University Bloodborne Pathogen Exposure Control Program

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Policy Number:
UW-6103
Responsible Office:
Environment, Health and Safety

University Policy

Rationale/​Purpose:

The purpose of this policy is to eliminate or minimize employee occupational exposure to human blood, other human body fluids or tissues, and to comply with Occupational Safety and Health Administration (OSHA) bloodborne pathogen standards (29 C.F.R. § 1910.1030) and Wis. Admin. Code SPS § 332.

Definitions:
Bio-Application Review for Research Oversight at Wisconsin (ARROW)
A platform for research oversight pertaining to human and animal subjects, stem cell research, and biological safety at UW-Madison.
Blood
Human blood, human blood components, and products made from human blood.
Bloodborne Pathogens
Pathogenic microorganisms that are found in blood and other bodily fluids that can cause disease in humans including, but not limited to, hepatitis B virus (HBV), heptatitis C virus (HCV), and human immunodeficiency virus (HIV)
Contaminated
The presence of blood or the reasonably anticipated presence of blood or other potentially infectious material on a surface or item.
Decontamination
The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they no longer are capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.
Engineering Controls
For purposes of this policy, items (e.g., sharps disposal containers, self-sheathing needles) designed to isolate or remove bloodborne pathogen hazards from the workplace.
Exposure Control Plan (ECP)
Measures to identify employees with occupational exposure, minimize exposure risk, and develop procedures for evaluating exposure incidents.
Exposure Incident
For purposes of this policy, 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. For purposes of this policy, this definition includes exposure to students in performance of academic activities.
Medical Waste
Waste materials that meet the definition of infectious waste - solid waste that contains pathogens with sufficient virulence and in sufficient quantity that exposure of a susceptible human to the solid waste could cause the human to contract an infectious disease.
Needleless Systems
Devices that do not use needles for the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established, the administration of medication or fluids, or any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
Occupational Exposure
Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or any other potentially infectious material that may result from the performance of an employee’s duties. For purposes of this policy, this definition includes exposure to students in performance of academic activities.
Other Potentially Infectious Materials (OPIM)

1. The following human body fluids:

  • cerebrospinal fluid
  • synovial fluid
  • pleural fluid
  • pericardial fluid
  • amniotic fluid
  • semen
  • vaginal secretions
  • saliva in dental procedures
  • any body fluid that is visibly contaminated with blood and all body fluids in situations when 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)

3. The following cultures:

  • human immnodeficiency virus (HIV)-containing cell or tissue culture
  • organ culture
  • human immnodeficiency virus (HIV), hepatitis C virus (HCV), or hepatitis B virus (HBV)-containing culture medium or other solutions

4. Blood, organs, or other tissues from experimental animals infected with HIV, HCV, or HBV

5. Human cell lines (including established cell lines and stem cells).

Parenteral
Piercing of mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Personal Protective Equipment (PPE)
For purposes of this policy, specialized clothing or equipment worn for protection against a hazard (e.g., gloves, gowns, face shields, masks, protective eyewear, mouthpieces and resuscitation bag, or other ventilation devices). General work clothes (e.g. uniforms, pants, shirts, or blouses) are not intended to function as protection against hazards and are not considered personal protective equipment.
Production Facility
A facility engaged in industrial-scale, large volume (10 L or more), or high concentration production of human immnodeficiency virus (HIV) or hepatitis B virus (HBV).
Regulated Waste
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 that are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials, also called Biohazardous Waste.
Research Laboratory
For purposes of this policy, a laboratory producing or using research laboratory scale amounts of human immunodeficiency virus (HIV), hepatitis C virus (HCV), or hepatitis B virus (HBV), that may produce high concentrations of HIV, HCV, or HBV but not in the volume found in production facilities.
Sharps
For purposes of this policy, an item that is designed to cut or puncture skin including unused, disinfected, or contaminated needles, syringes with needles, scalpel blades, lancets, razor blades, broken vials, and laboratory slides contaminated with infectious agents or human blood.
Sharps Injury Log
Documentation collected at the university level designed to track incidents involving sharps such as needles, scalpels, and other medical instruments to help identify patterns, evaluate risks, and prevent future injuries.
Sharps with Engineered Sharps Injury Protections
A non-needle sharp or a needle device used for withdrawing body fluids, accessing veins or arteries, or administering medications or other fluids with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
Standard Precautions
For purposes of this policy, basic practices that apply to all patient care regardless of the patient's suspected or confirmed infectious state, and to all settings where care is delivered. These practices and personal protective equipment protect healthcare providers and prevent the spread of infection to other patients.
Universal Precautions
An approach to infection control wherein all human blood and certain other human body fluids are treated as if known to be infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), or other bloodborne pathogens.
Work Practice Controls
Measures that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g. prohibiting the recapping of needles by a two-handed technique).
Scope:

This policy applies to all employees defined in UW-5000 Employment Categories and all enrolled students at UW-Madison who are occupationally exposed to blood or other potentially infectious materials during performance of employee duties or academic activities.

Policy:

  1. Exposure Control Plan (ECP)

    1. Compliance with Occupational Safety and Health Administration

      In compliance with 29 C.F.R. § 1910.1030(c)(1)(i) and Wis. Admin. Code SPS § 332.203, the University of Wisconsin-Madison hereby promulgates this Exposure Control Plan (ECP) designed to eliminate or minimize exposure incidents.

    2. Accessibility to ECPs

      ECPs are accessible and available in this policy, ARROW, and in units.

    3. Annual Review and Revision

      The ECP must be reviewed and revised annually, or as necessary, to reflect new or modified positions, tasks, and procedures subject to occupational exposure.

      1. The annual review must reflect any changes in technology that eliminate or reduce bloodborne pathogens; and
      2. The annual review must reflect consideration for and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
    4. Input

      Employees (non-managerial), including those responsible for direct patient care, who are potentially exposed to injuries from contaminated sharps must be asked for input on the selection of effective engineering and work practice controls, which must be documented in the ECP.

  2. Exposure Control Plan Requirements

    1. Exposure Determination
      1. All employees with occupational exposure to blood and other potentially infectious materials (OPIM) must be identified, documented, and categorized as follows, without regard to the use of personal protective equipment (PPE):
        1. By job classification where all employees have occupational exposure
        2. By job classification where some employees have occupational exposure
        3. By tasks and procedures where some employees have occupational exposure
      2. Exposure determination must be conducted and documented annually and whenever necessary as follows:
        1. On the Bloodborne Pathogen Exposure Plan in ARROW for employees in research roles
        2. On Employee Exposure Determination form (Appendix A) for employees in clinical and operational roles
    2. Methods of Compliance Required by OSHA
      1. Universal precautions must be observed in research settings (also known as standard precautions in healthcare settings) to prevent contact with blood and OPIM.
      2. Units must use and enforce OSHA engineering and work practice controls to eliminate or minimize employee exposure.
    3. Methods of Compliance Required by UW-Madison
      1. Equipment and Laboratories
        1. Use biosafety cabinets, blunt tip and self-sheathing needles, sharps with engineered injury protections, needless systems, and non-glass tubes and pipettes where feasible. Horizontal laminar flow cabinets (e.g., clean benches) must not be used as containment devices.
        2. Use proper centrifuging procedures to minimize exposure, including aerosolization:
          1. Use capped tubes and centrifuge in either sealed trunnion buckets or rotor heads with covers. If such equipment is not available, use unbreakable, screw-capped tubes.
          2. Open buckets, rotor heads, or screw-capped tubes within a biological safety cabinet or fume hood after centrifugation.
          3. Allow a minimum of 30 minutes for aerosol settling to occur before opening a centrifuge with broken tubes and decontaminate the centrifuge by autoclave.
        3. Ensure automated equipment (e.g., cell sorters and flow cytometers) is properly used.
        4. Ensure glassware and other reusable items are autoclaved prior to being washed and reprocessed. Alternatively, immersion in an effective chemical disinfectant is permitted.
        5. Ensure incoming clinical specimens are received in a designated area by trained staff who must wear proper PPE and inspect parcels for leakage. All contaminated or soiled materials must be discarded in a biohazard bag and the work area must be cleaned with a chemical disinfectant after specimen receipt and handling.
      2. Personal Hygiene and Protection Requirements
        1. Flush eyes for at least 15 minutes with eyewash where applicable after exposure and wash hands for at least 20 seconds with nonabrasive soap, preferably from a mechanical liquid soap dispenser, following contact with blood or OPIM, upon removing PPE, and before exiting areas where blood and OPIM are handled.
        2. Keep hands away from the face and head.
        3. Consume food, beverages, and chewing gum only in safe designated areas.
        4. Ensure individuals have access to PPE provided by the university and are trained on its proper use and care:
          1. PPE must be appropriate for the task.
          2. PPE must be worn each time the task is performed.
          3. PPE must be checked prior to use to ensure it is free of physical flaws that could compromise safety.
          4. PPE that is contaminated must not be laundered at home.
          5. PPE must be removed when it becomes contaminated, damaged, as soon as a task is completed, or before leaving the work area.
          6. Broken skin (e.g., cut or rash) must be bandaged prior to wearing gloves.
          7. Gloves must be removed and properly disposed of, and hands must be washed.
          8. Hand cream that degrades the effectiveness of gloves must not be used.
          9. Hypoallergenic gloves, glove liners, powderless gloves, or another alternative must be provided for individuals allergic to latex or vinyl gloves.
        5. Prohibit open toed or perforated shoes.
        6. Prohibit casual visitors (e.g., family members or tour groups without approval).
        7. Prohibit third-party service and maintenance personnel from entering a biohazard area until the laboratory's safety requirements are reviewed, the instrument to be serviced is decontaminated, and appropriate PPE is worn.
        8. Ensure contaminated equipment is decontaminated prior to shipping, handling, or servicing unless it can be shown that decontamination is not feasible, in which case a warning label must be affixed, and the manufacturer or service representative must be notified accordingly.
        9. Require doors to animal rooms and laboratories remain closed when work is in progress.
        10. Dispose of medical waste and sharps in accordance with Environment, Health & Safety's Office of Biological Safety standards.
          1. Needles and other sharps must not be reused.
          2. Recapping needles must be advoided. If recapping is required, tongs, a recapping device, or one-handed scoop method must be used.
          3. Tongs, forceps, or a dustpan and brush must be used to pick up broken glass which may be contaminated with blood or OPIM.
    4. Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) Research Laboratories and Production Facilties

      Special practices are required for research laboratories engaged in the culture, production, concentration, experimentation, and manipulation of HBV, HCV, and HIV.

      1. Research labs which use HBV, HCV, or HIV are required to adhere to practices outlined in the Centers for Disease Control and National Institutes for Health Biosafety and Microbiological and Biomedical Laboratories (BMBL) manual for appropriate biosafey levels.
      2. Additional initial training is required for employees as required by OSHA.
      3. For purposes of this ECP, HBV, HCV, and HIV are considered etiological agents as defined by the U.S. Department of Health and Human Services. Transfer of HBV, HCV, or HIV from a university research laboratory or production facility to another researcher, university, or other facility must comply with the U.S. Department of Transportation regulations pertaining to the packaging and shipment of etiological agents as described in 49 C.F.R. §§ 171 – 180.
    5. Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-Up

      In accordance with OSHA:

      1. UW-Madison provides the HBV vaccine at no cost to employees with occupational exposure.
        1. Employees must complete either the HBV vaccine consent or declination form.
        2. Employees who initially decline the vaccine may request the vaccine at a later date while still covered under this policy.
        3. Employees who have routine patient contact in healthcare settings may be offered post vaccination serologic testing.
      2. UW-Madison provides confidential post-exposure evaluation and follow-up to employees who have an exposure incident.
        1. Exposure incidents must be reported immediately to the supervisor or instructor.
          1. Employees will be directed to Occupational Medicine, unless they have dual appointments (e.g., UW Health, in which case they will be directed to UW Health Employee Health Services).
          2. Students will be directed to University Health Services.
        2. Exposure incidents must be documented with the Employee's Work Injury and Illness Report and the Supervisor's Incident Analysis and Prevention Report (both required of all employees) and the First Report of Biological Exposure or Release Event (required of individuals involved in research). These reports must include the following:
          1. Date and time of exposure
          2. Route(s) of exposure
          3. Duty being performed
          4. Cause of the incident (e.g., blade, needlestick, glassware, human bite)
        3. Identification of the source individual is necessary for simultaneous baseline testing of HBV, HCV, and HIV in both the employee and source individual.
        4. Recommendations may include the HBV vaccine if immunity is not already established, follow-up blood tests for three months post-exposure, and post-exposure prophylaxis.
    6. Communication of Hazards to Employees

      In accordance with OSHA:

      1. Fluorescent orange-red signs bearing the biohazard symbol, infectious agent, special requirements for entering the area, and contact information must be posted at entrances to clinical and research laboratories containing biohazardous materials.
      2. Fluorescent orange or orange-red labels bearing the biohazard symbol must be affixed to containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport, or ship blood or OPIM.
      3. Individual containers of blood or OPIM that are placed in a labled container during storage, transport, shipment, or disposal do not require individual labels.
      4. Contaminated equipment must be labled in accordance with the above requirements and must state which parts of the equipment remain contaminated.
      5. Employees with occupational exposure must be trained upon initial assignment and at least annually thereafter.
    7. Information and Training
      1. In accordance with OSHA, training must be provided at the time of initial assignment and annually thereafter. Additional training must be provided when tasks or procedures are added or changed in a manner that affects occupational exposure.
      2. The training program must, at minimum, contain the elements established by OSHA.
    8. Recordkeeping

      In accordance with OSHA, the following records must be maintained:

      1. Exposure determination records
      2. Medical records, including HBV vaccine acceptance and declination forms
      3. Training records
      4. Sharps injury log

  3. Roles and Responsibilities

    1. The Office of Biological Safety (responsible for research entities) and Occupational Health (responsible for non-research and non-UW Health entities) must:
      1. Manage overall implementation of the ECP.
      2. Provide oversight of the bloodborne pathogen program by monitoring compliance and annually evaluating the exposure control plan and program.
      3. Evaluate bloodborne pathogen and OPIM exposures that occur among UW faculty, staff, and students.
    2. The Office of Occupational Medicine must:
      1. Provide HBV vaccine and/or further testing if needed.
      2. Maintain records of HBV vaccines and declinations and provide receipt of same to supervisors.
      3. Conduct post-exposure medical evaluation and treatment when applicable.
      4. Maintain confidential medical records for exposure incidents, HBV vaccine, and follow-up for duration of employment plus 30 years.
    3. Supervisors or Principal Investigators must:
      1. Identify the persons in their work group who have occupational exposure and are subject to the ECP, and complete the Employee Exposure Determination in:
        1. ARROW for individuals with research roles.
        2. Appendix A for employees with clinical or operational roles.
      2. Ensure employees identified in the Employee Exposure Determination complete the HBV vaccine acceptance or declination form.
      3. Follow and enforce practices in this policy and the unit's ECP which must be accessible to employees.
      4. Provide engineering and work practice controls, including PPE, for their work group.
      5. Ensure universal precautions are understood and practiced by those with occupational exposure and ensure standard precautions are followed in healthcare settings. Ensure employees and students work in a safe and responsible manner.
      6. Inform employees, maintenance personnel, and visitors of bloodborne pathogens and OPIM hazards, consequences of exposure, and proper behavior in clinical, operational, and research environments.
      7. Restrict lab access following the recommendations of the Centers for Disease Control - National Institutes of Health Biosafety and Microbiological and Biomedical Laboratories (BMBL) manual and OSHA bloodborne pathogens standards.
      8. Train employees in compliance with OSHA standards. Ensure employees understand label and sign requirements, PPE use, and proper disposal of waste.
      9. Maintain records of annual training and continuing education for unit employees for a minimum of three years.
      10. Following an incident, ensure the exposed employee has available medical care. Document the incident using the Supervisor's Incident Analysis and Prevention Report.
      11. Annually conduct ECP review.
    4. Employees and students subject to this policy must:
      1. Read, understand, and comply with the ECP.
      2. Accept or decline the HBV vaccine and sign the acceptance or declination form accordingly.
      3. Successfully complete initial and annual bloodborne pathogen program and OPIM training in compliance with OSHA standards.
      4. Follow universal precautions when handling blood or OPIM, and standard precautions in healthcare settings.
      5. Follow safe work practices including engineering and work practice controls as identified by their supervisor (e.g., follow label and sign requirements, use PPE as directed, and dispose of waste properly).
      6. Notify their supervisor and Occupational Medicine immediately of an exposure incident, initiate first aid, and complete the Employee's Work Injury and Illness Report (required of all employees) and the First Report of Biological Exposure or Release Event (required of individuals involved in research).
      7. Notify their supervisor if job tasks or occupational exposure changes.
      8. Ask their supervisor or unit bloodborne pathogen coordinator questions that pertain to safe work with blood and OPIM.
Related UW-Madison Policies:
Related UW–Madison Documents, Web Pages, or Other Resources:
External References:

Policy Administration

Approval Authority:
Assistant Vice Chancellor, Environment, Health & Safety
Policy Manager:
Director of Environmental and Occupational Health
Contact:
Associate Biological Safety Officer - Animal Research Safety -- CARRIE ENSRUD, carrie.ensrud@wisc.edu, (608) 445-4516
Industrial Hygiene Program Manager -- Jessica Cebula, JESSICA.CEBULA@WISC.EDU, (608) 890-3992
Effective Date:
07-07-2025
Date Issued:
07-07-2025
Retrieved:
07-20-2025 05:27:28