Chris Miller, PHD
Last month`s column discussed several aspects of the Bloodborne Pathogens Standard, and this column continues the review.
Hepatitis B vaccination - The hepatitis B vaccination series (three inoculations at 0, 1 and 6 months) must be made available within 10 working days of initial employment of persons who have a potential of becoming exposed to blood or saliva while performing their job duties. However, before the vaccine is offered, free of charge, new employees must receive specific training about the vaccine so that they can make informed decisions. This training is to include information on the hepatitis B vaccine efficacy, safety, method of administration and the benefits of being vaccinated.
If an employee declines the vaccination after receiving the training, he or she must sign a specific statement declining the vaccination and the employer is to keep this in the employee`s medical records file.
The vaccination series must be made available to an employee at a reasonable time and place and by or under the supervision of a licensed health-care professional (HCP) - a physician or nurse practitioner. The employer must provide the HCP with a copy of the Bloodborne Pathogens Standard, and the HCP must administer the vaccine according to the current guidelines of the U.S. Public Health Service. The HCP must provide the employer with a written opinion stating whether the hepatitis B vaccination is indicated for the employee or if the employee has received the vaccination. The vaccination series need not be offered to those who have previously completed the vaccination series, those who have immunity as confirmed through antibody testing or those for whom the vaccine is contraindicated for medical reasons. Note: The U.S. Public Health Service still has not recommended the routine administration of a booster (fourth inoculation).
Post-exposure evaluation and medical follow-up -OSHA defines an exposure incident as "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." The employer is to establish a procedure for evaluation of an exposure incident, and this procedure is to be a part of the written Exposure Control Plan described in last month`s column.
An exposed employee should immediately report the incident to the employer to initiate the medical evaluation by the HCP. Such a timely report facilitates a prompt request for evaluation of the source patient`s HBV and HIV status. The exposed employee is directed to the HCP. The HCP is to be provided with five items:
- A copy of the Bloodborne Pathogens Standard.
- A description of the employee`s duties as related to the incident.
- A report of the specific exposure incident (e.g., an accident report) including routes of exposure and the circumstances under which the incident occurred.
- The results of the source patient`s blood tests, whenever they are available.
- Relevant employee medical records, including the hepatitis B vaccination status.
At that time, a baseline blood sample will be drawn, with the employee`s consent, to determine HBV and HIV status at the time of the incident. The employee may decline testing or delay HIV testing for up to 90 days, during which time the HCP must preserve the employee`s blood sample.
Testing the source patient`s blood usually cannot be done without written consent. Sometimes these tests are performed by the same HCP who is evaluating the exposed employee while other source patients prefer to have their personal physicians perform the tests. While the employer is responsible for making sure the results of these tests are transmitted to the evaluating HCP, the actual test results are confidential and should be directed only to the evaluating physician. The physician then can make these results known to the exposed employee.
Following the post-exposure evaluation, the evaluating HCP is to provide the employer with a written opinion stating that the exposed employee has been informed of the results of the evaluation and told of the need, if any, for further evaluation or treatment. All other information is confidential. The employer should keep this written opinion in the employee`s medical record file.
Communicating biohazards to employees - Warning labels are to be placed on containers of regulated waste, areas where blood or saliva are stored (e.g., refrigerator), and on other containers used to store, transport or ship blood, saliva, tissues or contaminated equipment. Red bags or red containers may be substituted for labels as long as everyone who may come in contact with the items has been trained as to the meaning of the color-coding. Labels required for contaminated equipment also shall indicate which portion of the equipment is contaminated.
Employee training - The employer must ensure that all employees covered under the standard participate in training, which must be provided at no cost to the employee and during working hours. This training shall occur at the time of initial employment and at least annually thereafter. This training must be comprehensive and at the education level, literacy and language of the employees. The person providing the training must be knowledgeable as to how the OSHA standard relates to dentistry (see related article).
Record-keeping - The standard requires the maintenance of training records and medical records. Each covered employee is to have a medical record that may be kept at the workplace or by the physician who provides vaccination and exposure evaluation services to the office employees. These records are to contain the hepatitis B vaccination status - the date of the vaccination, the written opinion from the health-care professional regarding the vaccination or the vaccination declination statement signed by the employee. These records also are to contain documentation of any exposure incidents involving the employee, including results of examinations, medical testing and follow-up procedures, the evaluating physician`s written opinion and a list of the information provided to the physician.
No part of the medical record is to be disclosed except to the employee, anyone having written consent of the employee or as permitted by state or federal law. These medical records are to be kept for 30 years past the employee`s last date of employment.
Training records are to document each training session and must be kept for three years. They are to include the date of training, an outline of the content, the trainer`s name and qualifications and names and job titles of the employees trained.
If an employer ceases to do business, the medical and training records are transferred to the new employer. If there is no new employer, the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services is to be contacted for directions regarding the disposition of the records at least three months prior to their intended disposal.
In summary, a review of the OSHA rules presented in the last two issues of RDH should serve as a check-up on the current state of disease-prevention procedures in your office.
Chris Miller is director of Infection Control Research and Services and professor of oral biology at Indiana University.
Contents of OSHA training
- An accessible copy of the regulatory text of the standard and an explanation of its contents.
- A general explanation of the epidemiology and symptoms of bloodborne diseases.
- An explanation of the modes of transmission of bloodborne pathogens.
- An explanation of the employer`s written Exposure Control Plan and how to obtain a copy.
- An explanation of the appropriate methods of recognizing tasks and other activities that may involve exposure to blood or saliva.
- 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.
- Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
- An explanation of the basis for selection of personal protective equipment.
- Information on the hepatitis B vaccine as described above.
- Information on the appropriate actions to take and the persons to contact in an emergency involving blood/saliva.
- An explanation of the procedures to follow in the event of an exposure incident including the method of reporting the incident and the medical follow-up that will be made available.
- Information on the post-exposure evaluation and the medical follow-up that will be made available.
- An explanation of the signs and labels and/or color-coding used to identify biohazards.
- A question and answer session over any aspect of the training.