Exposure Control Plan

Northwestern University complies with the Occupational Safety and Health Administration (OSHA) Occupational Exposure to Bloodborne Pathogens Standard (29 CFR 1910.1030).

In 1991, the United States OSHA enacted the Bloodborne Pathogen (BBP) Standard in response to the potential for occupational exposure to Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) in the workplace.

The OSHA BBP standard requires a written document called the Exposure Control Plan (ECP) under section 1910.1030 (c)(1). The ECP must be readily available to all affected faculty, staff, and students – see 1910.1030 (c)(1)(iii). 

This document is the Northwestern University ECP.

The ECP is a vital element of the Biological Safety Program at Northwestern. If you have any questions about the applicability of this standard, contact Research Safety (RS):

Chicago Campus: (312) 503-8300

Evanston Campus: (847) 497-5581

researchsafety@northwestern.edu

Scope

The OSHA BBP standard applies to all faculty, staff, and students in research-related activities at Northwestern University working with (or potentially exposed to) human blood (hereafter referred to simply as blood), blood from non-human primates, blood components, and blood-derived materials—hereafter called Other Potentially Infectious Materials (OPIM).

Examples of OPIM:

•  Human body fluids
  • Semen
  • Vaginal secretions
  • Cerebrospinal fluid
  • Synovial fluid
  • Pleural fluid
  • Pericardial fluid
  • Peritoneal fluid
  • Amniotic fluid
  • Saliva in dental procedures
  • Any fluid that is visibly contaminated (streaked or tainted) with blood
  • All body fluids in situations where it is difficult or impossible to differentialte between body fluids
•  Any unfixed tissue or organ (other than intact skin) from a human, living or dead
• Animal cells, blood, tissues, organs, cultures, culture medium, or other related solutions from animals that have been experimentally or incidentally infected with HIV or HBV

What is occupational exposure?

Occupational exposure occurs when unprotected contact with blood/OPIM happens via contact with the skin, eyes, and mucous membranes while conducting research activities for Northwestern University.

If you have any questions about this definition, contact Research Safety.

If you feel that you may have been occupationally exposed to blood/OPIM, render immediate first aid, seek medical care and report it as described in the Exposure Incidents section of this plan.

This critical response protects you, your lab, and the broader Northwestern community.

Ensuring health and safety is a shared responsibility at Northwestern.

The University has entrusted the necessary authority to Research Safety to correct unsafe actions or conditions.

The Laboratory Safety and Chemical Hygiene Plan and the Biological Safety Manual outline the roles and responsibilities for laboratory health and safety for all research faculty, staff, and students at Northwestern.

Research Safety administers the ECP at Northwestern and reviews the plan and its necessary components annually under section 1910.1030 (c)(1)(iv).

Senior Leaders, Deans, Department Chairs, and all Faculty/Principal Investigators are responsible for ensuring that the requirements of the ECP are met. Research Safety is responsible for conducting audits as part of its laboratory safety review process to assess compliance, and non-compliance is reported to the appropriate University leadership for resolution.

The ECP consists of the following parts:

• Exposure determination: this process occurs during entry of the research registration hazard profile in compliance with section 1910.1030(c)(2)(i) [A-B].
  
  • The research registration system accounts for lab location and assigns training based on lab hazards.
  • The research registration must be reviewed and recertified annually or when substantial changes in the lab's focus or the materials are handled.
• Adherence to Standard Precautions in compliance with section 1910.1030(d)(1)
• Provisions for the hepatitis B vaccine, in compliance with section 1910.1030(f)(1)(i)
• Process for incident investigation, in compliance with section 1910.1030(f)(3)

If you have any questions about the ECP, contact Research Safety.

Assume that human and non-human blood/OPIM contain HIV, HBV, and other bloodborne pathogens regardless of what is known about the source.

Work with blood/OPIM must be managed at Biosafety Level 2 (BSL2), and personnel must adhere to the requirements outlined in the Northwestern Biological Safety Manual. See 1910.1030(e)(2)(ii)(M)

Standard Precautions at Northwestern include:

• Completing Northwestern-specific training (supplemented with lab-specific training if necessary
• Using engineering controls
• Performing routine hand hygiene
• Using personal protective equipment properly
• Adhering to accepted safe work practices
• Rendering first aid and seeking medical care in an emergency
• Reporting exposure incidents promptly

All personnel with occupational exposure to blood/OPIM must complete the training required by Research Safety—reference 1910.1030 (g)(2). Training is required annually and documented by a comprehension test.

Training topics include:

• Existence of the standard and its key requirements
• Where to find a copy of the standard and this exposure control plan
• Relevant definitions covered in 1910.1030 (b)
• Epidemiology, symptoms, and modes of transmission of BBPs
• Hazards, risks, and potential consequences of a BBP exposure
• Availability of the HBV vaccine, its efficacy, and how to request it
• Labels, signs, and other forms of warning
• Use of engineering controls
  • Biological safety cabinet (BSC)
  • Centrifuge safety cups and rotors
  • Technical controls associated with animal use
• Importance of personal protective equipment (PPE)
  • Barrier protection
  • Disposable gloves
  • Eye and mucous membrane protection
  • Care, use, and disposal
• Safe work practices
  • Good laboratory practices
  • Sharps precautions
  • Methods of disinfection/decontamination
  • Spills and clean up
  • Waste disposal
  • Personal hygiene
  • First aid
  • Incident reporting

Training records for completing the Bloodborne Pathogens course are maintained in the myHR Learn system--reference 1910.1030(h).

If necessary, the PI is responsible for providing laboratory-specific training and must maintain a record in their lab. These records must include:

• Date(s) of training
• Summary of topics covered
• Name(s) of individuals who lead the discussion
• Printed names and signatures of those in attendance

Lab-specific Bloodborne Pathogens Training Attendance Form

See 1910.1030(g)(2)(vii)(L) for more information on lab-specific training.

If you have any questions about general or lab-specific training, contact Research Safety.

Access to laboratories at Northwestern with human blood/OPIM is restricted to authorized personnel only, and spaces are labeled with any specific entry and work practice requirements. See 1910.1030(e)(2)(ii)(C).

Research Safety provides the standard safety sign for lab entry based on the research registration profile.

Equipment and containers must be labeled with the universally recognized biohazard symbol—specifically doors, containers, storage locations, and waste receptacles when blood/OPIM are present. See 1910.1030(e)(2)(ii)(D).

Safety markings, labels, signage, and other forms of Warning should be updated regularly and for the present hazards.

Research Safety provides an assortment of labels, signs, and other warning forms to assist research personnel. Contact Research Safety with any questions or concerns.

By design, research laboratories have specialized exhaust systems and other features to help ensure the health and safety of the researchers.

A Biological Safety Cabinet is the preferred engineering control for work with blood/OPIM at BSL2. BSCs provide product, personnel, and environmental protection. See 1910.1030 (e)(2)(iii)(A).

BSCs must be certified annually and whenever they have been moved from one location to another. See 1910.1030(e)(2)(iii)(B). 

Unless approved (in writing) by the Biosafety Officer, all activities that generate aerosols (including vortexing, mixing, grinding, etc.) must be performed inside a BSC.

Additional work practice controls are necessary to prevent exposure to work involving blood/OPIM outside of a BSC. 

Contact Research Safety for assistance before starting any experiments involving potentially infectious materials outside a BSC. For additional information about the function, use, and maintenance of BSCs, consult the Biological Safety Manual.

Northwestern provides a wide assortment of PPE to faculty, staff, and students covered under the BBP Standard. This PPE is provided at no cost to the individual. Available PPE includes:

• Laboratory coats
• Disposable gloves
• Mucous membrane protection
• Eye and face protection
• Respiratory protection using N95 respirators (Only if enrolled in the Northwestern Respiratory Protection Program)

Research Safety provides a convenient drop-off laundry service on each campus. Soiled lab coats may be exchanged for a clean lab coat.

Housekeeping

Labs working with blood/OPIM must follow all BSL2 requirements described in the Northwestern Biological Safety Manual.

Labs must be visibly clean and unobstructed.

All waste must be contained in labeled,leakproof containers and disposed of routinely.

Good Laboratory Practices

• Use Research Safety-approved waste containers for all potentially infectious materials
  • Northwestern Hazardous Waste Disposal Guide
  • Research Safety Supply Catalog
• Storage containers must seal tightly and be leakproof
• Follow all sharps precautions
  • Immediately after use, place contaminated sharps in a Research Safety-approved sharps container that is puncture-resistant, labeled, color-coded, and leakproof.
  • Contaminated needles and other contaminated sharps must never be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited. See 1910.1030(d)(2)(vii).
    • Contaminated needles and sharps may be recapped or removed when no alternative is feasible or required by a specific medical procedure. See 1910.1030(d)(2)(vii)(A).
    • The recapping or removal of contaminated sharps is actively discouraged because of the high potential risk of an injection injury.
    • Any recapping or removal must use a mechanical device or a one-handed technique. See 1910.1030(d)(2)(vii)(B).
    • For guidance regarding a one-handed technique for recapping needles, please contact Research Safety or the Center for Comparative Medicine (CCM) training staff.
  • Sharps containers should be located as close to their use as possible to dispose of sharps items in the container safely. Once sharps containers are filled to their designated fill line, they should be permanently closed before transportation for disposal.
• Label all potentially infectious materials with the biohazard symbol. The label must be either red or orange. Research Safety has an assortment of standard labels available at no cost.
• Decontaminate everyday surfaces after any spill and at the end of the day (at a minimum). Use an EPA-approved disinfectant with a label claim for tuberculocidal activity. See 1910.1030(d)(4)(i).
• Decontaminate any equipment to be serviced or shipped according to procedures established by Research Safety.
  • Communicate potential hazards to employees, service personnel, and manufacturers as appropriate.
  • Contact Research Safety for assistance.
• Chemically decontaminate liquids according to established methods, allow them to stand, then dispose of them down the drain with a ten-fold excess of water.
• Eliminate the risk of ingestion.
  • Mouth pipetting is prohibited
  • Eating, drinking, smoking, applying cosmetics (including hand/body lotion and lip balm), and handling contact lenses are prohibited in work areas with a reasonable likelihood of occupational exposure.
  • 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.
• Ensure the availability of Northwestern-approved PPE.
• Remove gloves and lab coat before leaving the lab.
• Wash hands before leaving the lab, between glove changes, and after contact with blood/OPIM.
• Ensure that an approved first aid kit is readily available.
• Ensure that a working eyewash is in proximity.
• Post emergency numbers and procedures.
• Have an updated emergency plan.
• Discuss safety at each lab meeting.
• Contact Research Safety for help any time.

Hepatitis B is a viral infection caused by the hepatitis B virus (HBV), which causes death in one to two percent of all patients. Most people with HBV recover entirely, but five to ten percent become chronic carriers of the virus. Most chronic carriers have no symptoms but can continue to transmit the disease to others. Some chronic carriers develop chronic active hepatitis and cirrhosis. HBV also is a causative factor in the development of liver cancer. HBV may be transmitted from a pregnant woman to the fetus.

Immunization against HBV can prevent acute hepatitis and reduce the sickness and death from chronic active hepatitis, cirrhosis, and liver cancer. The Hepatitis B vaccine will not prevent hepatitis caused by other agents, such as other viruses known to infect the liver.

Northwestern provides the hepatitis B vaccine to all faculty, staff, and students covered by the BBP Standard.

The recombinant hepatitis B vaccine is a noninfectious vaccine derived from HBV surface antigen (the viral coating material) produced in yeast cells. A portion of the hepatitis B virus gene is cloned into yeast. The vaccine is safe and effective. A licensed health care worker discusses side effects before the first injection.

The vaccine is available to employees who have potential occupational exposure to BBPs. The vaccine shall be made available at a reasonable time and place.

The vaccination schedule involves three injections over six months for doses provided in the United States.

All records are subject to healthcare privacy requirements. Research Safety does not receive, access, or otherwise keep medical information.

Northwestern-provided Hepatitis B vaccinations are subject to the following:

• Assigned BBP training provided by Research Safety is completed within ten working days of initial assignment unless:
  • The individual has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the individual is immune, or the vaccine is contraindicated for medical reasons
• An employee who accepts vaccination should complete and sign the Hepatitis B Vaccination Certification found in myHR Learn
  • The employee may decline vaccination but decide to accept it later. If an employee declines vaccination but decides otherwise later, the employee the individual must contact Research Safety to update their Hepatitis B Vaccination Certification.

If you have questions about the hepatitis B vaccination program, contact Research Safety.

The BBP Standard requires that the employer keep a record of sharps injuries. See 1910.1030(h)(5)(ii).

This information is collected and maintained as part of the Northwestern incident reporting and Workers' Compensation program.

If you have any questions,  contact Risk Management.

Responding to Exposure Incidents

With any blood/OPIM exposure, render immediate first aid and seek medical attention. Post-exposure evaluation and follow-up are conducted for all incidents, including sharps injuries, as detailed in 1910.1030(f)(3) through 1910.1030(f)(6).

• Wash the exposed area thoroughly with povidone iodine and copious water for 15 minutes.
  • Povidone iodine is available at no cost in the Stockrooms.
  • If povidone iodine is not available, use soap.
• Flush with clean water (or sterile saline) for 15 minutes following eye exposure.
• Seek medical attention.
  • During business hours in Chicago, contact Northwestern Medicine at 312-926-8282.
  • During business hours in Evanston, contact Northshore at 847-657-1700.
  • After hours go to the nearest emergency room (Northwestern Memorial in Chicago or Evanston Hospital in Evanston) and inform your treatment team the exposure happened at work.
• Do not delay medical care to report the incident. As soon as you are able, report the exposure to your supervisor and complete an Incident Report.

Reporting

After the exposure has been evaluated by a medical professional, notify Risk Management. Your supervisor or Principal Investigator (or a designee) should file the initial report.

Risk Management Incident Report

Next notify Research Safety for assitance in follow-up and prevention.

Research Safety Incident Report