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Section D1: Bloodborne Pathogens


Blood or certain other body fluids may contain pathogenic agents, that is, microorganisms that cause disease. Among those pathogens that may be present are hepatitis B and C viruses (HBV or HCV) or human immunodeficiency virus (HIV) which causes AIDS. If an individual has blood exposure to broken or injured skin, mucous membranes of the eyes, nose, mouth, or by needle stick or other injection, there is the potential of infection with any possible pathogen that might be present. To minimize the risk of infection, information and training must be provided to those who will likely be exposed; hepatitis B vaccination is offered; protective measures in the work environment are instituted; and exposures are reported to ensure that proper medical evaluation and treatment can be provided. It is especially important that employees with potential exposure understand and follow the principle of "Universal Precautions" as required in the Occupational Safety and Health Administration standard. "Universal Precautions" is the infection control approach in which all blood and body fluids are treated as if they are infected and the necessary precautions are taken.

Scope and Application

Federal OSHA standards require a Bloodborne Pathogens Program for employees with job responsibilities which "reasonably expose" them to blood and certain other body fluids, unfixed human tissue or cell cultures. This program is intended to prevent infection with bloodborne pathogens. Under University policy, the Bloodborne Pathogens Program applies to all individuals, including students, who may be exposed through University programs and activities.

At Baylor University, individuals with responsibilities for medical support and emergency response (e.g., Public Safety security officers and proctors) are examples of those who have potential exposure and are included in the program. Research activities involving human blood or tissues places laboratory personnel at risk of exposure and requires those researchers to be in the program.

However, "good Samaritan" actions, such as an employee or student who provides assistance to another individual in the case of a nose bleed or other injury, are not covered under the Bloodborne Pathogens Program.

Program Description

Exposure Control Plan

Each department develops a written Exposure Control Plan indicating those job classifications and the tasks and procedures which involve potential exposure. The plan also includes an indication of the required engineering and work practice controls, personal protective equipment, housekeeping, labeling, training, and medical surveillance functions that will be instituted.

A model Exposure Control Plan is available through Environmental Health and Safety (EHS) in the Biosafety Manual (coming soon).


Training must be provided initially at the time workers are assigned tasks involving exposure and annually thereafter. This training is provided through an on-line, interactive web-based program, Protection Against Bloodborne Pathogens.

The online training consists of a number of informational modules including explanation of the OSHA Standard, epidemiology and transmission of bloodborne pathogens, appropriate work practices, and exposure control procedures.

Training will be followed by a testing section and concludes with registration in the Bloodborne Pathogens Program and offer of Hepatitis B vaccination. Each training module offers the opportunity to e-mail any questions you may have and to receive a response by the end of the following day.

It is the responsibility of the supervisor to ensure that workers complete initial and annual training.

Medical Surveillance

Those who are potentially exposed to bloodborne pathogens are offered the hepatitis B vaccination at no cost to the individual. Although this vaccination is strongly recommended, an individual can choose not to accept it and sign a declination statement.

Roles and Responsibilities


  • Identify individuals at risk of exposure and notify EHS.
  • Develop a written departmental Exposure Control Plan as described above.
  • Review the plan on an annual basis or as exposure conditions change.
  • Ensure that employees complete the required initial and annual training.
  • Provide personal protective equipment and engineering controls to eliminate or reduce exposure.
  • Maintain current written Exposure Control Plan.


  • Ensure that those exposed complete the required training.
  • Ensure that those exposed have available and use the appropriate personal protective equipment and that "Universal Precautions" are followed.


  • Conduct initial and annual training.
  • Provide and update on-line training program and training data base.
  • Provide assistance in meeting OSHA standard requirements.
  • Investigate exposure incidents.
  • Audit department program periodically.


  • Complete the provided training and understand the risk associated with the job.
  • Consider seriously the offer of hepatitis B vaccination.
  • Follow the appropriate practices and procedures established for the work environment to limit or prevent exposures, and adopt the principle of "Universal Precautions".
  • Report any exposures to supervisory personnel and undertake the necessary medical review and treatment.

For More Information

Contact EHS at 710-2900.

Further information is available in the following references:

Health and Safety Guide Table of Contents