29 CFR part 1910.1030, Occupational Exposure to 

Bloodborne Pathogens; Needlesticks and Other Sharps Injuries; Final Rule 

§ 1910.1030 Bloodborne Pathogens

(a) Scope and Application. This section applies to all occupational exposure to blood or 

other potentially infectious materials as defined by paragraph (b) of this section. 

(b) Definitions. For purposes of this section, the following shall apply: 

Assistant Secretary means the Assistant Secretary of Labor for Occupational Safety and 

Health, or designated representative. 

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). 

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 item 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. 

Director means the Director of the National Institute for Occupational Safety and Health, 

U.S. Department of Health and Human Services, or designated representative. 

Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing 

needles, safer medical devices, such as sharps with engineered sharps injury protections 

173 
 APPENDIX B-3 

and needleless systems) that isolate or remove the bloodborne pathogens hazard from the 

workplace. 

Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact 

skin, or parenteral contact with blood or other potentially infectious materials that results 

from the performance of an employee's duties. 

Handwashing Facilities means a facility providing an adequate supply of running 

potable water, soap and single use towels or hot air drying machines. 

Licensed Healthcare Professional is a person whose legally permitted scope of practice 

allows him or her to independently perform the activities required by paragraph (f) 

Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up. 

HBV means hepatitis B virus. 

HIV means human immunodeficiency virus. 

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 

visibly 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 or HBV. 

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. 

174 
 APPENDIX B-3 

Production Facility means a facility engaged in industrial-scale, large-volume or high 

concentration production of HIV or HBV. 

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 patients; clients in institutions for the 

developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; 

residents of hospices and nursing homes; human remains; and individuals who donate or 

sell blood or blood components. 

Sterilize means the use of a physical or chemical procedure to destroy all microbial life 

including highly resistant bacterial endospores. 

Universal Precautions is 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 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). 

(c) Exposure Control -

(c)(1) Exposure Control Plan. 

(c)(1)(i) Each employer having an employee(s) with occupational exposure as defined by 

paragraph (b) of this section shall establish a written Exposure Control Plan designed to 

eliminate or minimize employee exposure. 

(c)(1)(ii) The Exposure Control Plan shall contain at least the following elements: 

175 
 APPENDIX B-3 

(c)(1)(ii)(A) The exposure determination required by paragraph (c)(2), 

(c)(1)(ii)(B) The schedule and method of implementation for paragraphs (d) Methods of 

Compliance, (e) HIV and HBV Research Laboratories and Production Facilities, (f) 

Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up, (g) 

Communication of Hazards to Employees, and (h) Recordkeeping, of this standard, and 

(c)(1)(ii)(C) The procedure for the evaluation of circumstances surrounding exposure 

incidents as required by paragraph (f)(3)(i) of this standard. 

(c)(1)(iii) Each employer shall ensure that a copy of the Exposure Control Plan is 

accessible to employees in accordance with 29 CFR 1910.1020(e). 

(c)(1)(iv) The Exposure Control Plan shall be reviewed and updated at least annually and 

whenever necessary to reflect new or modified tasks and procedures which affect 

occupational exposure and to reflect new or revised employee positions with 

occupational exposure. The review and update of such plans shall also: 

(c)(1)(iv)(A) reflect changes in technology that eliminate or reduce exposure to 

bloodborne pathogens; and 

(c)(1)(iv)(B) document annually consideration and implementation of appropriate 

commercially available and effective safer medical devices designed to eliminate or 

minimize occupational exposure. 

(c)(1)(v) An employer, who is required to establish an Exposure Control Plan shall solicit 

input from non-managerial employees responsible for direct patient care who are 

potentially exposed to injuries from contaminated sharps in the identification, evaluation, 

and selection of effective engineering and work practice controls and shall document the 

solicitation in the Exposure Control Plan. 

(c)(1)(vi) The Exposure Control Plan shall be made available to the Assistant Secretary 

and the Director upon request for examination and copying. 

(c)(2) Exposure Determination. 

(c)(2)(i) Each employer who has an employee(s) with occupational exposure as defined 

by paragraph (b) of this section shall prepare an exposure determination. This exposure 

determination shall contain the following: 

(c)(2)(i)(A) A list of all job classifications in which all employees in those job 

classifications have occupational exposure; 

(c)(2)(i)(B) A list of job classifications in which some employees have occupational 

exposure, and 

176 
 APPENDIX B-3 

(c)(2)(i)(C) 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 paragraph (c)(2)(i)(B) of 

this standard. 

(c)(2)(ii) This exposure determination shall be made without regard to the use of personal 

protective equipment. 

(d) Methods of Compliance -

(d)(1) General. Universal precautions shall be observed to prevent contact with blood or 

other potentially infectious materials. Under circumstances in which differentiation 

between body fluid types is difficult or impossible, all body fluids shall be considered 

potentially infectious materials. 

(d)(2) Engineering and Work Practice Controls. 

(d)(2)(i) Engineering and work practice controls shall be used to eliminate or minimize 

employee exposure. Where occupational exposure remains after institution of these 

controls, personal protective equipment shall also be used. 

(d)(2)(ii) Engineering controls shall be examined and maintained or replaced on a regular 

schedule to ensure their effectiveness. 

(d)(2)(iii) Employers shall provide handwashing facilities which are readily accessible to 

employees. 

(d)(2)(iv) When provision of handwashing facilities is not feasible, the employer shall 

provide either an appropriate antiseptic hand cleanser in conjunction with clean 

cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes 

are used, hands shall be washed with soap and running water as soon as feasible. 

(d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon 

as feasible after removal of gloves or other personal protective equipment. 

(d)(2)(vi) Employers shall ensure that employees wash 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 other potentially infectious 

materials.

(d)(2)(vii) Contaminated needles and other contaminated sharps shall not be bent, 

recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) 

below. Shearing or breaking of contaminated needles is prohibited. 

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(d)(2)(vii)(A) Contaminated needles and other contaminated sharps shall not be bent, 

recapped or removed unless the employer can demonstrate that no alternative is feasible 

or that such action is required by a specific medical or dental procedure. 

(d)(2)(vii)(B) Such bending, recapping or needle removal must be accomplished through 

the use of a mechanical device or a one-handed technique. 

(d)(2)(viii) Immediately or as soon as possible after use, contaminated reusable sharps 

shall be placed in appropriate containers until properly reprocessed. These containers 

shall be: 

(d)(2)(viii)(A) puncture resistant; 

(d)(2)(viii)(B) labeled or color-coded in accordance with this standard; 

(d)(2)(viii)(C) leakproof on the sides and bottom; and 

(d)(2)(viii)(D) in accordance with the requirements set forth in paragraph (d)(4)(ii)(E) for 

reusable sharps. 

(d)(2)(ix) 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. 

(d)(2)(x) Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or 

on countertops or benchtops where blood or other potentially infectious materials are 

present. 

(d)(2)(xi) All procedures involving blood or other potentially infectious materials shall be 

performed in such a manner as to minimize splashing, spraying, spattering, and 

generation of droplets of these substances. 

(d)(2)(xii) Mouth pipetting/suctioning of blood or other potentially infectious materials is 

prohibited. 

(d)(2)(xiii) Specimens of blood or other potentially infectious materials shall be placed in 

a container which prevents leakage during collection, handling, processing, storage, 

transport, or shipping. 

(d)(2)(xiii)(A) The container for storage, transport, or shipping shall be labeled or colorcoded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or 

shipped. When a facility utilizes Universal Precautions in the handling of all specimens, 

the labeling/color-coding of specimens is not necessary provided containers are 

recognizable as containing specimens. This exemption only applies while such 

specimens/containers remain within the facility. Labeling or color-coding in accordance 

with paragraph (g)(1)(i) is required when such specimens/containers leave the facility. 

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(d)(2)(xiii)(B) If outside contamination of the primary container occurs, the primary 

container shall be placed within a second container which prevents leakage during 

handling, processing, storage, transport, or shipping and is labeled or color-coded 

according to the requirements of this standard. 

(d)(2)(xiii)(C) If the specimen could puncture the primary container, the primary 

container shall be placed within a secondary container which is puncture-resistant in 

addition to the above characteristics. 

(d)(2)(xiv) 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 the employer can demonstrate that decontamination 

of such equipment or portions of such equipment is not feasible. 

(d)(2)(xiv)(A) A readily observable label in accordance with paragraph (g)(1)(i)(H) shall 

be attached to the equipment stating which portions remain contaminated. 

(d)(2)(xiv)(B) The employer shall ensure that this information is conveyed to all affected 

employees, the servicing representative, and/or the manufacturer, as appropriate, prior to 

handling, servicing, or shipping so that appropriate precautions will be taken. 

(d)(3) Personal Protective Equipment -

(d)(3)(i) Provision. When there is occupational exposure, the employer shall provide, at 

no cost to the employee, appropriate personal protective equipment such as, but not 

limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and 

mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal 

protective equipment will be considered "appropriate" only if it does not permit blood or 

other potentially infectious materials to pass through to or reach the employee's work 

clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes 

under normal conditions of use and for the duration of time which the protective 

equipment will be used. 

(d)(3)(ii) Use. The employer shall ensure that the employee uses appropriate personal 

protective equipment unless the employer shows that the employee temporarily and 

briefly declined to use personal protective equipment when, under rare and extraordinary 

circumstances, it was the employee's professional judgment that in the specific instance 

its use would have prevented the delivery of health care or public safety services or 

would have posed an increased hazard to the safety of the worker or co-worker. When the 

employee makes this judgement, the circumstances shall be investigated and documented 

in order to determine whether changes can be instituted to prevent such occurrences in 

the future. 

(d)(3)(iii) Accessibility. The employer shall ensure that appropriate personal protective 

equipment in the appropriate sizes is readily accessible at the worksite or is issued to 

employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar 

179 
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alternatives shall be readily accessible to those employees who are allergic to the gloves 

normally provided. 

(d)(3)(iv) Cleaning, Laundering, and Disposal. The employer shall clean, launder, and 

dispose of personal protective equipment required by paragraphs (d) and (e) of this 

standard, at no cost to the employee. 

(d)(3)(v) Repair and Replacement. The employer shall repair or replace personal 

protective equipment as needed to maintain its effectiveness, at no cost to the employee. 

(d)(3)(vi) If a garment(s) is penetrated by blood or other potentially infectious materials, 

the garment(s) shall be removed immediately or as soon as feasible. 

(d)(3)(vii) All personal protective equipment shall be removed prior to leaving the work 

area. 

(d)(3)(viii) When personal protective equipment is removed it shall be placed in an 

appropriately designated area or container for storage, washing, decontamination or 

disposal. 

(d)(3)(ix) Gloves. Gloves shall be worn when it can be reasonably anticipated that the 

employee may have hand contact with blood, other potentially infectious materials, 

mucous membranes, and non-intact skin; when performing vascular access procedures 

except as specified in paragraph (d)(3)(ix)(D); and when handling or touching 

contaminated items or surfaces. 

(d)(3)(ix)(A) 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, 

punctured, or when their ability to function as a barrier is compromised. 

(d)(3)(ix)(B) Disposable (single use) gloves shall not be washed or decontaminated for 

re-use. 

(d)(3)(ix)(C) Utility gloves may be decontaminated for re-use if the integrity of the glove 

is not compromised. However, they must be discarded if they are cracked, peeling, torn, 

punctured, or exhibit other signs of deterioration or when their ability to function as a 

barrier is compromised. 

(d)(3)(ix)(D) If an employer in a volunteer blood donation center judges that routine 

gloving for all phlebotomies is not necessary then the employer shall: 

(d)(3)(ix)(D)(1) Periodically reevaluate this policy; 

(d)(3)(ix)(D)(2) Make gloves available to all employees who wish to use them for 

phlebotomy; 

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(d)(3)(ix)(D)(3) Not discourage the use of gloves for phlebotomy; and 

(d)(3)(ix)(D)(4) Require that gloves be used for phlebotomy in the following 

circumstances: 

(d)(3)(ix)(D)(4)(i) When the employee has cuts, scratches, or other breaks in his or her 

skin; 

(d)(3)(ix)(D)(4)(ii) When the employee judges that hand contamination with blood may 

occur, for example, when performing phlebotomy on an uncooperative source individual; 

and 

(d)(3)(ix)(D)(4)(iii) When the employee is receiving training in phlebotomy. 

(d)(3)(x) Masks, Eye Protection, and Face Shields. Masks in combination with eye 

protection devices, such as goggles or glasses with solid side shields, or chin-length face 

shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other 

potentially infectious materials may be generated and eye, nose, or mouth contamination 

can be reasonably anticipated. 

(d)(3)(xi) Gowns, Aprons, and Other Protective Body Clothing. Appropriate 

protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or 

similar outer garments shall be worn in occupational exposure situations. The type and 

characteristics will depend upon the task and degree of exposure anticipated. 

(d)(3)(xii) Surgical caps or hoods and/or shoe covers or boots shall be worn in instances 

when gross contamination can reasonably be anticipated (e.g., autopsies, orthopaedic 

surgery). 

(d)(4) Housekeeping -

(d)(4)(i) General. Employers shall ensure that the worksite is maintained in a clean and 

sanitary condition. The employer shall determine and implement an appropriate written 

schedule for cleaning and method of decontamination based upon the location within the 

facility, type of surface to be cleaned, type of soil present, and tasks or procedures being 

performed in the area. 

(d)(4)(ii) All equipment and environmental and working surfaces shall be cleaned and 

decontaminated after contact with blood or other potentially infectious materials. 

(d)(4)(ii)(A) Contaminated work surfaces shall be decontaminated with an appropriate 

disinfectant after completion of procedures; immediately or as soon as feasible when 

surfaces are overtly contaminated or after any spill of blood or other potentially 

infectious materials; and at the end of the work shift if the surface may have become

contaminated since the last cleaning. 

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(d)(4)(ii)(B) Protective coverings, such as plastic wrap, aluminum foil, or imperviouslybacked absorbent paper used to cover equipment and environmental surfaces, shall be 

removed and replaced as soon as feasible when they become overtly contaminated or at 

the end of the workshift if they may have become contaminated during the shift. 

(d)(4)(ii)(C) 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 upon visible 

contamination. 

(d)(4)(ii)(D) Broken glassware which may be contaminated shall not be picked up 

directly with the hands. It shall be cleaned up using mechanical means, such as a brush 

and dust pan, tongs, or forceps. 

(d)(4)(ii)(E) Reusable sharps that are contaminated with blood or other potentially 

infectious materials 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. 

(d)(4)(iii) Regulated Waste---

(d)(4)(iii)(A) Contaminated Sharps Discarding and Containment. 

(d)(4)(iii)(A)(1) Contaminated sharps shall be discarded immediately or as soon as 

feasible in containers that are: 

(d)(4)(iii)(A)(1)(i) Closable; 

(d)(4)(iii)(A)(1)(ii) Puncture resistant; 

(d)(4)(iii)(A)(1)(iii) Leakproof on sides and bottom; and 

(d)(4)(iii)(A)(1)(iv) Labeled or color-coded in accordance with paragraph (g)(1)(i) of this 

standard. 

(d)(4)(iii)(A)(2) During use, containers for contaminated sharps shall be: 

(d)(4)(iii)(A)(2)(i) 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 (e.g., 

laundries); 

(d)(4)(iii)(A)(2)(ii) Maintained upright throughout use; and 

(d)(4)(iii)(A)(2)(iii) Replaced routinely and not be allowed to overfill. 

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(d)(4)(iii)(A)(3) When moving containers of contaminated sharps from the area of use, 

the containers shall be: 

(d)(4)(iii)(A)(3)(i) Closed immediately prior to removal or replacement to prevent 

spillage or protrusion of contents during handling, storage, transport, or shipping; 

(d)(4)(iii)(A)(3)(ii) Placed in a secondary container if leakage is possible. The second 

container shall be: 

(d)(4)(iii)(A)(3)(ii)(A) Closable; 

(d)(4)(iii)(A)(3)(ii)(B) Constructed to contain all contents and prevent leakage during 

handling, storage, transport, or shipping; and 

(d)(4)(iii)(A)(3)(ii)(C) Labeled or color-coded according to paragraph (g)(1)(i) of this 

standard. 

(d)(4)(iii)(A)(4) Reusable containers shall not be opened, emptied, or cleaned manually 

or in any other manner which would expose employees to the risk of percutaneous injury. 

(d)(4)(iii)(B) Other Regulated Waste Containment -

(d)(4)(iii)(B)(1) Regulated waste shall be placed in containers which are: 

(d)(4)(iii)(B)(1)(i) Closable; 

(d)(4)(iii)(B)(1)(ii) Constructed to contain all contents and prevent leakage of fluids 

during handling, storage, transport or shipping; 

(d)(4)(iii)(B)(1)(iii) Labeled or color-coded in accordance with paragraph (g)(1)(i) this 

standard; and 

(d)(4)(iii)(B)(1)(iv) Closed prior to removal to prevent spillage or protrusion of contents 

during handling, storage, transport, or shipping. 

(d)(4)(iii)(B)(2) If outside contamination of the regulated waste container occurs, it shall 

be placed in a second container. The second container shall be: 

(d)(4)(iii)(B)(2)(i) Closable; 

(d)(4)(iii)(B)(2)(ii) Constructed to contain all contents and prevent leakage of fluids 

during handling, storage, transport or shipping; 

(d)(4)(iii)(B)(2)(iii) Labeled or color-coded in accordance with paragraph (g)(1)(i) of this 

standard; and 

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(d)(4)(iii)(B)(2)(iv) Closed prior to removal to prevent spillage or protrusion of contents 

during handling, storage, transport, or shipping. 

(d)(4)(iii)(C) Disposal of all regulated waste shall be in accordance with applicable 

regulations of the United States, States and Territories, and political subdivisions of 

States and Territories. 

(d)(4)(iv) Laundry. 

(d)(4)(iv)(A) Contaminated laundry shall be handled as little as possible with a minimum

of agitation. 

(d)(4)(iv)(A)(1) Contaminated laundry shall be bagged or containerized at the location 

where it was used and shall not be sorted or rinsed in the location of use. 

(d)(4)(iv)(A)(2) Contaminated laundry shall be placed and transported in bags or 

containers labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard. 

When a facility utilizes Universal Precautions in the handling of all soiled laundry, 

alternative labeling or color-coding is sufficient if it permits all employees to recognize 

the containers as requiring compliance with Universal Precautions. 

(d)(4)(iv)(A)(3) Whenever contaminated laundry is wet and presents a reasonable 

likelihood of soak-through of or leakage from the bag or container, the laundry shall be 

placed and transported in bags or containers which prevent soak-through and/or leakage 

of fluids to the exterior. 

(d)(4)(iv)(B) The employer shall ensure that employees who have contact with 

contaminated laundry wear protective gloves and other appropriate personal protective 

equipment. 

(d)(4)(iv)(C) When a facility ships contaminated laundry off-site to a second facility 

which does not utilize Universal Precautions in the handling of all laundry, the facility 

generating the contaminated laundry must place such laundry in bags or containers which 

are labeled or color-coded in accordance with paragraph (g)(1)(i). 

(e) HIV and HBV Research Laboratories and Production Facilities. 

(e)(1) This paragraph applies to research laboratories and production facilities engaged in 

the culture, production, concentration, experimentation, and manipulation of HIV and 

HBV. It does not apply to clinical or diagnostic laboratories engaged solely in the 

analysis of blood, tissues, or organs. These requirements apply in addition to the other 

requirements of the standard. 

(e)(2) Research laboratories and production facilities shall meet the following criteria: 

184 
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(e)(2)(i) Standard Microbiological Practices. All regulated waste shall either be 

incinerated or decontaminated by a method such as autoclaving known to effectively 

destroy bloodborne pathogens. 

(e)(2)(ii) Special Practices. 

(e)(2)(ii)(A) Laboratory doors shall be kept closed when work involving HIV or HBV is 

in progress. 

(e)(2)(ii)(B) Contaminated materials that are to be decontaminated at a site away from the 

work area shall be placed in a durable, leakproof, labeled or color-coded container that is 

closed before being removed from the work area. 

(e)(2)(ii)(C) Access to the work area shall be limited to authorized persons. Written 

policies and procedures shall be established whereby only persons who have been 

advised of the potential biohazard, who meet any specific entry requirements, and who 

comply with all entry and exit procedures shall be allowed to enter the work areas and 

animal rooms. 

(e)(2)(ii)(D) When other potentially infectious materials or infected animals are present 

in the work area or containment module, a hazard warning sign incorporating the 

universal biohazard symbol shall be posted on all access doors. The hazard warning sign 

shall comply with paragraph (g)(1)(ii) of this standard. 

(e)(2)(ii)(E) All activities involving other potentially infectious materials shall be 

conducted in biological safety cabinets or other physical-containment devices within the 

containment module. No work with these other potentially infectious materials shall be 

conducted on the open bench. 

(e)(2)(ii)(F) Laboratory coats, gowns, smocks, uniforms, or other appropriate protective 

clothing shall be used in the work area and animal rooms. Protective clothing shall not be 

worn outside of the work area and shall be decontaminated before being laundered. 

(e)(2)(ii)(G) Special care shall be taken to avoid skin contact with other potentially 

infectious materials. Gloves shall be worn when handling infected animals and when 

making hand contact with other potentially infectious materials is unavoidable. 

(e)(2)(ii)(H) Before disposal all waste from work areas and from animal rooms shall 

either be incinerated or decontaminated by a method such as autoclaving known to 

effectively destroy bloodborne pathogens. 

(e)(2)(ii)(I) Vacuum lines shall be protected with liquid disinfectant traps and highefficiency particulate air (HEPA) filters or filters of equivalent or superior efficiency and 

which are checked routinely and maintained or replaced as necessary. 

185 
 APPENDIX B-3 

(e)(2)(ii)(J) Hypodermic needles and syringes shall be used only for parenteral injection 

and aspiration of fluids from laboratory animals and diaphragm bottles. Only needlelocking syringes or disposable syringe-needle units (i.e., the needle is integral to the 

syringe) shall be used for the injection or aspiration of other potentially infectious 

materials. Extreme caution shall be used when handling needles and syringes. A needle 

shall not be bent, sheared, replaced in the sheath or guard, or removed from the syringe 

following use. The needle and syringe shall be promptly placed in a puncture-resistant 

container and autoclaved or decontaminated before reuse or disposal. 

(e)(2)(ii)(K) All spills shall be immediately contained and cleaned up by appropriate 

professional staff or others properly trained and equipped to work with potentially 

concentrated infectious materials. 

(e)(2)(ii)(L) A spill or accident that results in an exposure incident shall be immediately 

reported to the laboratory director or other responsible person. 

(e)(2)(ii)(M) A biosafety manual shall be prepared or adopted and periodically reviewed 

and updated at least annually or more often if necessary. Personnel shall be advised of 

potential hazards, shall be required to read instructions on practices and procedures, and 

shall be required to follow them. 

(e)(2)(iii) Containment Equipment. 

(e)(2)(iii)(A) Certified biological safety cabinets (Class I, II, or III) or other appropriate 

combinations of personal protection or physical containment devices, such as special 

protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotors, and 

containment caging for animals, shall be used for all activities with other potentially 

infectious materials that pose a threat of exposure to droplets, splashes, spills, or aerosols. 

(e)(2)(iii)(B) Biological safety cabinets shall be certified when installed, whenever they 

are moved and at least annually. 

(e)(3) HIV and HBV research laboratories shall meet the following criteria: 

(e)(3)(i) Each laboratory shall contain a facility for hand washing and an eye wash 

facility which is readily available within the work area. 

(e)(3)(ii) An autoclave for decontamination of regulated waste shall be available. 

(e)(4) HIV and HBV production facilities shall meet the following criteria: 

(e)(4)(i) The work areas shall be separated from areas that are open to unrestricted traffic 

flow within the building. Passage through two sets of doors shall be the basic requirement 

for entry into the work area from access corridors or other contiguous areas. Physical 

separation of the high-containment work area from access corridors or other areas or 

activities may also be provided by a double-doored clothes-change room (showers may 

186 
 APPENDIX B-3 

be included), airlock, or other access facility that requires passing through two sets of 

doors before entering the work area. 

(e)(4)(ii) The surfaces of doors, walls, floors and ceilings in the work area shall be water 

resistant so that they can be easily cleaned. Penetrations in these surfaces shall be sealed 

or capable of being sealed to facilitate decontamination. 

(e)(4)(iii) Each work area shall contain a sink for washing hands and a readily available 

eye wash facility. The sink shall be foot, elbow, or automatically operated and shall be 

located near the exit door of the work area. 

(e)(4)(iv) Access doors to the work area or containment module shall be self-closing. 

(e)(4)(v) An autoclave for decontamination of regulated waste shall be available within or 

as near as possible to the work area. 

(e)(4)(vi) A ducted exhaust-air ventilation system shall be provided. This system shall 

create directional airflow that draws air into the work area through the entry area. The 

exhaust air shall not be recirculated to any other area of the building, shall be discharged 

to the outside, and shall be dispersed away from occupied areas and air intakes. The 

proper direction of the airflow shall be verified (i.e., into the work area). 

(e)(5) Training Requirements. Additional training requirements for employees in HIV 

and HBV research laboratories and HIV and HBV production facilities are specified in 

paragraph (g)(2)(ix). 

(f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up -

(f)(1) General. 

(f)(1)(i) The employer shall make available the hepatitis B vaccine and vaccination series 

to all employees who have occupational exposure, and post-exposure evaluation and 

follow-up to all employees who have had an exposure incident. 

(f)(1)(ii) The employer shall ensure that all medical evaluations and procedures including 

the hepatitis B vaccine and vaccination series and post-exposure evaluation and followup, including prophylaxis, are: 

(f)(1)(ii)(A) Made available at no cost to the employee; 

(f)(1)(ii)(B) Made available to the employee at a reasonable time and place; 

(f)(1)(ii)(C) Performed by or under the supervision of a licensed physician or by or under 

the supervision of another licensed healthcare professional; and 

187 
 APPENDIX B-3 

(f)(1)(ii)(D) Provided according to recommendations of the U.S. Public Health Service 

current at the time these evaluations and procedures take place, except as specified by 

this paragraph (f). 

(f)(1)(iii) The employer shall ensure that all laboratory tests are conducted by an 

accredited laboratory at no cost to the employee. 

(f)(2) Hepatitis B Vaccination. 

(f)(2)(i) Hepatitis B vaccination shall be made available after the employee has received 

the training required in paragraph (g)(2)(vii)(I) and within 10 working days of initial 

assignment to all employees who have occupational exposure unless the employee has 

previously received the complete hepatitis B vaccination series, antibody testing has 

revealed that the employee is immune, or the vaccine is contraindicated for medical 

reasons. 

(f)(2)(ii) The employer shall not make participation in a prescreening program a 

prerequisite for receiving hepatitis B vaccination. 

(f)(2)(iii) If the employee initially declines hepatitis B vaccination but at a later date 

while still covered under the standard decides to accept the vaccination, the employer 

shall make available hepatitis B vaccination at that time. 

(f)(2)(iv) The employer shall assure that employees who decline to accept hepatitis B 

vaccination offered by the employer sign the statement in Appendix A. 

(f)(2)(v) 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 in 

accordance with section (f)(1)(ii). 

(f)(3) Post-exposure Evaluation and Follow-up. Following a report of an exposure 

incident, the employer shall make immediately available to the exposed employee a 

confidential medical evaluation and follow-up, including at least the following elements: 

(f)(3)(i) Documentation of the route(s) of exposure, and the circumstances under which 

the exposure incident occurred; 

(f)(3)(ii) Identification and documentation of the source individual, unless the employer 

can establish that identification is infeasible or prohibited by state or local law; 

(f)(3)(ii)(A) The source individual's blood shall be tested as soon as feasible and after 

consent is obtained in order to determine HBV 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. 

188 
 APPENDIX B-3 

(f)(3)(ii)(B) When the source individual is already known to be infected with HBV or 

HIV, testing for the source individual's known HBV or HIV status need not be repeated. 

(f)(3)(ii)(C) Results of the source individual's testing shall be made available 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. 

(f)(3)(iii) Collection and testing of blood for HBV and HIV serological status; 

(f)(3)(iii)(A) The exposed employee's blood shall be collected as soon as feasible and 

tested after consent is obtained. 

(f)(3)(iii)(B) 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. 

(f)(3)(iv) Post-exposure prophylaxis, when medically indicated, as recommended by the 

U.S. Public Health Service; 

(f)(3)(v) Counseling; and 

(f)(3)(vi) Evaluation of reported illnesses. 

(f)(4) Information Provided to the Healthcare Professional. 

(f)(4)(i) The employer shall ensure that the healthcare professional responsible for the 

employee's Hepatitis B vaccination is provided a copy of this regulation. 

(f)(4)(ii) The employer shall ensure that the healthcare professional evaluating an 

employee after an exposure incident is provided the following information: 

(f)(4)(ii)(A) A copy of this regulation; 

(f)(4)(ii)(B) A description of the exposed employee's duties as they relate to the exposure 

incident; 

(f)(4)(ii)(C) Documentation of the route(s) of exposure and circumstances under which 

exposure occurred; 

(f)(4)(ii)(D) Results of the source individual's blood testing, if available; and 

(f)(4)(ii)(E) All medical records relevant to the appropriate treatment of the employee 

including vaccination status which are the employer's responsibility to maintain. 

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 APPENDIX B-3 

(f)(5) Healthcare Professional's Written Opinion. The employer shall obtain and 

provide the employee with a copy of the evaluating healthcare professional's written 

opinion within 15 days of the completion of the evaluation. 

(f)(5)(i) The healthcare professional's written opinion for Hepatitis B vaccination shall be 

limited to whether Hepatitis B vaccination is indicated for an employee, and if the 

employee has received such vaccination. 

(f)(5)(ii) The healthcare professional's written opinion for post-exposure evaluation and 

follow-up shall be limited to the following information: 

(f)(5)(ii)(A) That the employee has been informed of the results of the evaluation; and 

(f)(5)(ii)(B) That the employee has been told about any medical conditions resulting from

exposure to blood or other potentially infectious materials which require further 

evaluation or treatment. 

(f)(5)(iii) All other findings or diagnoses shall remain confidential and shall not be 

included in the written report. 

(f)(6) Medical Recordkeeping. Medical records required by this standard shall be 

maintained in accordance with paragraph (h)(1) of this section. 

(g) Communication of Hazards to Employees -

(g)(1) Labels and Signs -

(g)(1)(i) Labels. 

(g)(1)(i)(A) Warning labels shall be affixed to containers of regulated waste, refrigerators 

and freezers containing blood or other potentially infectious material; and other 

containers used to store, transport or ship blood or other potentially infectious materials, 

except as provided in paragraph (g)(1)(i)(E), (F) and (G). 

(g)(1)(i)(B) Labels required by this section shall include the following legend: 

190 
 APPENDIX B-3 

(g)(1)(i)(C) These labels shall be fluorescent orange or orange-red or predominantly so, 

with lettering and symbols in a contrasting color. 

(g)(1)(i)(D) Labels shall be affixed as close as feasible to the container by string, wire, 

adhesive, or other method that prevents their loss or unintentional removal. 

(g)(1)(i)(E) Red bags or red containers may be substituted for labels. 

(g)(1)(i)(F) Containers of blood, blood components, or blood products that are labeled as 

to their contents and have been released for transfusion or other clinical use are exempted 

from the labeling requirements of paragraph (g). 

(g)(1)(i)(G) Individual containers of blood or other potentially infectious materials that 

are placed in a labeled container during storage, transport, shipment or disposal are 

exempted from the labeling requirement. 

(g)(1)(i)(H) Labels required for contaminated equipment shall be in accordance with this 

paragraph and shall also state which portions of the equipment remain contaminated. 

(g)(1)(i)(I) Regulated waste that has been decontaminated need not be labeled or colorcoded. 

(g)(1)(ii) Signs. 

(g)(1)(ii)(A) The employer shall post signs at the entrance to work areas specified in 

paragraph (e), HIV and HBV Research Laboratory and Production Facilities, which shall 

bear the following legend: 

(Name of the Infectious Agent) 

(Special requirements for entering the area) 

(Name, telephone number of the laboratory director or other responsible person.) 

(g)(1)(ii)(B) These signs shall be fluorescent orange-red or predominantly so, with 

lettering and symbols in a contrasting color. 

(g)(2) Information and Training. 

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(g)(2)(i) Employers shall ensure that all employees with occupational exposure 

participate in a training program which must be provided at no cost to the employee and 

during working hours. 

(g)(2)(ii) Training shall be provided as follows: 

(g)(2)(ii)(A) At the time of initial assignment to tasks where occupational exposure may 

take place; 

(g)(2)(ii)(B) Within 90 days after the effective date of the standard; and 

(g)(2)(ii)(C) At least annually thereafter. 

(g)(2)(iii) For employees who have received training on bloodborne pathogens in the year 

preceding the effective date of the standard, only training with respect to the provisions 

of the standard which were not included need be provided. 

(g)(2)(iv) Annual training for all employees shall be provided within one year of their 

previous training. 

(g)(2)(v) Employers shall provide additional training when changes such as modification 

of tasks or procedures or institution of new tasks or procedures affect the employee's 

occupational exposure. The additional training may be limited to addressing the new 

exposures created. 

(g)(2)(vi) Material appropriate in content and vocabulary to educational level, literacy, 

and language of employees shall be used. 

(g)(2)(vii) The training program shall contain at a minimum the following elements: 

(g)(2)(vii)(A) An accessible copy of the regulatory text of this standard and an 

explanation of its contents; 

(g)(2)(vii)(B) A general explanation of the epidemiology and symptoms of bloodborne 

diseases; 

(g)(2)(vii)(C) An explanation of the modes of transmission of bloodborne pathogens; 

(g)(2)(vii)(D) An explanation of the employer's exposure control plan and the means by 

which the employee can obtain a copy of the written plan; 

(g)(2)(vii)(E) An explanation of the appropriate methods for recognizing tasks and other 

activities that may involve exposure to blood and other potentially infectious materials; 

192 
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(g)(2)(vii)(F) An explanation of the use and limitations of methods that will prevent or 

reduce exposure including appropriate engineering controls, work practices, and personal 

protective equipment; 

(g)(2)(vii)(G) Information on the types, proper use, location, removal, handling, 

decontamination and disposal of personal protective equipment; 

(g)(2)(vii)(H) An explanation of the basis for selection of personal protective equipment; 

(g)(2)(vii)(I) Information on the hepatitis B vaccine, including information on its 

efficacy, safety, method of administration, the benefits of being vaccinated, and that the 

vaccine and vaccination will be offered free of charge; 

(g)(2)(vii)(J) Information on the appropriate actions to take and persons to contact in an 

emergency involving blood or other potentially infectious materials; 

(g)(2)(vii)(K) An explanation of the procedure to follow if an exposure incident occurs, 

including the method of reporting the incident and the medical follow-up that will be 

made available; 

(g)(2)(vii)(L) Information on the post-exposure evaluation and follow-up that the 

employer is required to provide for the employee following an exposure incident; 

(g)(2)(vii)(M) An explanation of the signs and labels and/or color coding required by 

paragraph (g)(1); and 

(g)(2)(vii)(N) An opportunity for interactive questions and answers with the person 

conducting the training session. 

(g)(2)(viii) The person conducting the training shall be knowledgeable in the subject 

matter covered by the elements contained in the training program as it relates to the 

workplace that the training will address. 

(g)(2)(ix) Additional Initial Training for Employees in HIV and HBV Laboratories and 

Production Facilities. Employees in HIV or HBV research laboratories and HIV or HBV 

production facilities shall receive the following initial training in addition to the above 

training requirements. 

(g)(2)(ix)(A) The employer shall assure that employees demonstrate proficiency in 

standard microbiological practices and techniques and in the practices and operations 

specific to the facility before being allowed to work with HIV or HBV. 

(g)(2)(ix)(B) The employer shall assure that employees have prior experience in the 

handling of human pathogens or tissue cultures before working with HIV or HBV. 

193 
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(g)(2)(ix)(C) The employer shall provide a training program to employees who have no 

prior experience in handling human pathogens. Initial work activities shall not include the 

handling of infectious agents. A progression of work activities shall be assigned as 

techniques are learned and proficiency is developed. The employer shall assure that 

employees participate in work activities involving infectious agents only after proficiency 

has been demonstrated. 

(h) Recordkeeping -

(h)(1) Medical Records. 

(h)(1)(i) The employer shall establish and maintain an accurate record for each employee 

with occupational exposure, in accordance with 29 CFR 1910.1020. 

(h)(1)(ii) This record shall include: 

(h)(1)(ii)(A) The name and social security number of the employee; 

(h)(1)(ii)(B) 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 as required by paragraph (f)(2); 

(h)(1)(ii)(C) A copy of all results of examinations, medical testing, and follow-up 

procedures as required by paragraph (f)(3); 

(h)(1)(ii)(D) The employer's copy of the healthcare professional's written opinion as 

required by paragraph (f)(5); and 

(h)(1)(ii)(E) A copy of the information provided to the healthcare professional as required 

by paragraphs (f)(4)(ii)(B)(C) and (D). 

(h)(1)(iii) Confidentiality. The employer shall ensure that employee medical records 

required by paragraph (h)(1) are: 

(h)(1)(iii)(A) Kept confidential; and 

(h)(1)(iii)(B) Not disclosed or reported without the employee's express written consent to 

any person within or outside the workplace except as required by this section or as may 

be required by law. 

(h)(1)(iv) The employer shall maintain the records required by paragraph (h) for at least 

the duration of employment plus 30 years in accordance with 29 CFR 1910.1020. 

(h)(2) Training Records. 

(h)(2)(i) Training records shall include the following information: 

194 
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(h)(2)(i)(A) The dates of the training sessions; 

(h)(2)(i)(B) The contents or a summary of the training sessions; 

(h)(2)(i)(C) The names and qualifications of persons conducting the training; and 

(h)(2)(i)(D) The names and job titles of all persons attending the training sessions. 

(h)(2)(ii) Training records shall be maintained for 3 years from the date on which the 

training occurred. 

(h)(3) Availability. 

(h)(3)(i) The employer shall ensure that all records required to be maintained by this 

section shall be made available upon request to the Assistant Secretary and the Director 

for examination and copying. 

(h)(3)(ii) Employee training records required by this paragraph shall be provided upon 

request for examination and copying to employees, to employee representatives, to the 

Director, and to the Assistant Secretary. 

(h)(3)(iii) Employee medical records required by this paragraph shall be provided upon 

request for examination and copying to the subject employee, to anyone having written 

consent of the subject employee, to the Director, and to the Assistant Secretary in 

accordance with 29 CFR 1910.1020. 

(h)(4) Transfer of Records. 

(h)(4)(i) The employer shall comply with the requirements involving transfer of records 

set forth in 29 CFR 1910.1020(h). 

(h)(4)(ii) If the employer ceases to do business and there is no successor employer to 

receive and retain the records for the prescribed period, the employer shall notify the 

Director, at least three months prior to their disposal and transmit them to the Director, if

required by the Director to do so, within that three month period. 

(h)(5) Sharps Injury Log. 

(h)(5)(i) The employer shall establish and maintain a sharps injury log for the recording 

of percutaneous injuries from contaminated sharps. The information in the sharps injury 

log shall be recorded and maintained in such manner as to protect the confidentiality of

the injured employee. The sharps injury log shall contain, at a minimum:

(h)(5)(i)(A) the type and brand of device involved in the incident, 

(h)(5)(i)(B) the department or work area where the exposure incident occurred, and 

195 
 APPENDIX B-3 

(h)(5)(i)(C) an explanation of how the incident occurred. 

(h)(5)(ii) The requirement to establish and maintain a sharps injury log shall apply to any 

employer who is required to maintain a log of occupational injuries and illnesses under 

29 CFR 1904. 

(h)(5)(iii) The sharps injury log shall be maintained for the period required by 29 CFR 

1904.6. 

(i) Dates -

(i)(1) Effective Date. The standard shall become effective on March 6, 1992. 

(i)(2) The Exposure Control Plan required by paragraph (c) of this section shall be 

completed on or before May 5, 1992. 

(i)(3) Paragraph (g)(2) Information and Training and (h) Recordkeeping shall take effect 

on or before June 4, 1992. 

(i)(4) Paragraphs (d)(2) Engineering and Work Practice Controls, (d)(3) Personal 

Protective Equipment, (d)(4) Housekeeping, (e) HIV and HBV Research Laboratories 

and Production Facilities, (f) Hepatitis B Vaccination and Post-Exposure Evaluation and 

Follow-up, and (g)(1) Labels and Signs, shall take effect July 6, 1992. 

APPENDIX A TO SECTION 1910.1030 - HEPATITIS B DECLINATION 

(MANDATORY) 

I understand that due to my occupational exposure to blood or other potentially infectious 

materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been 

given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. 

However, I decline hepatitis B vaccination at this time. I understand that by declining this 

vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future 

I continue to have occupational exposure to blood or other potentially infectious materials 

and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series 

at no charge to me. 

196 
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APPENDIX B-4 

Updated U.S. Public Health Service Guidelines for the Management of 

Occupational Exposures to HBV, HCV, and HIV and Recommendations for 

Postexposure Prophylaxis (Morbidity and Mortality Weekly, June 29, 2001 / 

50(RR11);1-42) 

Summary 

This report updates and consolidates all previous U.S. Public Health Service 

recommendations for the management of health-care personnel (HCP) who have 

occupational exposure to blood and other body fluids that might contain hepatitis B virus 

(HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV). 

Recommendations for HBV postexposure management include initiation of the hepatitis 

B vaccine series to any susceptible, unvaccinated person who sustains an occupational 

blood or body fluid exposure. Postexposure prophylaxis (PEP) with hepatitis B immune 

globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational 

exposures after evaluation of the hepatitis B surface antigen status of the source and the 

vaccination and vaccine-response status of the exposed person. Guidance is provided to 

clinicians and exposed HCP for selecting the appropriate HBV PEP. 

Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not 

recommended for PEP of hepatitis C. For HCV postexposure management, the HCV 

status of the source and the exposed person should be determined, and for HCP exposed 

to an HCV positive source, follow-up HCV testing should be performed to determine if 

infection develops. 

Recommendations for HIV PEP include a basic 4-week regimen of two drugs 

(zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] 

and d4T) for most HIV exposures and an expanded regimen that includes the addition of 

a third drug for HIV exposures that pose an increased risk for transmission. When the 

source person's virus is known or suspected to be resistant to one or more of the drugs 

considered for the PEP regimen, the selection of drugs to which the source person's virus 

is unlikely to be resistant is recommended. 

In addition, this report outlines several special circumstances (e.g., delayed exposure 

report, unknown source person, pregnancy in the exposed person, resistance of the source 

virus to antiretroviral agents, or toxicity of the PEP regimen) when consultation with 

local experts and/or the National Clinicians' Post-Exposure Prophylaxis Hotline 

([PEPline] 1-888-448-4911) is advised. 

Occupational exposures should be considered urgent medical concerns to ensure timely 

postexposure management and administration of HBIG, hepatitis B vaccine, and/or HIV 

PEP. 

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INTRODUCTION 

Avoiding occupational blood exposures is the primary way to prevent transmission of 

hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus 

(HIV) in health-care settings (1). However, hepatitis B immunization and postexposure 

management are integral components of a complete program to prevent infection 

following bloodborne pathogen exposure and are important elements of workplace safety 

(2). 

The U.S. Public Health Service (PHS) has published previous guidelines for the 

management of HIV exposures that included considerations for postexposure prophylaxis 

(PEP) (3--5). Since publication of the 1998 HIV exposure guidelines (5), several new 

antiretroviral agents have been approved by the Food and Drug Administration (FDA), 

and more information is available about the use and safety of HIV PEP (6--11). In 

addition, questions exist regarding considerations about PEP regimens when the source 

person's virus is known or suspected to be resistant to one or more of the antiretroviral 

agents that might be used for PEP. Concern also has arisen about the use of PEP when it 

is not warranted. Data indicate that some health-care personnel (HCP) take a full course 

of HIV PEP after exposures that do not confer an HIV transmission risk (10,11). 

In September 1999, a meeting of a PHS interagency working group* and expert 

consultants was convened by CDC. The PHS working group decided to issue updated 

recommendations for the management of occupational exposure to HIV. In addition, the 

report was to include recommendations for the management of occupational HBV and 

HCV exposures so that a single document could comprehensively address the 

management of occupational exposures to bloodborne pathogens. This report updates and 

consolidates the previous PHS guidelines and recommendations for occupational HBV, 

HCV, and HIV exposure management for HCP. Specific practice recommendations for 

the management of occupational bloodborne pathogen exposures are outlined to assist 

health-care institutions with the implementation of these PHS guidelines (Appendices A 

and B). As relevant information becomes available, updates of these recommendations 

will be published. Recommendations for nonoccupational (e.g., sexual, pediatric, and 

perinatal) HBV, HCV, and HIV exposures are not addressed in these guidelines and can 

be found elsewhere (12--15). 

Definition of Health-Care Personnel and Exposure 

In this report, health-care personnel (HCP) are defined as persons (e.g., employees, 

students, contractors, attending clinicians, public-safety workers, or volunteers) whose 

activities involve contact with patients or with blood or other body fluids from patients in 

a health-care, laboratory, or public-safety setting. The potential exists for blood and body 

fluid exposure to other workers, and the same principles of exposure management could 

be applied to other settings. 

An exposure that might place HCP at risk for HBV, HCV, or HIV infection is defined as 

a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous 

198 
 APPENDIX B-4 

membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with 

dermatitis) with blood, tissue, or other body fluids that are potentially infectious (16,17). 

In addition to blood and body fluids containing visible blood, semen and vaginal 

secretions also are considered potentially infectious. Although semen and vaginal 

secretions have been implicated in the sexual transmission of HBV, HCV, and HIV, they 

have not been implicated in occupational transmission from patients to HCP. The 

following fluids also are considered potentially infectious: cerebrospinal fluid, synovial 

fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk for 

transmission of HBV, HCV, and HIV infection from these fluids is unknown; the 

potential risk to HCP from occupational exposures has not been assessed by 

epidemiologic studies in health-care settings. Feces, nasal secretions, saliva, sputum, 

sweat, tears, urine, and vomitus are not considered potentially infectious unless they 

contain blood. The risk for transmission of HBV, HCV, and HIV infection from these 

fluids and materials is extremely low. 

Any direct contact (i.e., contact without barrier protection) to concentrated virus in a 

research laboratory or production facility is considered an exposure that requires clinical 

evaluation. For human bites, the clinical evaluation must include the possibility that both 

the person bitten and the person who inflicted the bite were exposed to bloodborne 

pathogens. Transmission of HBV or HIV infection only rarely has been reported by this 

route (18--20) (CDC, unpublished data, 1998). 

BACKGROUND 

This section provides the rationale for the postexposure management and prophylaxis 

recommendations presented in this report. Additional details concerning the risk for 

occupational bloodborne pathogen transmission to HCP and management of occupational 

bloodborne pathogen exposures are available elsewhere (5,12,13,21-24). 

Occupational Transmission of HBV 

Risk for Occupational Transmission of HBV 

HBV infection is a well recognized occupational risk for HCP (25). The risk of HBV 

infection is primarily related to the degree of contact with blood in the work place and 

also to the hepatitis B e antigen (HBeAg) status of the source person. In studies of HCP 

who sustained injuries from needles contaminated with blood containing HBV, the risk of 

developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- 

and HBeAg-positive was 22%--31%; the risk of developing serologic evidence of HBV 

infection was 37%--62%. By comparison, the risk of developing clinical hepatitis from a 

needle contaminated with HBsAg-positive, HBeAg-negative blood was 1%--6%, and the 

risk of developing serologic evidence of HBV infection, 23%--37% (26). 

Although percutaneous injuries are among the most efficient modes of HBV 

transmission, these exposures probably account for only a minority of HBV infections 

199 
 APPENDIX B-4 

among HCP. In several investigations of nosocomial hepatitis B outbreaks, most infected 

HCP could not recall an overt percutaneous injury (27,28), although in some studies, up 

to one third of infected HCP recalled caring for a patient who was HBsAg-positive 

(29,30). In addition, HBV has been demonstrated to survive in dried blood at room

temperature on environmental surfaces for at least 1 week (31). Thus, HBV infections 

that occur in HCP with no history of nonoccupational exposure or occupational 

percutaneous injury might have resulted from direct or indirect blood or body fluid 

exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, 

or on mucosal surfaces (32--34). The potential for HBV transmission through contact 

with environmental surfaces has been demonstrated in investigations of HBV outbreaks 

among patients and staff of hemodialysis units (35--37). 

Blood contains the highest HBV titers of all body fluids and is the most important vehicle 

of transmission in the health-care setting. HBsAg is also found in several other body 

fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, 

saliva, semen, sweat, and synovial fluid (38). However, the concentration of HBsAg in 

body fluids can be 100--1000---fold higher than the concentration of infectious HBV 

particles. Therefore, most body fluids are not efficient vehicles of transmission because 

they contain low quantities of infectious HBV, despite the presence of HBsAg. 

In serologic studies conducted in the United States during the 1970s, HCP had a 

prevalence of HBV infection approximately 10 times higher than the general population 

(39--42). Because of the high risk of HBV infection among HCP, routine preexposure 

vaccination of HCP against hepatitis B and the use of standard precautions to prevent 

exposure to blood and other potentially infectious body fluids have been recommended 

since the early 1980s (43). Regulations issued by the Occupational Safety and Health 

Administration (OSHA) (2) have increased compliance with these recommendations. 

Since the implementation of these recommendations, a sharp decline has occurred in the 

incidence of HBV infection among HCP. 

PEP for HBV 

Efficacy of PEP for HBV. The effectiveness of hepatitis B immune globulin (HBIG) 

and/or hepatitis B vaccine in various postexposure settings has been evaluated by 

prospective studies. For perinatal exposure to an HBsAg-, HBeAg-positive mother, a 

regimen combining HBIG and initiation of the hepatitis B vaccine series at birth is 85%--

95% effective in preventing HBV infection (44,45). Regimens involving either multiple 

doses of HBIG alone or the hepatitis B vaccine series alone are 70%--75% effective in 

preventing HBV infection (46). In the occupational setting, multiple doses of HBIG 

initiated within 1 week following percutaneous exposure to HBsAg-positive blood 

provides an estimated 75% protection from HBV infection (47--49). Although the 

postexposure efficacy of the combination of HBIG and the hepatitis B vaccine series has 

not been evaluated in the occupational setting, the increased efficacy of this regimen 

observed in the perinatal setting, compared with HBIG alone, is presumed to apply to the 

occupational setting as well. In addition, because persons requiring PEP in the 

200 
 APPENDIX B-4 

occupational setting are generally at continued risk for HBV exposure, they should 

receive the hepatitis B vaccine series. 

Safety of PEP for HBV. Hepatitis B vaccines have been found to be safe when 

administered to infants, children, or adults (12,50). Through the year 2000, approximately 

100 million persons have received hepatitis B vaccine in the United States. The most 

common side effects from hepatitis B vaccination are pain at the injection site and mild to 

moderate fever (50--55). Studies indicate that these side effects are reported no more 

frequently among persons vaccinated than among those receiving placebo (51,52). 

Approximately 45 reports have been received by the Vaccine Adverse Event Reporting 

System (VAERS) of alopecia (hair loss) in children and adults after administration of 

plasma-derived and recombinant hepatitis B vaccine; four persons sustained hair loss 

following vaccination on more than one occasion (56). Hair loss was temporary for 

approximately two thirds of persons who experienced hair loss. An epidemiologic study 

conducted in the Vaccine Safety Datalink found no statistical association between 

alopecia and receipt of hepatitis B vaccine in children (CDC, unpublished data, 1998). A 

low rate of anaphylaxis has been observed in vaccine recipients based on reports to 

VAERS; the estimated incidence is 1 in 600,000 vaccine doses distributed. Although 

none of the persons who developed anaphylaxis died, anaphylactic reactions can be lifethreatening; therefore, further vaccination with hepatitis B vaccine is contraindicated in 

persons with a history of anaphylaxis after a previous dose of vaccine. 

Hepatitis B immunization programs conducted on a large scale in Taiwan, Alaska, and 

New Zealand have observed no association between vaccination and the occurrence of 

serious adverse events. Furthermore, in the United States, surveillance of adverse events 

following hepatitis B vaccination has demonstrated no association between hepatitis B 

vaccine and the occurrence of serious adverse events, including Guillain-Barré syndrome, 

transverse myelitis, multiple sclerosis, optic neuritis, and seizures (57--59) (CDC, 

unpublished data, 1991). However, several case reports and case series have claimed an 

association between hepatitis B vaccination and such syndromes and diseases as multiple 

sclerosis, optic neuritis, rheumatoid arthritis, and other autoimmune diseases (57,60--66). 

Most of these reported adverse events have occurred in adults, and no report has 

compared the frequency of the purported vaccine-associated syndrome/disease with the 

frequency in an unvaccinated population. In addition, recent case-control studies have 

demonstrated no association between hepatitis B vaccination and development or shortterm risk of relapse of multiple sclerosis (67,68), and reviews by international panels of 

experts have concluded that available data do not demonstrate a causal association 

between hepatitis B vaccination and demyelinating diseases, including multiple sclerosis 

(69). 

HBIG is prepared from human plasma known to contain a high titer of antibody to 

HBsAg (anti-HBs). The plasma from which HBIG is prepared is screened for HBsAg and 

antibodies to HIV and HCV. The process used to prepare HBIG inactivates and 

eliminates HIV from the final product. Since 1996, the final product has been free of 

HCV RNA as determined by the polymerase chain reaction (PCR), and, since 1999, all 

201 
 APPENDIX B-4 

products available in the United States have been manufactured by methods that 

inactivate HCV and other viruses. No evidence exists that HBV, HCV, or HIV have ever 

been transmitted by HBIG commercially available in the United States (70,71). 

Serious adverse effects from HBIG when administered as recommended have been rare. 

Local pain and tenderness at the injection site, urticaria and angioedema might occur; 

anaphylactic reactions, although rare, have been reported following the injection of 

human immune globulin (IG) preparations (72). Persons with a history of anaphylactic 

reaction to IG should not receive HBIG. 

PEP for HBV During Pregnancy. No apparent risk exists for adverse effects to 

developing fetuses when hepatitis B vaccine is administered to pregnant women (CDC, 

unpublished data, 1990). The vaccine contains noninfectious HBsAg particles and should 

pose no risk to the fetus. HBV infection during pregnancy might result in severe disease 

for the mother and chronic infection for the newborn. Therefore, neither pregnancy nor 

lactation should be considered a contraindication to vaccination of women. HBIG is not 

contraindicated for pregnant or lactating women. 

Occupational Transmission of HCV 

Risk for Occupational Transmission of HCV 

HCV is not transmitted efficiently through occupational exposures to blood. The average 

incidence of anti-HCV seroconversion after accidental percutaneous exposure from an 

HCV-positive source is 1.8% (range: 0%--7%) (73--76), with one study indicating that 

transmission occurred only from hollow-bore needles compared with other sharps (75). 

Transmission rarely occurs from mucous membrane exposures to blood, and no 

transmission in HCP has been documented from intact or nonintact skin exposures to 

blood (77,78). Data are limited on survival of HCV in the environment. In contrast to 

HBV, the epidemiologic data for HCV suggest that environmental contamination with 

blood containing HCV is not a significant risk for transmission in the health-care setting 

(79,80), with the possible exception of the hemodialysis setting where HCV transmission 

related to environmental contamination and poor infection-control practices have been 

implicated (81--84). The risk for transmission from exposure to fluids or tissues other 

than HCV-infected blood also has not been quantified but is expected to be low. 

Postexposure Management for HCV 

In several studies, researchers have attempted to assess the effectiveness of IG following 

possible exposure to non-A, non-B hepatitis. These studies have been difficult to interpret 

because they lack uniformity in diagnostic criteria and study design, and, in all but one 

study, the first dose of IG was administered before potential exposure (48,85,86). In an 

experiment designed to model HCV transmission by needlestick exposure in the healthcare setting, high anti-HCV titer IG administered to chimpanzees 1 hour after exposure to 

HCV-positive blood did not prevent transmission of infection (87). In 1994, the Advisory 

Committee on Immunization Practices (ACIP) reviewed available data regarding the 

202 
 APPENDIX B-4 

prevention of HCV infection with IG and concluded that using IG as PEP for hepatitis C 

was not supported (88). This conclusion was based on the following facts: 

• No protective antibody response has been identified following HCV infection. 

• Previous studies of IG use to prevent posttransfusion non-A, non-B hepatitis 

might not be relevant in making recommendations regarding PEP for hepatitis C. 

• Experimental studies in chimpanzees with IG containing anti-HCV failed to 

prevent transmission of infection after exposure. 

No clinical trials have been conducted to assess postexposure use of antiviral agents (e.g., 

interferon with or without ribavirin) to prevent HCV infection, and antivirals are not 

FDA-approved for this indication. Available data suggest that an established infection 

might need to be present before interferon can be an effective treatment. Kinetic studies 

suggest that the effect of interferon on chronic HCV infection occurs in two phases. 

During the first phase, interferon blocks the production or release of virus from infected 

cells. In the second phase, virus is eradicated from the infected cells (89); in this later 

phase, higher pretreatment alanine aminotransferase (ALT) levels correlate with an 

increasing decline in infected cells, and the rapidity of the decline correlates with viral 

clearance. In contrast, the effect of antiretrovirals when used for PEP after exposure to 

HIV is based on inhibition of HIV DNA synthesis early in the retroviral replicative cycle. 

In the absence of PEP for HCV, recommendations for postexposure management are 

intended to achieve early identification of chronic disease and, if present, referral for 

evaluation of treatment options. However, a theoretical argument is that intervention with 

antivirals when HCV RNA first becomes detectable might prevent the development of 

chronic infection. Data from studies conducted outside the United States suggest that a 

short course of interferon started early in the course of acute hepatitis C is associated with 

a higher rate of resolved infection than that achieved when therapy is begun after chronic 

hepatitis C has been well established (90--92). These studies used various treatment 

regimens and included persons with acute disease whose peak ALT levels were 500--

1,000 IU/L at the time therapy was initiated (2.6--4 months after exposure). 

No studies have evaluated the treatment of acute infection in persons with no evidence of 

liver disease (i.e., HCV RNA-positive <6 months duration with normal ALT levels); 

among patients with chronic HCV infection, the efficacy of antivirals has been 

demonstrated only among patients who also had evidence of chronic liver disease (i.e., 

abnormal ALT levels). In addition, treatment started early in the course of chronic HCV 

infection (i.e., 6 months after onset of infection) might be as effective as treatment started 

during acute infection (13). Because 15%--25% of patients with acute HCV infection 

spontaneously resolve their infection (93), treatment of these patients during the acute 

phase could expose them unnecessarily to the discomfort and side effects of antiviral 

therapy. 

Data upon which to base a recommendation for therapy of acute infection are insufficient 

because a) no data exist regarding the effect of treating patients with acute infection who 

have no evidence of disease, b) treatment started early in the course of chronic infection 

203 
 APPENDIX B-4 

might be just as effective and would eliminate the need to treat persons who will 

spontaneously resolve their infection, and c) the appropriate regimen is unknown. 

Occupational Transmission of HIV 

Risk for Occupational Transmission of HIV 

In prospective studies of HCP, the average risk of HIV transmission after a percutaneous 

exposure to HIV-infected blood has been estimated to be approximately 0.3% (95% 

confidence interval [CI] = 0.2%--0.5%) (94) and after a mucous membrane exposure, 

approximately 0.09% (95% CI = 0.006%--0.5%) (95). Although episodes of HIV 

transmission after nonintact skin exposure have been documented (96), the average risk 

for transmission by this route has not been precisely quantified but is estimated to be less 

than the risk for mucous membrane exposures (97). The risk for transmission after 

exposure to fluids or tissues other than HIV-infected blood also has not been quantified 

but is probably considerably lower than for blood exposures (98). 

As of June 2000, CDC had received voluntary reports of 56 U.S. HCP with documented 

HIV seroconversion temporally associated with an occupational HIV exposure. An 

additional 138 episodes in HCP are considered possible occupational HIV transmissions. 

These workers had a history of occupational exposure to blood, other infectious body 

fluids, or laboratory solutions containing HIV, and no other risk for HIV infection was 

identified, but HIV seroconversion after a specific exposure was not documented (99). 

Epidemiologic and laboratory studies suggest that several factors might affect the risk of 

HIV transmission after an occupational exposure. In a retrospective case-control study of 

HCP who had percutaneous exposure to HIV, the risk for HIV infection was found to be 

increased with exposure to a larger quantity of blood from the source person as indicated 

by a) a device visibly contaminated with the patient's blood, b) a procedure that involved 

a needle being placed directly in a vein or artery, or c) a deep injury (100). The risk also 

was increased for exposure to blood from source persons with terminal illness, possibly 

reflecting either the higher titer of HIV in blood late in the course of AIDS or other 

factors (e.g., the presence of syncytia-inducing strains of HIV). A laboratory study that 

demonstrated that more blood is transferred by deeper injuries and hollow-bore needles 

lends further support for the observed variation in risk related to blood quantity (101). 

The use of source person viral load as a surrogate measure of viral titer for assessing 

transmission risk has not yet been established. Plasma viral load (e.g., HIV RNA) reflects 

only the level of cell-free virus in the peripheral blood; latently infected cells might 

transmit infection in the absence of viremia. Although a lower viral load (e.g., <1,500 

RNA copies/mL) or one that is below the limits of detection probably indicates a lower 

titer exposure, it does not rule out the possibility of transmission. 

Some evidence exists regarding host defenses possibly influencing the risk for HIV 

infection. A study of HIV-exposed but uninfected HCP demonstrated an HIV-specific 

cytotoxic T-lymphocyte (CTL) response when peripheral blood mononuclear cells were 

204 
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stimulated in vitro with HIV-specific antigens (102). Similar CTL responses have been 

observed in other groups who experienced repeated HIV exposure without resulting 

infection (103--108). Among several possible explanations for this observation is that the 

host immune response sometimes might prevent establishment of HIV infection after a 

percutaneous exposure; another is that the CTL response simply might be a marker for 

exposure. In a study of 20 HCP with occupational exposure to HIV, a comparison was 

made of HCP treated with zidovudine (ZDV) PEP and those not treated. The findings 

from this study suggest that ZDV blunted the HIV-specific CTL response and that PEP 

might inhibit early HIV replication (109). 

Rationale for HIV PEP 

Considerations that influence the rationale and recommendations for PEP include 

• the pathogenesis of HIV infection, particularly the time course of early infection; 

• the biological plausibility that infection can be prevented or ameliorated by using 

antiretroviral drugs; 

• direct or indirect evidence of the efficacy of specific agents used for prophylaxis; 

and 

• the risk and benefit of PEP to exposed HCP. 

The following discussion considers each of these concerns. 

Role of Pathogenesis in Considering Antiretroviral Prophylaxis. Information about 

primary HIV infection indicates that systemic infection does not occur immediately, 

leaving a brief window of opportunity during which postexposure antiretroviral 

intervention might modify or prevent viral replication. In a primate model of simian 

immunodeficiency virus (SIV) infection, infection of dendritic-like cells occurred at the 

site of inoculation during the first 24 hours following mucosal exposure to cell-free virus. 

Over the subsequent 24--48 hours, migration of these cells to regional lymph nodes 

occurred, and virus was detectable in the peripheral blood within 5 days (110). 

Theoretically, initiation of antiretroviral PEP soon after exposure might prevent or inhibit 

systemic infection by limiting the proliferation of virus in the initial target cells or lymph 

nodes. 

Efficacy of Antiretrovirals for PEP in Animal Studies. Data from animal studies have 

been difficult to interpret, in part, because of problems identifying an animal model that 

is comparable to humans. In early studies, differences in controlled variables (e.g., choice 

of viral strain [based on the animal model used], inoculum size, route of inoculation, time 

of prophylaxis initiation, and drug regimen) made extrapolation of the results to humans 

difficult. Recently, refinements in methodology have facilitated more relevant studies; in 

particular, the viral inocula used in animal studies have been reduced to levels more 

analogous to human exposures but sufficient to cause infection in control animals (111--

113). These studies provide encouraging evidence of postexposure chemoprophylactic 

efficacy. 

205 
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Studies among primates and in murine and feline animal models have demonstrated that 

larger viral inocula decrease prophylactic efficacy (114--117). In addition, delaying 

initiation, shortening the duration, or decreasing the antiretroviral dose of PEP, 

individually or in combination, decreased prophylactic efficacy (113,118--124). For 

example, when (R)-9-(2-phosphonylmethoxypropyl) adenine (tenofovir) was 

administered 48 hours before, 4 hours after, or 24 hours after intravenous SIV inoculation 

to long-tailed macaques, a 4-week regimen prevented infection in all treated animals 

(122). A subsequent study confirmed the efficacy of tenofovir PEP when administered 24 

hours after intravenous inoculation of a dose of SIV that uniformly results in infection in 

untreated macaques. In the same study, protection was incomplete if the tenofovir 

administration was delayed to 48 or 72 hours postexposure or if the total duration of 

treatment was curtailed to 3 or 10 days (123). 

Efficacy of Antiretrovirals for PEP in Human Studies. Little information exists from

which the efficacy of PEP in humans can be assessed. Seroconversion is infrequent 

following an occupational exposure to HIV-infected blood; therefore, several thousands 

of exposed HCP would need to enroll in a prospective trial to achieve the statistical 

power necessary to directly demonstrate PEP efficacy (125). 

In the retrospective case-control study of HCP, after controlling for other risk factors for 

HIV transmission, use of ZDV as PEP was associated with a reduction in the risk of HIV 

infection by approximately 81% (95% CI = 43%--94%) (100). Although the results of 

this study suggest PEP efficacy, its limitations include the small number of cases studied 

and the use of cases and controls from different cohorts. 

In a multicenter trial in which ZDV was administered to HIV-infected pregnant women 

and their infants, the administration of ZDV during pregnancy, labor, and delivery and to 

the infant reduced transmission by 67% (126). Only part of the protective effect of ZDV 

was explained by reduction of the HIV viral load in the maternal blood, suggesting that 

ZDV prophylaxis, in part, involves a mechanism other than the reduction of maternal 

viral burden (127,128). Since 1998, studies have highlighted the importance of PEP for 

prevention of perinatal HIV transmission. In Africa, the use of ZDV in combination with 

lamivudine (3TC) decreased perinatal HIV transmission by 50% when administered 

during pregnancy, labor, and for 1 week postpartum, and by 37% when started at the 

onset of labor and continued for 1 week postpartum (129). Studies in the United States 

and Uganda also have demonstrated that rates of perinatal HIV transmission have been 

reduced with the use of abbreviated PEP regimens started intrapartum or during the first 

48--72 hours of life (130--132). 

The limitations of all of these studies with animals and humans must be considered when 

reviewing evidence of PEP efficacy. The extent to which data from animal studies can be 

extrapolated to humans is largely unknown, and the exposure route for mother-to-infant 

HIV transmission is not similar to occupational exposures; therefore, these findings might 

not be directly applicable to PEP in HCP. 

206 
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Reports of Failure of PEP. Failure of PEP to prevent HIV infection in HCP has been 

reported in at least 21 instances (78,133--139). In 16 of the cases, ZDV was used alone as 

a single agent; in two cases, ZDV and didanosine (ddI) were used in combination 

(133,138); and in three cases, >3 drugs were used for PEP (137--139). Thirteen of the 

source persons were known to have been treated with antiretroviral therapy before the 

exposure. Antiretroviral resistance testing of the virus from the source person was 

performed in seven instances, and in four, the HIV infection transmitted was found to 

have decreased sensitivity to ZDV and/or other drugs used for PEP. In addition to 

possible exposure to an antiretroviral-resistant strain of HIV, other factors that might 

have contributed to these apparent failures might include a high titer and/or large 

inoculum exposure, delayed initiation and/or short duration of PEP, and possible factors 

related to the host (e.g., cellular immune system responsiveness) and/or to the source 

person's virus (e.g., presence of syncytia-forming strains) (133). Details regarding the 

cases of PEP failure involving combinations of antiretroviral agents are included in this 

report (Table 1). 

Antiretroviral Agents for PEP 

Antiretroviral agents from three classes of drugs are available for the treatment of HIV 

infection. These agents include the nucleoside reverse transcriptase inhibitors (NRTIs), 

nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs). 

Only antiretroviral agents that have been approved by FDA for treatment of HIV 

infection are discussed in these guidelines. 

Determining which agents and how many to use or when to alter a PEP regimen is largely 

empiric. Guidelines for the treatment of HIV infection, a condition usually involving a 

high total body burden of HIV, include recommendations for the use of three drugs (140); 

however, the applicability of these recommendations to PEP remains unknown. In HIVinfected patients, combination regimens have proved superior to monotherapy regimens 

in reducing HIV viral load, reducing the incidence of opportunistic infections and death, 

and delaying onset of drug resistance (141,142). A combination of drugs with activity at 

different stages in the viral replication cycle (e.g., nucleoside analogues with a PI) 

theoretically could offer an additional preventive effect in PEP, particularly for 

occupational exposures that pose an increased risk of transmission. Although the use of a 

three-drug regimen might be justified for exposures that pose an increased risk of 

transmission, whether the potential added toxicity of a third drug is justified for lowerrisk exposures is uncertain. Therefore, the recommendations at the end of this document 

provide guidance for two- and three-drug PEP regimens that are based on the level of risk 

for HIV transmission represented by the exposure. 

NRTI combinations that can be considered for PEP include ZDV and 3TC, 3TC and 

stavudine (d4T), and ddI and d4T. In previous PHS guidelines, a combination of ZDV 

and 3TC was considered the first choice for PEP regimens (3). Because ZDV and 3TC 

are available in a combination formulation (CombivirTM, manufactured by Glaxo 

Wellcome, Inc., Research Triangle Park, NC), the use of this combination might be more 

convenient for HCP. However, recent data suggest that mutations associated with ZDV 

207 
 APPENDIX B-4 

and 3TC resistance might be common in some areas (143). Thus, individual clinicians 

might prefer other NRTIs or combinations based on local knowledge and experience in 

treating HIV infection and disease. 

The addition of a third drug for PEP following high-risk exposures is based on 

demonstrated effectiveness in reducing viral burden in HIV-infected persons. Previously, 

indinavir (IDV) or nelfinavir (NFV) were recommended as first-choice agents for 

inclusion in an expanded PEP regimen (5). Since the publication of the 1998 PEP 

guidelines, efavirenz (EFV), an NNRTI; abacavir (ABC), a potent NRTI; and KaletraTM, 

a PI, have been approved by FDA. Although side effects might be common with the 

NNRTIs, EFV might be considered for expanded PEP regimens, especially when 

resistance to PIs in the source person's virus is known or suspected. ABC has been 

associated with dangerous hypersensitivity reactions but, with careful monitoring, may be 

considered as a third drug for PEP. Kaletra, a combination of lopinavir and ritonavir, is a 

potent HIV inhibitor that, with expert consultation, may be considered in an expanded 

PEP regimen. 

Toxicity and Drug Interactions of Antiretroviral Agents. When administering PEP, an 

important goal is completion of a 4-week PEP regimen when PEP is indicated. Therefore, 

the toxicity profile of antiretroviral agents, including the frequency, severity, duration, 

and reversibility of side effects, is a relevant consideration. All of the antiretroviral agents 

have been associated with side effects (Table 2). However, studies of adverse events have 

been conducted primarily with persons who have advanced disease (and longer treatment 

courses) and who therefore might not reflect the experience in persons who are 

uninfected (144). 

Several primary side effects are associated with antiretroviral agents (Table 2). Side 

effects associated with many of the NRTIs are chiefly gastrointestinal (e.g., nausea or 

diarrhea); however, ddI has been associated with cases of fatal and nonfatal pancreatitis 

among HIV-infected patients treated for >4 weeks. The use of PIs has been associated 

with new onset diabetes mellitus, hyperglycemia, diabetic ketoacidosis, exacerbation of 

preexisting diabetes mellitus, and dyslipidemia (145--147). Nephrolithiasis has been 

associated with IDV use; however, the incidence of this potential complication might be 

limited by drinking at least 48 ounces (1.5 L) of fluid per 24-hour period (e.g., six 8- 

ounce glasses of water throughout the day) (148). NFV has been associated with the 

development of diarrhea; however, this side effect might respond to treatment with 

antimotility agents that can be prescribed for use, if necessary, at the time the drug is 

recommended for PEP. The NNRTIs have been associated with severe skin reactions, 

including life-threatening cases of Stevens-Johnson syndrome and toxic epidermal 

necrolysis. Hepatotoxicity, including fatal hepatic necrosis, has occurred in patients 

treated with nevirapine (NVP); some episodes began during the first few weeks of 

therapy (FDA, unpublished data, 2000). EFV has been associated with central nervous 

system side effects, including dizziness, somnolence, insomnia, and abnormal dreaming. 

All of the approved antiretroviral agents might have potentially serious drug interactions 

when used with certain other drugs (Appendix C). Careful evaluation of concomitant 

208 
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medications used by an exposed person is required before PEP is prescribed, and close 

monitoring for toxicity is also needed. Further information about potential drug 

interactions can be found in the manufacturer's package insert. 

Toxicity Associated with PEP. Information from the National Surveillance System for 

Health Care Workers (NaSH) and the HIV Postexposure Registry indicates that nearly 

50% of HCP experience adverse symptoms (e.g., nausea, malaise, headache, anorexia, 

and headache) while taking PEP and that approximately 33% stop taking PEP because of 

adverse signs and symptoms (6,7,10,11). Some studies have demonstrated that side 

effects and discontinuation of PEP are more common among HCP taking three-drug 

combination regimens for PEP compared with HCP taking two-drug combination 

regimens (7,10). Although similar rates of side effects were observed among persons who 

took PEP after sexual or drug use exposures to HIV in the San Francisco Post-Exposure 

Prevention Project, 80% completed 4 weeks of therapy (149). Participants in the San 

Francisco Project were followed at 1, 2, 4, 26, and 52 weeks postexposure and received 

medication adherence counseling; most participants took only two drugs for PEP. 

Serious side effects, including nephrolithiasis, hepatitis, and pancytopenia have been 

reported with the use of combination drugs for PEP (6,7,150,151). One case of NVPassociated fulminant liver failure requiring liver transplantation and one case of 

hypersensitivity syndrome have been reported in HCP taking NVP for HIV PEP (152). 

Including these two cases, from March 1997 through September 2000, FDA received 

reports of 22 cases of serious adverse events related to NVP taken for PEP (153). These 

events included 12 cases of hepatotoxicity, 14 cases of skin reaction (including one 

documented and two possible cases of Stevens-Johnson syndrome), and one case of 

rhabdomyolysis; four cases involved both hepatotoxicty and skin reaction, and one case 

involved both rhabdomyolysis and skin reaction. 

Resistance to Antiretroviral Agents. Known or suspected resistance of the source virus 

to antiretroviral agents, particularly to agents that might be included in a PEP regimen, is 

a concern for persons making decisions about PEP. Resistance to HIV infection occurs 

with all of the available antiretroviral agents, and cross-resistance within drug classes is 

frequent (154). Recent studies have demonstrated an emergence of drug-resistant HIV 

among source persons for occupational exposures (143,155). A study conducted at seven 

U.S. sites during 1998--1999 found that 16 (39%) of 41 source persons whose virus was 

sequenced had primary genetic mutations associated with resistance to RTIs, and 4 (10%) 

had primary mutations associated with resistance to PIs (143). In addition, occupational 

transmission of resistant HIV strains, despite PEP with combination drug regimens, has 

been reported (137,139). In one case, a hospital worker became infected after an HIV 

exposure despite a PEP regimen that included ddI, d4T, and NVP (139). The transmitted 

HIV contained two primary genetic mutations associated with resistance to NNRTIs (the 

source person was taking EFV at the time of the exposure). Despite recent studies and 

case reports, the relevance of exposure to a resistant virus is still not well understood. 

Empiric decisions about the presence of antiretroviral drug resistance are often difficult to 

make because patients generally take more than one antiretroviral agent. Resistance 

209 
 APPENDIX B-4 

should be suspected in source persons when they are experiencing clinical progression of 

disease or a persistently increasing viral load, and/or decline in CD4 T-cell count, despite 

therapy or a lack of virologic response to therapy. However, resistance testing of the 

source virus at the time of an exposure is not practical because the results will not be 

available in time to influence the choice of the initial PEP regimen. Furthermore, in this 

situation, whether modification of the PEP regimen is necessary or will influence the 

outcome of an occupational exposure is unknown. No data exist to suggest that 

modification of a PEP regimen after receiving results from resistance testing (usually a 

minimum of 1--2 weeks) improves efficacy of PEP. 

Antiretroviral Drugs During Pregnancy. Data are limited on the potential effects of

antiretroviral drugs on the developing fetus or neonate (156). Carcinogenicity and/or 

mutagenicity is evident in several in vitro screening tests for ZDV and all other FDAlicensed NRTIs. The relevance of animal data to humans is unknown; however, because 

teratogenic effects were observed in primates at drug exposures similar to those 

representing human therapeutic exposure, the use of EFV should be avoided in pregnant 

women (140). IDV is associated with infrequent side effects in adults (i.e., 

hyperbilirubinemia and renal stones) that could be problematic for a newborn. Because 

the half-life of IDV in adults is short, these concerns might be relevant only if the drug is 

administered shortly before delivery. 

In a recent study in France of perinatal HIV transmission, two cases of progressive 

neurologic disease and death were reported in uninfected infants exposed to ZDV and 

3TC (157). Laboratory studies of these children suggested mitochondrial dysfunction. In 

a careful review of deaths in children followed in U.S. perinatal HIV cohorts, no deaths 

attributable to mitochondrial disease have been found (158). 

Recent reports of fatal and nonfatal lactic acidosis in pregnant women treated throughout 

gestation with a combination of d4T and ddI have prompted warnings about use of these 

drugs during pregnancy (159). Although the case-patients were HIV-infected women 

taking the drugs for >4 weeks, pregnant women and their providers should be advised to 

consider d4T and ddI only when the benefits of their use outweigh the risks. 

PEP Use in Hospitals in the United States. Analysis of data from NaSH provides 

information on the use of PEP following occupational exposures in 47 hospitals in the 

United States. A total of 11,784 exposures to blood and body fluids was reported from

June 1996 through November 2000 (CDC, unpublished data, 2001). For all exposures 

with known sources, 6% were to HIV-positive sources, 74% to HIV-negative sources, 

and 20% to sources with an unknown HIV status. Sixty-three percent of HCP exposed to 

a known HIV-positive source started PEP, and 54% of HCP took it for at least 20 days, 

whereas 14% of HCP exposed to a source person subsequently found to be HIV-negative 

initiated PEP, and 3% of those took it for at least 20 days. Information recorded about 

HIV exposures in NaSH indicates that 46% of exposures involving an HIV-positive 

source warranted only a two-drug PEP regimen (i.e., the exposure was to mucous 

membranes or skin or was a superficial percutaneous injury and the source person did not 

have end-stage AIDS or acute HIV illness); however, 53% of these exposed HCP took >3 

210 
 APPENDIX B-4 

drugs (CDC, unpublished data, 2000). Similarly, the National Clinicians' Post-Exposure 

Prophylaxis Hotline (PEPline) reported that PEPline staff recommended stopping or not 

starting PEP for approximately one half of the HCP who consulted them about exposures 

(D. Bangsberg, San Francisco General Hospital, unpublished data, September 1999). The 

observation that some HCP exposed to HIV-negative source persons take PEP from

several days to weeks following their exposures suggests that strategies be employed 

such as the use of a rapid HIV antibody assay, which could minimize exposure to 

unnecessary PEP (11). A recent study demonstrated that use of a rapid HIV test for 

evaluation of source persons after occupational exposures not only resulted in decreased 

use of PEP, but also was cost-effective compared with use of the standard enzyme

immunoassay (EIA) test for source persons subsequently found to be HIV-negative (160). 

RECOMMENDATIONS FOR THE MANAGEMENT OF HCP POTENTIALLY 

EXPOSED TO HBV, HCV, or HIV 

Exposure prevention remains the primary strategy for reducing occupational bloodborne 

pathogen infections; however, occupational exposures will continue to occur. Health-care 

organizations should make available to their personnel a system that includes written 

protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of 

occupational exposures that might place HCP at risk for acquiring a bloodborne infection. 

HCP should be educated concerning the risk for and prevention of bloodborne infections, 

including the need to be vaccinated against hepatitis B (17,21,161--163). Employers are 

required to establish exposure-control plans that include postexposure follow-up for their 

employees and to comply with incident reporting requirements mandated by the 1992 

OSHA bloodborne pathogen standard (2). Access to clinicians who can provide 

postexposure care should be available during all working hours, including nights and 

weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV PEP should be 

available for timely administration (i.e., either by providing access on-site or by creating 

linkages with other facilities or providers to make them available off-site). Persons 

responsible for providing postexposure management should be familiar with evaluation 

and treatment protocols and the facility's plans for accessing HBIG, hepatitis B vaccine, 

and antiretroviral drugs for HIV PEP. 

HCP should be educated to report occupational exposures immediately after they occur, 

particularly because HBIG, hepatitis B vaccine, and HIV PEP are most likely to be 

effective if administered as soon after the exposure as possible. HCP who are at risk for 

occupational exposure to bloodborne pathogens should be familiarized with the principles 

of postexposure management as part of job orientation and ongoing job training. 

Hepatitis B Vaccination 

Any person who performs tasks involving contact with blood, blood-contaminated body 

fluids, other body fluids, or sharps should be vaccinated against hepatitis B (2,21). 

Prevaccination serologic screening for previous infection is not indicated for persons 

being vaccinated because of occupational risk, unless the hospital or health-care 

organization considers screening cost-effective. 

211 
 APPENDIX B-4 

Hepatitis B vaccine should always be administered by the intramuscular route in the 

deltoid muscle with a needle 1--1.5 inches long. Hepatitis B vaccine can be administered 

at the same time as other vaccines with no interference with antibody response to the 

other vaccines (164). If the vaccination series is interrupted after the first dose, the second 

dose should be administered as soon as possible. The second and third doses should be 

separated by an interval of at least 2 months. If only the third dose is delayed, it should be 

administered when convenient. HCP who have contact with patients or blood and are at 

ongoing risk for percutaneous injuries should be tested 1--2 months after completion of 

the 3dose vaccination series for anti-HBs (21). Persons who do not respond to the 

primary vaccine series (i.e., anti-HBs <10 mIU/mL) should complete a second 3-dose 

vaccine series or be evaluated to determine if they are HBsAg-positive. Revaccinated 

persons should be retested at the completion of the second vaccine series. Persons who do 

not respond to an initial 3-dose vaccine series have a 30%--50% chance of responding to 

a second 3-dose series (165). Persons who prove to be HBsAg-positive should be 

counseled regarding how to prevent HBV transmission to others and regarding the need 

for medical evaluation (12,163,166). Nonresponders to vaccination who are HBsAgnegative should be considered susceptible to HBV infection and should be counseled 

regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis 

for any known or probable parenteral exposure to HBsAg-positive blood. Booster doses 

of hepatitis B vaccine are not necessary, and periodic serologic testing to monitor 

antibody concentrations after completion of the vaccine series is not recommended. Any 

blood or body fluid exposure sustained by an unvaccinated, susceptible person should 

lead to the initiation of the hepatitis B vaccine series. 

Treatment of an Exposure Site 

Wounds and skin sites that have been in contact with blood or body fluids should be 

washed with soap and water; mucous membranes should be flushed with water. No 

evidence exists that using antiseptics for wound care or expressing fluid by squeezing the 

wound further reduces the risk of bloodborne pathogen transmission; however, the use of 

antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the 

injection of antiseptics or disinfectants into the wound is not recommended. 

Exposure Report 

If an occupational exposure occurs, the circumstances and postexposure management 

should be recorded in the exposed person's confidential medical record (usually on a form

the facility designates for this purpose) (Box 1). In addition, employers should follow all 

federal (including OSHA) and state requirements for recording and reporting 

occupational injuries and exposures. 

212 
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Evaluation of the Exposure and the Exposure Source 

Evaluation of the Exposure 

The exposure should be evaluated for the potential to transmit HBV, HCV, and HIV 

based on the type of body substance involved and the route and severity of the exposure 

(Box 2). Blood, fluid containing visible blood, or other potentially infectious fluid 

(including semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, 

pericardial, and amniotic fluids) or tissue can be infectious for bloodborne viruses. 

Exposures to these fluids or tissue through a percutaneous injury (i.e., needlestick or 

other penetrating sharps-related event) or through contact with a mucous membrane are 

situations that pose a risk for bloodborne virus transmission and require further 

evaluation. For HCV and HIV, exposure to a blood-filled hollow needle or visibly bloody 

device suggests a higher risk exposure than exposure to a needle that was most likely 

used for giving an injection. In addition, any direct contact (i.e, personal protective 

equipment either was not present or was ineffective in protecting skin or mucous 

membranes) with concentrated virus in a research laboratory or production facility is 

considered an exposure that requires clinical evaluation. 

For skin exposure, follow-up is indicated only if it involves exposure to a body fluid 

previously listed and evidence exists of compromised skin integrity (e.g., dermatitis, 

abrasion, or open wound). In the clinical evaluation for human bites, possible exposure of 

both the person bitten and the person who inflicted the bite must be considered. If a bite 

results in blood exposure to either person involved, postexposure follow-up should be 

provided. 

Evaluation of the Exposure Source 

The person whose blood or body fluid is the source of an occupational exposure should 

be evaluated for HBV, HCV, and HIV infection (Box 3). Information available in the 

medical record at the time of exposure (e.g., laboratory test results, admitting diagnosis, 

or previous medical history) or from the source person, might confirm or exclude 

bloodborne virus infection. 

If the HBV, HCV, and/or HIV infection status of the source is unknown, the source 

person should be informed of the incident and tested for serologic evidence of 

bloodborne virus infection. Procedures should be followed for testing source persons, 

including obtaining informed consent, in accordance with applicable state and local laws. 

Any persons determined to be infected with HBV, HCV, or HIV should be referred for 

appropriate counseling and treatment. Confidentiality of the source person should be 

maintained at all times. 

Testing to determine the HBV, HCV, and HIV infection status of an exposure source 

should be performed as soon as possible. Hospitals, clinics and other sites that manage 

exposed HCP should consult their laboratories regarding the most appropriate test to use 

to expedite obtaining these results. An FDA-approved rapid HIV-antibody test kit should 

213 
 APPENDIX B-4 

be considered for use in this situation, particularly if testing by EIA cannot be completed 

within 24--48 hours. Repeatedly reactive results by EIA or rapid HIV-antibody tests are 

considered to be highly suggestive of infection, whereas a negative result is an excellent 

indicator of the absence of HIV antibody. Confirmation of a reactive result by Western 

blot or immunofluorescent antibody is not necessary to make initial decisions about 

postexposure management but should be done to complete the testing process and before 

informing the source person. Repeatedly reactive results by EIA for anti-HCV should be 

confirmed by a supplemental test (i.e., recombinant immunoblot assay [RIBATM] or HCV 

PCR). Direct virus assays (e.g., HIV p24 antigen EIA or tests for HIV RNA or HCV 

RNA) for routine HIV or HCV screening of source persons are not recommended. 

If the exposure source is unknown or cannot be tested, information about where and 

under what circumstances the exposure occurred should be assessed epidemiologically 

for the likelihood of transmission of HBV, HCV, or HIV. Certain situations as well as the 

type of exposure might suggest an increased or decreased risk; an important consideration 

is the prevalence of HBV, HCV, or HIV in the population group (i.e., institution or 

community) from which the contaminated source material is derived. For example, an 

exposure that occurs in a geographic area where injection-drug use is prevalent or 

involves a needle discarded in a drug-treatment facility would be considered 

epidemiologically to have a higher risk for transmission than an exposure that occurs in a 

nursing home for the elderly. 

Testing of needles or other sharp instruments implicated in an exposure, regardless of 

whether the source is known or unknown, is not recommended. The reliability and 

interpretation of findings in such circumstances are unknown, and testing might be 

hazardous to persons handling the sharp instrument. 

Examples of information to consider when evaluating an exposure source for possible 

HBV, HCV, or HIV infection include laboratory information (e.g., previous HBV, HCV, 

or HIV test results or results of immunologic testing [e.g., CD4+ T-cell count]) or liver 

enzymes (e.g., ALT), clinical symptoms (e.g., acute syndrome suggestive of primary HIV 

infection or undiagnosed immunodeficiency disease), and history of recent (i.e., within 3 

months) possible HBV, HCV, or HIV exposures (e.g., injection-drug use or sexual 

contact with a known positive partner). Health-care providers should be aware of local 

and state laws governing the collection and release of HIV serostatus information on a 

source person, following an occupational exposure. 

If the source person is known to have HIV infection, available information about this 

person's stage of infection (i.e., asymptomatic, symptomatic, or AIDS), CD4+ T-cell 

count, results of viral load testing, current and previous antiretroviral therapy, and results 

of any genotypic or phenotypic viral resistance testing should be gathered for 

consideration in choosing an appropriate PEP regimen. If this information is not 

immediately available, initiation of PEP, if indicated, should not be delayed; changes in 

the PEP regimen can be made after PEP has been started, as appropriate. Reevaluation of 

exposed HCP should be considered within 72 hours postexposure, especially as 

additional information about the exposure or source person becomes available. 

214 
 APPENDIX B-4 

If the source person is HIV seronegative and has no clinical evidence of AIDS or 

symptoms of HIV infection, no further testing of the person for HIV infection is 

indicated. The likelihood of the source person being in the "window period" of HIV 

infection in the absence of symptoms of acute retroviral syndrome is extremely small. 

Management of Exposures to HBV 

For percutaneous or mucosal exposures to blood, several factors must be considered 

when making a decision to provide prophylaxis, including the HBsAg status of the source 

and the hepatitis B vaccination and vaccine-response status of the exposed person. Such 

exposures usually involve persons for whom hepatitis B vaccination is recommended. 

Any blood or body fluid exposure to an unvaccinated person should lead to initiation of 

the hepatitis B vaccine series. 

The hepatitis B vaccination status and the vaccine-response status (if known) of the 

exposed person should be reviewed. A summary of prophylaxis recommendations for 

percutaneous or mucosal exposure to blood according to the HBsAg status of the 

exposure source and the vaccination and vaccine-response status of the exposed person is 

included in this report (Table 3). 

When HBIG is indicated, it should be administered as soon as possible after exposure 

(preferably within 24 hours). The effectiveness of HBIG when administered >7 days after 

exposure is unknown. When hepatitis B vaccine is indicated, it should also be 

administered as soon as possible (preferably within 24 hours) and can be administered 

simultaneously with HBIG at a separate site (vaccine should always be administered in 

the deltoid muscle). 

For exposed persons who are in the process of being vaccinated but have not completed 

the vaccination series, vaccination should be completed as scheduled, and HBIG should 

be added as indicated (Table 3). Persons exposed to HBsAg-positive blood or body fluids 

who are known not to have responded to a primary vaccine series should receive a single 

dose of HBIG and reinitiate the hepatitis B vaccine series with the first dose of the 

hepatitis B vaccine as soon as possible after exposure. Alternatively, they should receive 

two doses of HBIG, one dose as soon as possible after exposure, and the second dose 1 

month later. The option of administering one dose of HBIG and reinitiating the vaccine 

series is preferred for nonresponders who did not complete a second 3-dose vaccine 

series. For persons who previously completed a second vaccine series but failed to 

respond, two doses of HBIG are preferred. 

Management of Exposures to HCV 

Individual institutions should establish policies and procedures for testing HCP for HCV 

after percutaneous or mucosal exposures to blood and ensure that all personnel are 

familiar with these policies and procedures. The following are recommendations for 

follow-up of occupational HCV exposures: 

215 
 APPENDIX B-4 

• For the source, perform testing for anti-HCV. 

• For the person exposed to an HCV-positive source 

--- perform baseline testing for anti-HCV and ALT activity; and 

--- perform follow-up testing (e.g., at 4--6 months) for anti-HCV and ALT 

activity (if earlier diagnosis of HCV infection is desired, testing for HCV 

RNA may be performed at 4--6 weeks). 

• Confirm all anti-HCV results reported positive by enzyme immunoassay using 

supplemental anti-HCV testing (e.g., recombinant immunoblot assay [RIBATM]) 

(13). 

Health-care professionals who provide care to persons exposed to HCV in the 

occupational setting should be knowledgeable regarding the risk for HCV infection and 

appropriate counseling, testing, and medical follow-up. 

IG and antiviral agents are not recommended for PEP after exposure to HCV-positive 

blood. In addition, no guidelines exist for administration of therapy during the acute 

phase of HCV infection. However, limited data indicate that antiviral therapy might be 

beneficial when started early in the course of HCV infection. When HCV infection is 

identified early, the person should be referred for medical management to a specialist 

knowledgeable in this area. 

Counseling for HCP Exposed to Viral Hepatitis 

HCP exposed to HBV- or HCV-infected blood do not need to take any special 

precautions to prevent secondary transmission during the follow-up period (12,13); 

however, they should refrain from donating blood, plasma, organs, tissue, or semen. The 

exposed person does not need to modify sexual practices or refrain from becoming 

pregnant. If an exposed woman is breast feeding, she does not need to discontinue. 

No modifications to an exposed person's patient-care responsibilities are necessary to 

prevent transmission to patients based solely on exposure to HBV- or HCV-positive 

blood. If an exposed person becomes acutely infected with HBV, the person should be 

evaluated according to published recommendations for infected HCP (165). No 

recommendations exist regarding restricting the professional activities of HCP with HCV 

infection (13). As recommended for all HCP, those who are chronically infected with 

HBV or HCV should follow all recommended infection-control practices, including 

standard precautions and appropriate use of hand washing, protective barriers, and care in 

the use and disposal of needles and other sharp instruments (162). 

216 
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Management of Exposures to HIV 

Clinical Evaluation and Baseline Testing of Exposed HCP 

HCP exposed to HIV should be evaluated within hours (rather than days) after their 

exposure and should be tested for HIV at baseline (i.e., to establish infection status at the 

time of exposure). If the source person is seronegative for HIV, baseline testing or further 

follow-up of the exposed person normally is not necessary. Serologic testing should be 

made available to all HCP who are concerned that they might have been occupationally 

infected with HIV. For purposes of considering HIV PEP, the evaluation also should 

include information about medications the exposed person might be taking and any 

current or underlying medical conditions or circumstances (i.e., pregnancy, breast 

feeding, or renal or hepatic disease) that might influence drug selection. 

PEP for HIV 

The following recommendations (Table 4 and Table 5) apply to situations when a person 

has been exposed to a source person with HIV infection or when information suggests the 

likelihood that the source person is HIV-infected. These recommendations are based on 

the risk for HIV infection after different types of exposure and on limited data regarding 

efficacy and toxicity of PEP. Because most occupational HIV exposures do not result in 

the transmission of HIV, potential toxicity must be carefully considered when prescribing 

PEP. To assist with the initial management of an HIV exposure, health-care facilities 

should have drugs for an initial PEP regimen selected and available for use. When 

possible, these recommendations should be implemented in consultation with persons 

who have expertise in antiretroviral therapy and HIV transmission (Box 4). 

Timing and Duration of PEP. PEP should be initiated as soon as possible. The interval 

within which PEP should be initiated for optimal efficacy is not known. Animal studies 

have demonstrated the importance of starting PEP soon after an exposure (111,112,118). 

If questions exist about which antiretroviral drugs to use or whether to use a basic or 

expanded regimen, starting the basic regimen immediately rather than delaying PEP 

administration is probably better. Although animal studies suggest that PEP probably is 

substantially less effective when started more than 24--36 hours postexposure 

(112,119,122), the interval after which no benefit is gained from PEP for humans is 

undefined. Therefore, if appropriate for the exposure, PEP should be started even when 

the interval since exposure exceeds 36 hours. Initiating therapy after a longer interval 

(e.g., 1 week) might be considered for exposures that represent an increased risk for 

transmission. The optimal duration of PEP is unknown. Because 4 weeks of ZDV 

appeared protective in occupational and animal studies (100,123), PEP probably should 

be administered for 4 weeks, if tolerated. 

Use of PEP When HIV Infection Status of Source Person is Unknown. If the source 

person's HIV infection status is unknown at the time of exposure, use of PEP should be 

decided on a case-by-case basis, after considering the type of exposure and the clinical 

and/or epidemiologic likelihood of HIV infection in the source (Table 4 and Table 5). If 

217 
 APPENDIX B-4 

these considerations suggest a possibility for HIV transmission and HIV testing of the 

source person is pending, initiating a two-drug PEP regimen until laboratory results have 

been obtained and later modifying or discontinuing the regimen accordingly is 

reasonable. The following are recommendations regarding HIV postexposure 

prophylaxis: 

• If indicated, start PEP as soon as possible after an exposure. 

• Reevaluation of the exposed person should be considered within 72 hours 

postexposure, especially as additional information about the exposure or source 

person becomes available. 

• Administer PEP for 4 weeks, if tolerated. 

• If a source person is determined to be HIV-negative, PEP should be discontinued. 

PEP for Pregnant HCP. If the exposed person is pregnant, the evaluation of risk of 

infection and need for PEP should be approached as with any other person who has had 

an HIV exposure. However, the decision to use any antiretroviral drug during pregnancy 

should involve discussion between the woman and her health-care provider(s) regarding 

the potential benefits and risks to her and her fetus. 

Certain drugs should be avoided in pregnant women. Because teratogenic effects were 

observed in primate studies, EFV is not recommended during pregnancy. Reports of fatal 

lactic acidosis in pregnant women treated with a combination of d4T and ddI have 

prompted warnings about these drugs during pregnancy. Because of the risk of 

hyperbilirubinemia in newborns, IDV should not be administered to pregnant women 

shortly before delivery. 

Recommendations for the Selection of Drugs for HIV PEP 

Health-care providers must strive to balance the risk for infection against the potential 

toxicity of the agent(s) used when selecting a drug regimen for HIV PEP. Because PEP is 

potentially toxic, its use is not justified for exposures that pose a negligible risk for 

transmission (Table 4 and Table 5). Also, insufficient evidence exists to support 

recommending a three-drug regimen for all HIV exposures. Therefore, two regimens for 

PEP are provided (Appendix C): a "basic" two-drug regimen that should be appropriate 

for most HIV exposures and an "expanded" three-drug regimen that should be used for 

exposures that pose an increased risk for transmission (Table 4 and Table 5). When 

possible, the regimens should be implemented in consultation with persons who have 

expertise in antiretroviral treatment and HIV transmission. 

Most HIV exposures will warrant a two-drug regimen using two nucleoside analogues 

(e.g., ZDV and 3TC; or 3TC and d4T; or d4T and ddI). The addition of a third drug 

should be considered for exposures that pose an increased risk for transmission. Selection 

of the PEP regimen should consider the comparative risk represented by the exposure and 

information about the exposure source, including history of and response to antiretroviral 

therapy based on clinical response, CD4+ T-cell counts, viral load measurements, and 

current disease stage. When the source person's virus is known or suspected to be 

218 
 APPENDIX B-4 

resistant to one or more of the drugs considered for the PEP regimen, the selection of 

drugs to which the source person's virus is unlikely to be resistant is recommended; 

expert consultation is advised. If this information is not immediately available, initiation 

of PEP, if indicated, should not be delayed; changes in the PEP regimen can be made 

after PEP has been started, as appropriate. Reevaluation of the exposed person should be 

considered within 72 hours postexposure, especially as additional information about the 

exposure or source person becomes available. 

Follow-up of HCP Exposed to HIV 

Postexposure Testing. HCP with occupational exposure to HIV should receive followup counseling, postexposure testing, and medical evaluation, regardless of whether they 

receive PEP. HIV-antibody testing should be performed for at least 6 months 

postexposure (e.g., at 6 weeks, 12 weeks, and 6 months). Extended HIV follow-up (e.g., 

for 12 months) is recommended for HCP who become infected with HCV following 

exposure to a source coinfected with HIV and HCV. Whether extended follow-up is 

indicated in other circumstances (e.g., exposure to a source coinfected with HIV and 

HCV in the absence of HCV seroconversion or for exposed persons with a medical 

history suggesting an impaired ability to develop an antibody response to acute infection) 

is unclear. Although rare instances of delayed HIV seroconversion have been reported 

(167,168), the infrequency of this occurrence does not warrant adding to the anxiety level 

of the exposed persons by routinely extending the duration of postexposure follow-up. 

However, this recommendation should not preclude a decision to extend follow-up in an 

individual situation based on the clinical judgement of the exposed person's health-care 

provider. HIV testing should be performed on any exposed person who has an illness that 

is compatible with an acute retroviral syndrome, regardless of the interval since exposure. 

When HIV infection is identified, the person should be referred to a specialist 

knowledgeable in the area of HIV treatment and counseling for medical management. 

HIV-antibody testing with EIA should be used to monitor for seroconversion. The routine 

use of direct virus assays (e.g., HIV p24 antigen EIA or tests for HIV RNA) to detect 

infection in exposed HCP generally is not recommended (169). The high rate of falsepositive results of these tests in this setting could lead to unnecessary anxiety and/or 

treatment (170,171). Despite the ability of direct virus assays to detect HIV infection a 

few days earlier than EIA, the infrequency of occupational seroconversion and increased 

costs of these tests do not warrant their routine use in this setting. 

• HIV-antibody testing should be performed for at least 6 months postexposure. 

• Direct virus assays for routine follow-up of HCP are not recommended. 

• HIV testing should be performed on any exposed person who has an illness 

compatible with an acute retroviral syndrome. 

Monitoring and Management of PEP Toxicity. If PEP is used, HCP should be 

monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP. 

The scope of testing should be based on medical conditions in the exposed person and the 

toxicity of drugs included in the PEP regimen. Minimally, lab monitoring for toxicity 

219 
 APPENDIX B-4 

should include a complete blood count and renal and hepatic function tests. Monitoring 

for evidence of hyperglycemia should be included for HCP whose regimens include any 

PI; if the exposed person is receiving IDV, monitoring for crystalluria, hematuria, 

hemolytic anemia, and hepatitis also should be included. If toxicity is noted, modification 

of the regimen should be considered after expert consultation; further diagnostic studies 

may be indicated. 

Exposed HCP who choose to take PEP should be advised of the importance of 

completing the prescribed regimen. Information should be provided to HCP about 

potential drug interactions and the drugs that should not be taken with PEP, the side 

effects of the drugs that have been prescribed, measures to minimize these effects, and 

the methods of clinical monitoring for toxicity during the follow-up period. HCP should 

be advised that the evaluation of certain symptoms should not be delayed (e.g., rash, 

fever, back or abdominal pain, pain on urination or blood in the urine, or symptoms of 

hyperglycemia [increased thirst and/or frequent urination]). 

HCP who fail to complete the recommended regimen often do so because of the side 

effects they experience (e.g., nausea and diarrhea). These symptoms often can be 

managed with antimotility and antiemetic agents or other medications that target the 

specific symptoms without changing the regimen. In other situations, modifying the dose 

interval (i.e., administering a lower dose of drug more frequently throughout the day, as 

recommended by the manufacturer), might facilitate adherence to the regimen. Serious 

adverse events should be reported to FDA's MedWatch Program. 

Counseling and Education. Although HIV infection following an occupational exposure 

occurs infrequently, the emotional effect of an exposure often is substantial (172--174). 

In addition, HCP are given seemingly conflicting information. Although HCP are told 

that a low risk exists for HIV transmission, a 4-week regimen of PEP might be 

recommended, and they are asked to commit to behavioral measures (e.g., sexual 

abstinence or condom use) to prevent secondary transmission, all of which influence their 

lives for several weeks to months (172). Therefore, access to persons who are 

knowledgeable about occupational HIV transmission and who can deal with the many 

concerns an HIV exposure might generate for the exposed person is an important element 

of postexposure management. HIV-exposed HCP should be advised to use the following 

measures to prevent secondary transmission during the follow-up period, especially the 

first 6--12 weeks after the exposure when most HIV-infected persons are expected to 

seroconvert: exercise sexual abstinence or use condoms to prevent sexual transmission 

and to avoid pregnancy; and refrain from donating blood, plasma, organs, tissue, or 

semen. If an exposed woman is breast feeding, she should be counseled about the risk of 

HIV transmission through breast milk, and discontinuation of breast feeding should be 

considered, especially for high-risk exposures. Additionally, NRTIs are known to pass 

into breast milk, as is NVP; whether this also is true for the other approved antiretroviral 

drugs is unknown. 

The patient-care responsibilities of an exposed person do not need to be modified, based 

solely on an HIV exposure, to prevent transmission to patients. If HIV seroconversion is 

220 
 APPENDIX B-4 

detected, the person should be evaluated according to published recommendations for 

infected HCP (175). 

Exposed HCP should be advised to seek medical evaluation for any acute illness that 

occurs during the follow-up period. Such an illness, particularly if characterized by fever, 

rash, myalgia, fatigue, malaise, or lymphadenopathy, might be indicative of acute HIV 

infection but also might be indicative of a drug reaction or another medical condition. 

For exposures for which PEP is considered appropriate, HCP should be informed that a) 

knowledge about the efficacy of drugs used for PEP is limited; b) experts recommend 

combination drug regimens because of increased potency and concerns about drugresistant virus; c) data regarding toxicity of antiretroviral drugs in persons without HIV 

infection or in pregnant women are limited; d) although the short-term toxicity of 

antiretroviral drugs is usually limited, serious adverse events have occurred in persons 

taking PEP; and e) any or all drugs for PEP may be declined or stopped by the exposed 

person. HCP who experience HIV occupational exposures for which PEP is not 

recommended should be informed that the potential side effects and toxicity of taking 

PEP outweigh the negligible risk of transmission posed by the type of exposure. 

Guidelines for counseling and educating HCP with HIV exposure include 

• Exposed HCP should be advised to use precautions to prevent secondary 

transmission during the follow-up period. 

• For exposures for which PEP is prescribed, HCP should be informed about 

possible drug toxicities and the need for monitoring, and possible drug 

interactions. 

Occupational Exposure Management Resources 

Several resources are available that provide guidance to HCP regarding the management 

of occupational exposures. These resources include PEPline; the Needlestick! website; 

the Hepatitis Hotline; CDC (receives reports of occupationally acquired HIV infections 

and failures of PEP); the HIV Antiretroviral Pregnancy Registry; FDA (receives reports 

of unusual or severe toxicity to antiretroviral agents); and the HIV/AIDS Treatment 

Information Service (Box 5). 

*This interagency working group comprised representatives of CDC, the Food and Drug Administration 

(FDA), the Health Resources and Services Administration, and the National Institutes of Health. 

Information included in these recommendations may not represent FDA approval or approved labeling for 

the particular product or indications in question. Specifically, the terms "safe" and "effective" may not be 

synonymous with the FDA-defined legal standards for product approval. 

221 
 APPENDIX B-4 

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135.Lot F, Abiteboul D. Infections professionnelles par le V.I.H. en France chez le personnel de santé-

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239 
APPENDIX C 

APPENDIX C 

SOURCES OF ADDITIONAL 

INFORMATION 

241 
APPENDIX C 

FEDERAL

 AGENCY NOTES 

United States Fire Administration 

National Fire Programs 

16825 South Seton Avenue 

Emmitsburg, MD 21727 

http://www.usfa.fema.gov/ 

Developed Guide to Managing an 

Emergency Service Infection Control 

Program 

Two-day course: Infection Control for 

Emergency Response Personnel: The 

Supervisor’s Role 

U.S. Department of Health and Human Services 

Public Health Service, Centers for Disease Control 

1600 Clifton Rd.

Atlanta, GA 30333 

http://www.cdc.gov 

Conducts ongoing research 

Oversees National Prevention 

Information Network 

Publishes MMWR 

Morbidity and Mortality Weekly Report 

Epidemiology Program Office MS C-08 

Centers for Disease Control and Prevention 

1600 Clifton Rd. 

Atlanta, GA 30333 

http://www2.cdc.gov/mmwr/ 

Weekly reports from CDC on 

communicable diseases 

National Highway Traffic Safety Administration 

Division of EMS 

Department of Transportation 

400 7th Street, N.W.

Washington, D.C. 20590 

http://www.nhtsa.dot.gov/people/injury/ems/ 

Developed A Leadership Guide to 

Quality Improvement for Emergency 

Medical Services Systems 

U.S. Department of Labor 

Occupational Health & Safety Administration 

Office of Public Affairs, Room N3647 

200 Constitution Avenue, N.W.

Washington, D.C. 20210 

http://www.osha.gov/ 

29 CFR Part 1910.1030 Occupational 

Exposure to Bloodborne Pathogens; 

Final Rule (http://www.oshaslc.gov/Preamble/Blood_data/BLOOD

9.html) 

STATE

Public Health Agencies Liaison with CDC 

Enforce CDC guidelines 

Fire and EMS Agencies Liaison with USFA and NFA 

Sponsor training on infection control 

243 
APPENDIX C 

 AGENCY NOTES 

State OSHA (where applicable) Enforce OSHA regulations and CDC 

guidelines 

http://www.osha-slc.gov/fso/osp/ 

provides links to State OSHA contacts 

LOCAL

Public Health Agencies Liaison with State, public, health 

agencies 

Screening, testing, evaluation, 

immunization, and treatment 

capabilities 

Regional EMS Agencies Liaison to State EMS agencies 

Hospitals Access to current information on 

infection control 

Notify responders of possible 

exposures 

OTHER HELPFUL WEB SITES

http://www.oshaslc.gov/FedReg_osha_pdf/FED20010118A.pdf 

29 CFR Part 1910, Occupational 

Exposure to Bloodborne Pathogens; 

Needlesticks and Other Sharps 

Injuries; Final Rule 

http://www.oshaslc.gov/SLTC/needlestick/saferneedledevices/safern

eedledevices.html

Safer Needle Devices: Protecting 

Health Care Workers (OSHA) 

http://www.oshaslc.gov/html/hotfoias/tib/TIB19990412.html

Technical Information Bulletin - 

Potential for Allergy to Natural 

Rubber Latex Gloves and other 

Natural Rubber Products (OSHA) 

http://www.oshaslc.gov/OshDoc/Directive_data/CPL_2-2_44D.html

CPL 2-2.44D - Enforcement 

Procedures for the Occupational 

Exposure to Bloodborne Pathogens

(OSHA) 

244 
APPENDIX C 

 AGENCY NOTES 

http://www.cdc.gov/ncidod/diseases/hepatitis/index.

htm

Viral Hepatitis (CDC) 

http://www.cdc.gov/hiv/pubs/facts/hivtb.pdf The Deadly Intersection between TB 

and HIV (CDC) 

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/

00035909.htm

Guidelines for Preventing the 

Transmission of Mycobacterium 

tuberculosis in Health-Care Facilities, 

1994 (CDC) 

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/

00053391.htm

Measles, Mumps, and Rubella -- 

Vaccine Use and Strategies for 

Elimination of Measles, Rubella, and 

Congenital Rubella Syndrome and 

Control of Mumps: Recommendations 

of the Advisory Committee on 

Immunization Practices (ACIP)

(CDC) 

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/

top 

Prevention and Control of 

Meningococcal Disease (CDC) 

http://www.oshaslc.gov/OshStd_data/1910_0134.html29 CFR Respiratory Protection 

(OSHA 1910.134) 

http://www.oshaslc.gov/OshDoc/Directive_data/CPL_2-2_44D.html

Enforcement Procedures for the 

Occupational Exposure to Bloodborne 

Pathogens (OSHA Directive CPL2-

2.44D) 

http://www.osha.gov/oshpubs/osha3130.pdf Occupational Exposure to Bloodborne 

Pathogens – Precautions for 

Emergency Responders ((OSHA 3130 

Revised) 

NATIONAL ORGANIZATIONS

Association for Professionals in Infection Control 

1275 K. St. N.W., Suite 1000 

Washington, D.C. 20005-4006 

(202) 789-1890 

http://www.apic.org/ 

Published APIC Text of Infection 

Control and Epidemiology

245 
APPENDIX C 

 AGENCY NOTES 

National Fire Protection Association 

Batterymarch Park 

Quincy, MA 02269-9904 

(800) 344-3555 (to order documents) 

http://www.nfpa.org 

NFPA 1581, Standard on Fire 

Department Infection Control 

Program 

International Association of Firefighters 

Department of Occupational Health & Safety 

1750 New York Avenue, N.W.

Washington, D.C. 20006 

(202) 737-8484 

http://www.iaff.org/iaff/Health_Safety/health_safety.

html

Develops knowledge within the fire 

service so firefighters, paramedics and 

EMT’s can recognize and control the 

safety and health hazards associated 

with the profession 

International Association of Fire Chiefs 

1329 18th St., N.W.

Washington, D.C. 20036 

(202) 833-3420 

http://www.iafc.org/ 

Promotes infection control policies 

and practices 

National Prevention Information Network 

P.O. Box 6003 

Rockville, MD 20850 

800-458-5231 

http://www.cdc.gov/hiv/hivinfo/npin.htm

Formerly AIDS Information 

Clearinghouse. Distributes 

HIV/AIDS, STD, and TB information 

246