Administration Policies

VI-11.00(A)

UMB Policy on Prevention and Management of Student and Employee Infection with Bloodborne Pathogens

Administration   |   Approved August 13, 2019

Responsible VP/AVP

Dawn M. Rhodes, DBA, MBA

Purpose

This Policy sets forth the principles and general practices of UMB with respect to education, prevention, and management of exposure to Bloodborne Pathogens. All related policies, guidelines and practices of UMB's Schools and other Units are expected to be consistent with this Policy. This Policy shall be made available to the UMB community, students, and prospective and current employees.

UMB must comply with the laws and regulations relating to Bloodborne Pathogens which have been enacted or issued by the United States Government and by the State of Maryland. Other UMB policies specifically address compliance with those regulations. This Policy shall be interpreted to be consistent with State and federal laws and regulations in all respects. This Policy also shall be interpreted and applied consistently with the applicable Maryland and federal laws of professional licensure, informed consent, and confidentiality of student and other personally identifiable records. The President or the President’s designee may waive or modify this Policy as required to attain compliance with such laws and regulations.

This Policy sets forth the principles and general practices of UMB with respect to education, prevention, and management of exposure to Bloodborne Pathogens. All related policies, guidelines and practices of UMB's Schools and other Units are expected to be consistent with this Policy. This Policy shall be made available to the UMB community, students, and prospective and current employees.

UMB must comply with the laws and regulations relating to Bloodborne Pathogens which have been enacted or issued by the United States Government and by the State of Maryland. Other UMB policies specifically address compliance with those regulations. This Policy shall be interpreted to be consistent with State and federal laws and regulations in all respects. This Policy also shall be interpreted and applied consistently with the applicable Maryland and federal laws of professional licensure, informed consent, and confidentiality of student and other personally identifiable records. The President or the President’s designee may waive or modify this Policy as required to attain compliance with such laws and regulations.

Policy Statement

  1. Non-Discrimination
    1. Patients and Clients. All Schools and Units of UMB shall make their facilities and services for health care and for client services available to patients and clients without regard to their status as Source Individuals or Confirmed Source Individuals. However, as medically appropriate, some Source Individuals and Confirmed Source Individuals may be referred to treatment in special settings or denied access to some programs in order to safeguard their welfare, the health of other patients or clients, and the safety of UMB Personnel. All UMB Personnel who provide health care, counseling or other client services are required to provide services to all eligible patients and clients.
    2. Employees and students. Inquiries about infection with HBV, HCV or HIV will not be made of prospective UMB Personnel. Neither admission nor employment will be denied any otherwise qualified individual on the basis of infection with Bloodborne Pathogens. Depending on the circumstances, programs may communicate to prospective students and employees how infection with Bloodborne Pathogens may limit their training and professional opportunities.
    3. Public Materials. All program brochures, catalogues, and other materials for clients, patients, students, and employees shall provide notice of the policy of non-discrimination and the expectation that UMB Personnel will provide services to all patients and clients.
  2. Standard Precautions
    1. School or Unit. Each School and Unit is responsible to identify its UMB Personnel who have Occupational Exposure and are at risk of an Exposure Incident; to ensure that these UMB Personnel receive training in Standard Precautions; and to require the use of Standard Precautions by these UMB Personnel.
    2. UMB Personnel. UMB Personnel may be subject to disciplinary action (including but not limited to termination of employment or dismissal from academic programs) for failing to use or implement Standard Precautions.
  3. Education and Communication on Exposure to Bloodborne Pathogens

Each UMB School and Unit shall communicate with its UMB Personnel who could be at risk of being exposed to known biohazards and shall educate its UMB Personnel with Occupational Exposure regarding HIV, HBV, HCV, and other bloodborne diseases. The requirements of 29 CFR 1910.1030(g) (paragraph (g) of the OSHA Standard) shall be followed for UMB employees and, to the fullest extent practical and appropriate, shall be followed for other UMB Personnel.

  1. Immunization Against HBV
    1. Students. Students enrolling in academic programs that have educational components that have the potential for exposure to human blood or body fluids must be vaccinated against HBV at their own expense unless an individual School has elected to provide vaccination at no cost to its students. Students should check with their School if they have questions on whether the program they are enrolling in requires them to be vaccinated against Hepatitis B. Students may be vaccinated at the primary Student Health Office, which is UMaryland Immediate Care (UMIC) located at 408 W. Lombard Street. Baltimore, Maryland. Those who were immunized prior to enrollment must provide evidence of immunization to the School or Unit. Immunization can be waived only for documented medical contraindications. Each School or Unit, in consultation with the Student Health Center, will establish the schedule for students to obtain vaccinations or present evidence of immunization.
    2. Employees. As required by the OSHA Standard, UMB shall make the HBV vaccine and vaccination series available to all UMB employees who have Occupational Exposure or have had an Exposure Incident. The vaccination shall be offered at no cost to employees. Employees who decline the vaccination must sign a Hepatitis B Vaccine Declination Statement.
    3. Consultants, Visitors, and Volunteers. Consultants, visitors, and volunteers who have Occupational Exposure shall be offered the HBV vaccine and vaccination series at their own expense. Alternatively, the School or Unit in which such personnel work may support the cost of vaccination, at the discretion of the responsible School or Unit administrator.
  2. Affiliated Institutions

Many UMB Personnel perform their duties in affiliated institutions that have their own infection control policies. UMB Personnel assigned temporarily or permanently to affiliated institutions are expected to know and follow the policies of those institutions.   

  1. Management of Exposure Incidents
    1. Compliance with OSHA Standard. Management of Exposure Incidents involving UMB Personnel will comply with the OSHA Standard. Exposure Incidents involving students during experiences that are required or are otherwise part of their UMB educational program will be managed under the OSHA Standard, notwithstanding that the OSHA Standard applies only to employees.  Exposure Control Plans shall be developed by Schools or Units and publicized among students. These plans shall provide information about the steps to be followed in the event of an Exposure Incident.
    2. Reporting. Following a suspected or known Exposure Incident, the affected UMB Personnel should report the incident to the appropriate authority identified in the Exposure Control Plan.
    3. Testing and Treatment. Following a suspected or known Exposure Incident, testing will be available to the affected UMB Personnel through the University of Maryland Immediate Care Center. Testing is at the option of the exposed individual.  Costs of testing and treatment for students are generally covered under the student’s primary and accident-only health insurance. If students have any additional costs due to an exposure after claims have been submitted to their primary health insurance and the UMB Student Accident Plan, students may contact the UMB Office of Academic Affairs to seek reimbursement of any remaining costs (see Academic Affairs Student Reimbursement Request: Blood-Borne Pathogens www.umaryland.edu/academicaffairs/policies/bloodbornepathogens/     Testing and treatment will be provided at no cost to UMB employees.
    4. Counseling.  Pre-test and post-test counseling will be offered to all UMB Personnel affected by a suspected or known Exposure Incident.  Counseling will be provided at no cost to students by the Student and Employee Health Center.  Counseling will be provided at no cost to UMB employees.  Counseling will include a review of the advantages and disadvantages of anti-viral preventive medications, which generally can be offered by UMB.
    5. Consultants, Visitors, and Volunteers. Costs of testing, counseling, and treatment for consultants, visitors, or volunteers who may be affected by a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials will not be covered by UMB unless a School or Unit agrees to assume such costs.
    6. Off-Site Exposure Incidents. Exposure Incidents that occur while UMB Personnel are performing their duties or assignments at any location other than at UMB optimally should be handled by an appropriate exposure control plan and procedures in place at that site; however, if appropriate procedures are not available, Student and Employee Health will provide testing, counseling and treatment services as specified above.
    7. Off-Site Exposure Incidents at Hospitals in Maryland. If an Exposure Incident occurs at a hospital in Maryland, the designated infectious disease/communicable disease officer of the hospital may be required to order a test for the presence of antibodies to HIV pursuant to Maryland Annotated Code, Health-General Article § 18-338.3.  The affected UMB Personnel should contact Student and Employee Health for assistance.       
    8. Information about Confirmed Source Individuals. To the extent permitted by law, UMB will provide to exposed UMB Personnel, and will ask the relevant health care facility to provide to exposed UMB Personnel, information about the infectious status of Confirmed Source Individuals involved in Exposure Incidents with UMB Personnel.
  2. Respective Roles of Schools and Units and the Office of Environmental Health and Safety (EHS) in UMB Policies for Bloodborne Pathogens
    1. In general, it will be the responsibility of Schools and Units of UMB to implement and monitor compliance with the OSHA Standard, this Policy, and other UMB, School and Unit policies (as applicable in specific cases) related to Bloodborne Pathogens. Each School or Unit required to do so by the nature of its activities must develop an Exposure Control Plan. The plan should be developed in consultation with, and is subject to approval by, the EHS Institutional Biosafety Committee.
    2. Each School or Unit will be responsible for identifying its UMB Personnel having Occupational Exposure (such identification to be made on the basis of job responsibilities, not job title), communicating that determination to EHS, and maintaining a list of such positions.
    3. Schools and Units should arrange with EHS appropriate training programs as required by the OSHA Standard. Such training may be accomplished either by course(s) developed and given by EHS, or by courses developed and given by the School or Unit after review and approval of course content and format by EHS.
    4. EHS will keep Schools and Units informed of changes in laws and regulations related to exposure to Bloodborne Pathogens.

Definitions

In this Policy, the following terms have the meanings set forth in this section:

  1. “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, HBV, HCV, and HIV (each as defined below).
  2. “Confirmed Source Individual” means a Source Individual (as defined below) known, as a result of pre-exposure or post-exposure testing, to be infected with a Bloodborne Pathogen.
  3. “Exposure Incident” means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact of UMB Personnel (as defined below) with blood or other potentially infectious materials that results from the performance of the UMB Personnel’s duties or assignments.
  4. “HBV” means hepatitis B virus.
  5. “HCV” means hepatitis C virus.
  6. “HIV” means human immunodeficiency virus.
  7. “Occupational Exposure” means reasonably anticipated eye, mouth, other mucous membrane, non-intact skin, or parenteral contact of UMB Personnel with blood or other potentially infectious materials that may result from the performance of UMB Personnel's duties or assignments, including assigned work, volunteer tasks being performed by UMB Personnel, academic programs, and academic practicum experiences. Occupational Exposure may occur in many contexts, including but not limited to, patient care, client services, research activities, classroom work, housekeeping, maintenance, and security services.
  8. “OSHA Standard” means the Bloodborne Pathogens Standard issued by the U.S. Department of Labor Occupational Safety and Health Administration, as amended from time to time and published as 29 CFR 1910.1030.
  9.  “Source Individual” means any individual, living or dead, whose blood or other potentially infectious materials may be a source of Occupational Exposure to UMB Personnel. 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.
  10. “Standard Precautions” is an approach to infection control where all human blood, unfixed tissues and certain human body fluids are treated as potentially infectious. Standard Precautions are the minimum infection prevention practices to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources.
  11.  “UMB Personnel” means (i) all part-time and full-time students of UMB; and (ii) all employees of UMB, including full-time, part-time, temporary, and contractual personnel in any employment category.  Consultants, visiting personnel and volunteers, other than UMB Personnel performing volunteer tasks, are specifically excluded. 
  12. Any term used in this Policy which is defined in 29 CFR 1910.1030(g) (paragraph (b) of the OSHA Standard) shall have the meaning set forth in the OSHA Standard unless a different meaning is set forth in this part of this Policy.
Related Procedures
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