Bloodborne Pathogen Program

Read the Bloodborne Pathogen Guide: Bloodborne Pathogen Guide


The purpose of this program document is to address the Occupational Exposure to Bloodborne Pathogen Program at California State University San Marcos, per 29CFR 1910.1030 and Title 8, CCR, Sec 5193. This program will serve as the written aspect of an Exposure Control Program to reduce the potential for exposure to occupational incidents involving bloodborne infectious disease in general and Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) in particular.


This program applies to all employees who are potentially exposed to human blood or blood components, e.g., serum, or other potentially infectious materials as a result of the performance of their duties. Examples of employees who might be exposed are, employees of Public Safety, principle investigators or laboratory technicians performing work with human blood or potentially infectious materials, phlebotomist, custodial and maintenance personnel, contractor's custodial personnel and handlers of biomedical waste products. The definition of "potentially infectious materials" means human body fluids such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva or any other body fluid that is visibly contaminated with blood, such as saliva or vomitus. This is especially important in emergency response situations. Public Safety personnel stand the greatest risk because of the emergency nature of their work and the physical confrontations with perpetrators.

California has a number of regulations that already address exposure to hazards on the job. A list of regulations from Title 8, CCR are listed in the following table:



(c)(1)(A) Exposure Control Section 3203
(c)(1)(C) Exposure Control Section 3204(e)
(d)(3) Personal Protective Equipment Sections 3401-3411
(d)(3)(B) Personal Protective Equipment Section 3203
(d)(3)(I) Hand Protection Section 3384
(d)(3)(J) Eye and Face Protection Section 3382
Respiratory Protection Section 5144
(d)(3)(K)&(L) Body Protection Section 3383
(g)(1)(A) Labels and Tags Section 6004
(g)(1)(B) Signs Section 6003
(g)(2) Training Section 3203
(h) Recordkeeping Section 3204

The Exposure Control Plan (ECP) will be reviewed annually by each supervisor of personnel identified as participants under the ECP. The review will be documented on the ECP. This ECP will go into effect immediately per the date posted on the ECP coversheet.


Each supervisor will insure that the potentially occupationally exposed employees under their supervision will receive initial training at the time of initial assignment and at least annually thereafter. The initial training will be given within 10 days of hire. The initial training shall be recorded on the Form IIPP-7 and any group or follow-up training will be recorded on the Form IIPP-6. Enclosures 1 and 2 include copies of these forms. These training records will be retained by the supervisor for at least three years from the date on which the training occurred. If there is a change in task or procedures or institution of new tasks or procedures that affect the employee's occupational exposure, additional training will be administered. RM&S will conduct initial supervisor training and new supervisor training as needed. Supervisor's and employee's bloodborne pathogen training will include:

  1. Informing the individual where a copy of Title 8, CCR, Sec. 5193 is located, and that the regulation is available for employee's review.
  2. A general explanation of the epidemiology and symptoms of bloodborne diseases.
  3. An explanation of the modes of transmission of bloodborne pathogens.
  4. An explanation of the Exposure Control Plan and how an employee can obtain a copy of the written plan.
  5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  6. 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 (PPE).
  7. Information on the types, proper use, location, removal, handling, decontamination and disposal of PPE.
  8. An explanation of the basis for selection of PPE.
  9. 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.
  10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
  11. 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.
  12. Information on the post-exposure evaluation and follow-up that the University has established to provide care for the employee following an exposure incident.
  13. An explanation of the signs and labels and color coding used by the University to identify biohazardous areas and materials.
  14. An opportunity for questions from employees about the University's Bloodborne Pathogen Plan.

Medical records will be handled in the following manner:

  1. Medical records shall be stored in Human Resources Management.
  2. They shall be made available, during normal work hours, to the employee to whom the record pertains.
  3. The medical records shall be maintained for the duration of the employee's employment plus 30 years.
  4. All medical records shall be kept separate from personnel records and medical records shall be kept confidential.
  5. All training and medical records will be made available to representatives from Cal/OSHA, the employee, and employee's representative, with written consent from the subject employee.


Every employee with a job classification listed below will be offered the opportunity to receive the hepatitis B vaccine and antibody titer.

  1. Public Safety Officers
  2. Custodians
  3. Maintenance Worker, Plumber
  4. Laboratory Support Technician
  5. Faculty who performs work utilizing human blood or other potentially infectious materials
  6. Health Services Employees

Prior to receiving the hepatitis B vaccine each employee identified above as a potential candidate for exposure to hepatitis will undergo training as outlined in this program manual. The initial training will take place within 10 days of hire or reassignment. The potentially exposed employee will receive the hepatitis B vaccine at no cost to the employee. Medical contradictions to the employee receiving the vaccine, or if the antibody titer reveals that the employee is immune, are reasons for the employee to not participate in the hepatitis B vaccination program. If an employee refuses to participate in the hepatitis B vaccination program, the Hepatitis B Vaccination Declination form will be duly administered. A copy of the declination form will be retained in the employee's medical record. RM&S personnel will interview the declining employee to determine the employee's understanding of the ramifications of the employee's decision to not participate in the hepatitis vaccination program. A copy of the Hepatitis B Vaccination Declination form is included as Enclosure 3 of this publication.


All employee "Exposure Incidents" will be reported to RM&S as quickly as possible. An "Exposure Incident" is a specific eye, mouth, other mucous membrane, non-intact skin, or penetration by a blood, or potentially infectious material, contaminated needle, knife, scalpel, micro-slide or pipette incident that results from the performance of an employee's duties. The employee's immediate supervisor will complete a Form IIPP-5, Accident, Injury & Occupational Illness Investigation Form, see Enclosure 4 for a copy of this form. The Form IIPP-5 will serve as the "Exposure Incidents" report form.

RM&S, upon receiving the Form IIPP-5, will schedule a confidential medical evaluation and follow-up immediately for the exposed employee.

RM&S will conduct an exposure incident investigation to include:

  1. Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred.
  2. Identification and documentation of the source individual if applicable to investigation.

RM&S will insure, when feasible, that the source individual's blood is tested for hepatitis B virus and human immunodeficiency virus infectivity. Local police, sheriff or University Public Safety units assistance in locating the source individual may be required. Local Public Health departments may be contacted by RM&S to assist in locating and obtaining a blood sample from the source individual. The 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 by the treating physician.

As part of the injury investigation, RM&S will insure the exposed employee's blood is collected and tested for HBV and HIV as a baseline. The exposed employee's consent is required for HIV serologic testing. If consent is not given at the time the blood sample is obtained, the sample shall be preserved for as long as possible so the employee can have the opportunity to give consent for HIV baseline testing. Any further baseline blood testing may be requested by the employee's or the University's physician at the University's or University's health plan provider's expense.

Post-exposure prophylaxis, counseling, reporting and evaluation of reported illness will be conducted by either/or the employee's or University's physician.

  1. A copy of Title 8 CCR, Sec. 5193, will be provided to the treating physician and the exposed employee.
  2. A description of the exposed employee's duties as they relate to the exposure incident will be provided to the treating physician.
  3. A copy of the Form IIPP-5 will be provided to the treating physician.
  4. Copies of all medical records available to the University will be made available to the treating physician, upon request.

The physician's post-exposure evaluation and follow-up written report to the University shall contain an opinion whether hepatitis B vaccination is indicated for the employee, if the employee has received such vaccination, if the employee has been informed of the results of the full evaluation and, that the employee has been informed about medical conditions resulting from exposure to blood or potentially infectious materials which require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written post-exposure evaluation report.


Biohazard labels will be affixed to the containers of biomedical waste. The containers may be stored in a refrigerator or freezer with a temperature of less than 32¡ F for up to 90 days. If biomedical waste is stored at a temperature greater than 32¡ F, the storage time period is reduced to no more than 7 days. The label shall contain the international symbol for biohazard and shall have "California State University San Marcos, San Marcos CA 92096-0001, (760)750-4510" printed on the label. Biohazardous waste that has been properly autoclaved or otherwise sterilized, may be disposed either as sewage or normal waste. Sharps (scalpels, pipettes, micro-slides, broken glass and needles/syringes) must be placed into a rigid, liquid tight container marked with the biohazard label. This sharps container must be disposed through an authorized biohazard/biomedical waste broker. If the sharps container does not contain organic putrefying material, it may be stored above 32¡ F for as long as it takes to fill a container to the indicated full level. If the container contains organic putrefying material, the retention time period is the same as for the biomedical waste referred to at the first of this paragraph.

The international biohazard sign shall be posted at the entrance to work areas. The sign shall contain:

  1. The name of the infectious agent.
  2. Special requirements for entering the area.
  3. Name and telephone numbers, both work and home, of the laboratory director, principle investigator or person-in-charge of the area where biomedical/biohazardous waste is stored.
  4. The biosafety level designation of the area where the biomedical/biohazardous waste is stored must be posted on the sign.

The room where biomedical/biohazardous materials are stored will be kept locked or otherwise monitored to discourage unauthorized entry.


Supervisors shall insure that identified individuals:

  1. Receive training on the hazards of bloodborne pathogens.
  2. Are provided engineering controls, when possible.
  3. Use safe work practices.
  4. Use indicated personal protective equipment (PPE).
  5. Are provided a copy of this program.

If the nature of the task, activity or job requires direct contact with human blood or other potentially infectious materials to which Universal Precautions apply, PPE shall be available and worn as outlined in Enclosure 5 of this program. Use of PPE will not be used in the exposure determination process. If an activity is performed without blood exposure, but exposure could occur in an emergency, the PPE shall be available.

Universal Precautions are intended to supplement rather than replace routine infection control recommendations, such as hand washing and use of gloves to prevent contamination of hands. Universal Precautions, in part, assume that all human blood, blood products and other potentially infectious materials are infected and present a hazard to anyone being exposed to the agents. Consequently, if contact with infectious agents is possible, the necessary PPE must, either be worn, or be immediately available.

Surgical or examination rubber or plastic gloves shall not be washed or disinfected for reuse. They also should not be used when visibly soiled, torn, punctured, or when their ability to function as a protective barrier is compromised. Housekeeping gloves may be used as a physical barrier against contamination. They may be washed, disinfected and reused, but checks for damage are just as important with housekeeping gloves as it is for surgical or disposable plastic gloves. Masks and face or eye protection shall be worn whenever splashes, sprays, splatters, or droplets of blood or other potentially infectious material may be generated and there is potential for eye, nose and/or mouth contamination.

Appropriate protective clothing, such as aprons, lab coats or gowns shall be worn if the potential for soiling the employee's street clothing exists. Closed shoes will be worn as part of the protective clothing ensemble.

Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses are prohibited in laboratories and other work areas supporting laboratories. Food and drink shall not be stored in refrigerators, freezers, or cabinets within laboratories.

To prevent injuries caused by needles, scalpels, and other sharps, employees should not recap, bend or attempt to cut needles from disposable syringes. They should be placed directly into the sharps container. Rigid sharps containers shall be colored red and labeled with the word "BIOHAZARD," or will have a biohazard label.

Although saliva has not been implicated in HIV transmission, to minimize contact in emergency mouth-to-mouth resuscitation situations, mouthpieces, resuscitation bags, or other ventilation devices shall be available to the person who will render the emergency care.

Because pregnant employees could, not only receive an infection from handling human blood products and potentially infectious materials, but could place the infant at risk of infection resulting from perinatal transmission. Pregnant employees within the "at risk" job classifications should be especially familiar with and strictly adhere to precautions to minimize the risk of HIV and HBV transmission.

The worksite will be maintained in a clean and sanitary condition. An appropriate written cleaning schedule will be kept with the method of decontamination determined by location within the facility, type of surface to be cleaned, type of soil present and the tasks and procedures being performed. All equipment and environmental surfaces shall be promptly and properly cleaned and disinfected after contact with human blood or other potentially infectious material. RM&S will provide guidance in selecting proper cleaning and disinfectant agents for use in CSUSM. Gloves will be worn during cleaning and disinfecting procedures.

Specimens of human blood or other potentially infectious materials shall be placed in a closeable, leak proof, container with biohazard labeling prior to being stored or transported. If outside contamination of the primary container is likely, then a second leak proof container that is biohazard labeled shall be placed over the outside of the first container and closed.

After sterilizing liquid or semi-liquid potentially infectious material, the material may be disposed of by pouring down a sanitary sewer. When sterilizing petri or culture plates, place the open plates into a metal container. Place enough open plates to 3/4 fill the metal container. Add enough water to metal container to fill 1/4 of the container. When sterilizer cycle is complete and the inside indicator device confirms a complete sterilizing cycle, remove the metal container with oven mittens ( to prevent burns) and decant the liquid and semi-liquid material down a sanitary sewer drain. The remaining plates may be discarded into the normal laboratory waste stream. Flush the sanitary sewer drain well after pouring the liquid into the drain. Because of the extra water in contact with the plates, an extra time factor may have to be added to the total sterilizing cycle. To insure the liquid in the bottom of the metal container has reached the necessary temperature, place a temperature indicator device into the bottom of the metal container at the beginning of the sterilizer cycle. If either of the temperature indicators inside the sterilizer fail to indicate that the sterilizing temperature was achieved, the entire sterilizer load will be re-autoclaved until the necessary temperatures have been achieved.

PPE shall be maintained by the University. Reusable PPE, e.g., lab coats, household gloves, shall be kept clean and stored in the area where it is necessary for PPE to be worn. All PPE will be removed prior to leaving the work area.

Sharps containers are to be properly marked with the international biohazard symbol. Sharps, even after sterilization are considered to be a biomedical waste. Sharps will always be disposed of properly in the designated sharps container. Employees should cease using a sharps container when the sharps container is at the 3/4 full level. Sharps should never be forced into a container. Employees should never attempt to recap needles manually unless a one hand technique is utilized. Prior to disposal, sharps containers are to be sealed.


Laboratory doors shall be kept closed when work is performed on bloodborne pathogens. The area is to be posted with the biohazard sign. See Enclosure 6 for an example of the biohazard sign. Access to the work area shall be limited to authorized persons. Only persons trained in biohazards may be authorized to enter work areas and animal rooms. Inside the laboratory, all activities involving human blood, other potentially infectious material, and infected animals will be conducted inside a biological safety cabinet. No work with these potentially infectious materials shall be conducted on the open bench. One exception is medical microscopy conducted in a medical environment. Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters that are checked annually when the biosafety hoods are certified.


Special attention should be given to the use of disposable airway equipment or resuscitation bags and the wearing of gloves when in contact with blood or other potentially infectious materials. Clear plastic face masks with one-way valves are available for use during mouth-to-mask ventilation. These masks provide diversion of the victim's exhaled gas away from the rescuer and may be used by health care providers and public safety personnel properly trained in their use during two-person rescue to replace the mouth-to-mouth ventilation technique. Such devices require two hands to secure a proper face seal and to maintain an open airway. The user of this device must be specially trained in the correct use of this device.

This program document was compiled from information extracted from Title 8, CCR, Section 5193 and 29 CFR Part 1910.1030.