Policy

Working Safely with Blood and Body Fluids - Policy

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1.  Purpose and Objectives

The purpose of this policy is to ensure that the University meets  its duty of care under OH&S legislation and the University OH&S policy, as it relates to the handling and/or exposure to blood and body fluids.

2.  Definitions, Terms, Acronyms

Blood and body fluids - blood, blood products, tissue, body fluids and any derivatives produced by chemical or physical means (e.g. protein, enzyme or blood fractions).

3.  Policy Scope/Coverage

This policy applies to all staff, students, contractors and visitors who handle blood and body fluids or may be exposed to blood and body fluids.

4.  Policy Statement

This Policy is intended to inform and guide staff, students, contractors and visitors in the course of their work or study when conducting or participating in approved work or research for UQ. This policy has been developed to provide high-quality health and safety advice for staff, students, contractors and visitors.

The University of Queensland is committed to providing staff, students, contractors and visitors with a healthy and safe environment for work and study. The University recognises that staff, students, contractors and visitors working or studying at the University may handle or be exposed to blood and body fluids. In addition, in the clinical setting (when teaching or conducting research), patients could be accidentally exposed to blood from health care students or staff.

The areas in which there is an increased risk of exposure include:

Exposures to human blood and body fluids are associated with the risk of contracting potentially fatal infectious diseases, some of which are not vaccine-preventable. For this reason, this policy relates in particular to human blood and body fluid exposure.  Precautions must however be applied to the handing of all blood and body fluids whether of human or animal origin.

The University promotes continual assessment of the risks to staff, students, contractors and visitors who work with blood and body fluids or perform exposure prone invasive procedures. The University requires the maintenance of an on-going risk assessment and management program using the UQ Risk Management Database.

The University has based all procedures and work instructions on the assumption that blood and body fluids must always be handled as if they are infected.

This policy must be read in conjunction with the Working Safely with Blood and Body Fluids - Guideline.

5. Roles and Responsibilities of University Staff in Working Safely with Blood and Body Fluids

The University as a whole is responsible for providing the resources for implementation of this policy and associated guideline. 

  • the Vice-Chancellor, Deputy Vice-Chancellors, Directors, Executive Deans, Institute Directors and Heads of Schools are responsible for implementation of the Working with Blood and Body Fluids Policy;
  • Heads of organisational units are responsible for recognising situations where the guidelines may apply, ensuring local safe procedures are developed and implemented in their units, and advising the Occupational Health & Safety Division of difficulties in implementing these local safe procedures;
  • supervisors are responsible for ensuring that individuals under their control understand the risk and comply with the guidelines and ensuring that these individuals are supplied with the necessary safety equipment to protect staff, students and visitors to the laboratory and are given access to appropriate advice on the need for immunisation where appropriate and available;
  • all staff and students whose work or study requires them to work with blood and or body fluids must comply with the requirements of this policy;
  • the Director, Occupational Health & Safety is responsible for advising the University Occupational Health & Safety Council on the implementation of the policy; and
  • the Director, Occupational Health & Safety, the Biological Safety Advisor and the Occupational Health Nurse Adviser are responsible for providing advice regarding safe work practices and procedures.
 
Custodians
Director, Occupational Health and Safety
Mr Jim Carmichael

Guidelines

Working Safely with Blood and Body Fluids - Guidelines

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Body

1. Purpose and Objectives

These guidelines provide a basis for developing, maintaining and implementing local safe work instructions for staff, students, contractors and visitors at The University of Queensland who handle or may be exposed to human or animal blood and body fluids. This document particularly relates to blood and body fluid of human origin however all such materials, irrespective of their origin, should be handled as if potentially infectious.

2. Definitions, Terms, Acronyms

Blood and body fluids - blood, blood products, tissue, body fluids and any derivatives which harbour the potential to transmit human or zoonotic infection.

Exposure prone procedures - Any situation where there is a potentially high risk of transmission of blood borne disease from HCW to patients during medical or dental procedures. These situations are usually characterised by the potential for direct contact between the skin (usually fingers and thumb) of the HCW and sharp surgical instruments, needles, or sharp tissues (spicules of bone or teeth) in body cavities or in poorly visualised or confined body sites, including the mouth.

HBV - Hepatitis B virus.

HCV - Hepatitis C virus.

HCW - Health care worker.

HIV - Human Immunodeficiency Virus.

Invasive procedures - Any surgical entry into tissue, body cavities or organs, or repair of traumatic injury.

P2 mask - an AS/NZS1716 rated particle respiratory filter mask. P2 masks are suitable to capture particles in the sub micron range such as mechanically and thermally generated particles and very small particulates such as bacteria and viruses.

PC3 Laboratory - Certain dealings with biological materials or genetically modified organisms must be contained within physical containment facilities. There are four levels of laboratory containment that reflect the level of risk to the worker, community and the environment. A laboratory that has been certified as PC3 has achieved a level 3 standard of physical containment. A PC3 facility is suitable for work involving specific high risk or genetically modified organisms as listed in the AS/NZS 2243.3:2010 Safety in Laboratories Part 3 : Microbiological safety and containment (Available from Sai Global on-line Standards database via UQ Library).

Zoonotic disease - A disease that can be passed between animals and humans.

3. Guidelines Scope/Coverage

These guidelines apply to all staff, students and volunteers who work with or who are potentially exposed to human or animal blood and body fluids as a consequence of their workplace activities at UQ.

4. Guidelines Statement

Working with human or animal blood products, tissue and body fluids increases the risk of a worker acquiring a blood borne infectious disease. Some blood borne infections do not have a vaccination available to prevent transmission of disease, therefore all blood and body fluids should be handled as if they are potentially infectious. This guideline supplements PPL 2.60.10 Working Safely with Blood and Body Fluids.

All UQ staff and students working in Queensland Health care facilities must also refer to the Queensland Health Guideline for the management of occupational exposure to blood and body fluids.

5. Identifying Workers at Risk

Each faculty/school/centre is responsible for identifying workers at risk of being exposed to human or animal blood and body fluids. Those at risk will include staff, students, contractors and visitors:

  • working in laboratories in which blood and body fluids are handled.
  • working in clinical settings and some research laboratories in which blood and body fluids are handled and/or exposure-prone invasive procedures are performed.

Where there is doubt about the potential for exposure, contact the Occupational Health and Safety Division or the Occupational Health Nurse Advisor for assistance with the risk assessment.

5.1 Risk assessment and training

Each faculty/school/centre is responsible for ensuring the safety of staff, students, contractors and visitors by maintaining an ongoing and appropriate risk identification and management process, which includes the following:

  • Identifying the tasks in which potentially infectious material is handled and assessing the associated risks.
  • Applying local safe work instructions and procedures to minimise the level of risk involved.
  • Implementing recommended immunisation requirements.
  • Ensuring personal and workplace hygiene is of the highest standard.
  • Completing workplace inductions for all new staff, students and contractors as well as visitors to the area to ensure they are familiar and compliant with safe operating procedures and occupational immunisation requirements.
  • Ensuring all persons who are potentially exposed to human or zoonotic infectious pathogens, are informed about possible routes of pathogen transmission and signs and symptoms associated with an infection for the specific pathogens they are working with or are potentially exposed to.
  • Ensuring all female employees of reproductive age, potentially exposed to human or zoonotic infectious pathogens, are informed of the risks associated with occupational exposure to infectious pathogens that could adversely affect foetal development or their own maternal health during pregnancy. For further information refer to PPL 2.60.05 - Working Safely with Reproductive Hazards - Guideline.
  • Ensuring adequate provision of sharps disposal containers wherever sharps are being used.
  • Ensuring adequate provision of scalpel blade removal devices for tasks requiring the use of scalpel blades.
  • Ensuring adequate provision of appropriate sharps safety devices in situations where high risk biological or chemical substances are being used and the risk of a sharps injury exists.

Risk assessments should be completed using the UQ Risk Management Database.

Local reporting procedures must be implemented for the following incidents and documented on the UQ Incident and Injury Database.

  • Blood, blood products, tissue or body fluids entering through the skin (needlestick or other contaminated sharp injuries) or onto mucosal surfaces (e.g. inside the mouth, nose or onto eyes).
  • Any “near miss” incidents, including splashes on to the skin, particularly facial skin.

6. Immunisation

PPL 2.60.08 Vaccination and Immunisation - Policy and Guideline should be read in detail as those handling human or animal blood, blood products, tissues and body fluids or performing exposure prone invasive procedures are at risk of contracting infectious diseases, some of which are vaccine-preventable.

Staff and students should also refer to their school or centre’s immunisation requirements. The University recognises that many of its students and staff perform duties or placements in Queensland government facilities and these students and staff (and the University) are obliged to observe the immunisation requirements imposed by the state government. In particular, Queensland Health requires that all potentially at-risk health care staff and visitors (including students) be vaccinated against hepatitis B. The University of Queensland adopts and complies with the Queensland Health 'Vaccination of Health Care Workers' guideline in this area.

6.1 Screening

The University of Queensland adopts and complies with the Queensland Health 'Vaccination of Health Care Workers' guideline and the Australian Government NHMRC Australian Guidelines for the prevention and Control of Infection in Healthcare in this area. Queensland Health requires that all health care workers in the Queensland health care system should consider their infectivity status for HBV, HCV and HIV and seek voluntary testing where appropriate. Health care workers involved in direct patient contact or contact with patient contaminated material (e.g. blood and other body fluids) must be aware of their status regarding HBV, HCV and HIV infection by seeking serological testing every 12 months if they are:

  • untested and presently performing exposure prone procedures.
  • about to commence performing exposure prone procedures.
  • performing exposure prone procedures and are involved in a significant exposure to blood and body substances.

Hepatitis B vaccination or proof that an individual is not susceptible to hepatitis B is a condition of employment in Queensland Health facilities for all staff and students who have direct contact with blood or body substances. Queensland Health does not recommend that health care facilities request evidence of compliance with the guidelines for serological testing for other blood borne viruses.

Health care workers who are hepatitis B e Antigen positive, HBV DNA or PCR positive, HCV PCR positive, or HIV Antibody positive must not perform ’exposure prone procedures’. Health care workers who are hepatitis B s Antigen positive should determine their hepatitis B e Antigen and HBV DNA and PCR status and seek specialist advice (even if the latter two tests are negative).

Queensland Health Guideline for the Vaccination of Health Care Workers 2012 recommends that health care and laboratory workers who have direct contact with human blood or body substances have a full hepatitis B immunisation course and further, should seek serological testing for hepatitis B surface antibody so that non-responders can be alerted to the need for hepatitis B immunoglobulin after an occupational exposure. Health care workers who have no immunity to HBV, that is are hepatitis B surface Antibody negative despite vaccination, should seek advice before performing ‘exposure prone procedures’.

6.2 Baseline serum sample

It is not recommended that blood samples be taken routinely from new or current staff and students for baseline serum levels. However, it may be required as a result of the outcome of a risk assessment and the facility containment level involved. Persons working in Physical Containment 3 (PC3) facilities will require health monitoring. This may include initial and periodic examinations requiring a medical examination, chest X-ray, appropriate vaccination and where relevant, a baseline serum sample. Such blood samples must be taken after obtaining informed consent. The sample must be stored securely with appropriate documentation, bearing in mind the medical and legal implications involved in the subsequent use of such specimens.

7. First Aid

When working with blood and body fluids a prompt response to wounds is critical, especially cuts and needle stick injuries. Following are important points that should be incorporated into faculties/school/centre local safe work instructions:

  • Bleeding should be encouraged but squeezing and rubbing the affected site should be avoided.
  • Puncture wounds or cuts should be washed with soap and water.
  • Splashes into the eye should be flushed using an eye wash fountain or saline with eye open for at least 30 seconds.
  • If splashing to the face occurs then gentle washing and rinsing several times with water should be used for the skin, nose and mouth.
  • All staff and students working in Queensland health care facilities are also advised to refer to the Guideline for the management of occupational exposure to blood and body fluids.

Immediately following such incidents, advice from a medical practitioner should be sought. Appropriate advice can be obtained from The University of Queensland Health Services, hospital infection control or from a general practitioner. The incident should be reported to the supervisor and also reported on-line in the UQ Injury, Incident and Illness database. It is imperative that local safe work instructions provide details for immediate referral to a medical practitioner, and where possible, give the name and contact details of a preferred medical practitioner familiar with the workplace and its occupational hazards. Immediate referral should be made to an infectious disease specialist if the injury is high risk for HIV infection as prophylactic treatment to prevent HIV infection may be indicated and should be started within a few hours of such an injury.

8. Decontamination and Disposal

8.1 Disposal of contaminated items

UQ staff and students working in Queensland Health facilities should refer to local hospital/facility guidelines and the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010).

The use of disposable equipment should be considered wherever it is impossible to ensure decontamination and sterilisation.

Local safe work instructions should include:

  • Clarification of responsibility to ensure an item is safe before it is moved from the site where it has been used.
  • Detailed instructions regarding safety devices for removal of scalpel blades.
  • Detailed procedures regarding disposal of needles, scalpel blades and syringes in rigid-walled puncture resistant containers.
  • Detailed procedures for re-using glassware and safe disposal of discarded glassware.
  • Procedures for management of linen (both laundering and disposal as infectious waste).

8.2 Disinfection and management of spills

UQ staff and students working in Queensland Health facilities should refer to local hospital/facility guidelines and the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010).

Local safe work instructions for disinfection should be very specific to the tasks and items used and the following should be reinforced:

  • Disinfection and cleaning up after work with human blood and animal body fluids should be conscientiously performed.
  • Spills should be cleaned up immediately using similar techniques.<
  • Gloves must be worn.
  • Use tongs to pick up broken glass.
  • Remove the blood or body fluid with absorbent material.
  • Using a detergent solution, clean the site thoroughly.
  • Wipe down the site with disposable towels soaked in a disinfectant solution containing 500 mg/litre (500 parts per million) of available chlorine.
  • Dispose of all contaminated waste material into leak-proof bags.
  • If the site is porous or cannot be adequately cleaned prior to disinfection then a solution containing at least 5000-10000 (ppm) or 0.5-1% of available chlorine should be used.
  • Commercial laundry bleach (approx 5% available chlorine) is suitable and is diluted with tap water 1:10 to obtain 5000 ppm.
  • Hypochlorite solutions must be prepared daily.

Chemicals effective against HBV are effective against HCV and HIV. Sodium hypochlorite is recommended as a safe and effective agent for surface disinfection. Some unpainted metals are corroded by sodium hypochlorite and a phenolic or iodophor disinfectant may be substituted. In each case the manufacturer’s instructions for the use of the disinfectant should be followed. It is not recommended that glutaraldehyde be used as surface disinfectant due to its toxicity.

8.3 Instrument decontamination, repair and transport

Instruments and equipment should be used in such a manner that minimises surface contamination or the production of droplets.

In the event of minor spillage occurring surfaces and equipment should be decontaminated as soon as practicable.

In the event of major spillage occurring, staff and students should vacate the area prior to clean up and signage should be applied to relevant areas (e.g. instructing users not to enter a contaminated area or use contaminated equipment). Signage should indicate the relevant date and time of the spill.

For any spill that generates an aerosol such as a centrifuge spill or spill from height, personnel should vacate the area and the aerosol should be allowed to settle for 30 minutes before proceeding with disinfecting equipment.

In the event of a breakage or leakage within a centrifuge, as with spills, gloves must be worn and the centrifuge decontaminated, remembering to disinfect the outside of all unbroken vials.

Equipment surfaces exposed to potential contamination should be disinfected daily. If necessary the equipment manufacturer’s advice should be sought regarding compatibility of disinfectants with surfaces or functions. All instruments and equipment that require service or repair must be cleaned free of blood and disinfected before leaving the laboratory.

Local safe work instructions must take into account:

  • The need for transport and repair of instruments used in areas in which blood and body fluids are handled or stored.
  • The requirement that the Biosafety Adviser or the manufacturer be consulted for advice should any instrument need external servicing, particularly if it cannot be decontaminated before being transported.

9. Laboratory Plans and Procedures

9.1 Working safely in a laboratory

The University of Queensland Institutional Biosafety Committee require research projects involving unscreened human blood or body specimens or potentially infectious blood or body specimens from animal origin, have a UQ biosafety approval in place prior to the project commencing as outlined in PPL 2.40.15 Working with Potentially Hazardous Biologicals.

9.1.1 Local safe work procedures

Local safe work procedures should take into account the following recommendations for laboratory design and layout:

  • Laboratory space and placement of equipment should not create a crowded working environment nor inhibit cleaning.
  • Laboratory surfaces and floors should be made of impervious material to allow for effective cleaning.
  • Facilities for hand washing with elbow or foot operated taps should be provided in each work area.
  • Eyewash stations should be available in each work area.
  • Biohazard containers for the safe disposal of contaminated materials and sharps should be provided in adequate numbers in appropriate places in each work area.
  • Laboratory doors and specimen storage areas should be marked as containing a biohazard.
  • Offices and study areas should be separated from laboratory work areas.
  • Restriction of laboratory access should be enforced as appropriate.

9.1.2 Containment of aerosols

  • Local safe work procedures should be specific about control of aerosols.
  • Define the tasks required to always be undertaken in laminar flow cabinet.
  • Define the tasks to be undertaken in Biological Safety cabinets.
  • As a minimum, Class I or Class II biological safety cabinets should be used for any procedures likely to produce aerosols of blood, bodily fluids or their products (e.g. sonication, agitation, blending, procedures producing foam, froth, spray and aerosols as well as the decanting of large volumes of fluids in open containers).
  • Define the maintenance and testing procedures for Biological Safety cabinets and all ventilation systems to ensure that they are operating to specification. Ensure they are tested and serviced at intervals of not more than one year.
  • If a Biological safety cabinet is not working, "DO NOT USE" warning signage must be displayed.
  • Centrifuge tubes should be sealed closed or sealed rotors should be used for spinning of any potentially contaminated material. Operators should ensure the rotor has completely stopped turning before opening the lid.

9.2 Emergency procedures

Emergency plans should be prepared in consultation with the Occupational Health Nurse Adviser, the Biosafety Adviser and OHS Division. This plan should be displayed prominently and cover the following:

  • Location of emergency equipment.
  • UQ Emergency Procedures.
  • Management of accidental swallowing of potentially hazardous material, accidental skin puncture or cut and breakages/leakages.

9.3 Transport of specimens

The Transport of Dangerous Goods Class 6.2 Infectious Substances are regulated by the following, depending on the mode of transport:

  • International Air Transport Association (IATA) Dangerous Goods regulations.
  • Australia Post Dangerous and Prohibited Goods and Packaging Post Guide.
  • Australian Code for the Transport of Dangerous Goods by Road and Rail.

These regulations require mandatory training for:

  • packaging to IATA standards (i.e. to send biological material on either domestic or international flights).
  • packaging and transport for land transport of biological material. An important issue is the lack of insurance cover if such material is transported in a private vehicle.

If you are transporting biological material, which is either infectious or diagnostic, please contact the Biosafety Adviser at the Occupational Health and Safety Division for advice and refer to PPL 2.40. Transport of Biological Materials.

10. Protective Clothing

Detailed advice about the best type of protective clothing appropriate for use in each circumstance can be sought from OHS Division. The following are important points which should, as appropriate, be incorporated in local safe work instructions and on-site training.

10.1 Gloves

  • Always wear when likely to be in contact with the specimen or contaminated surfaces or material.
  • Always wear if there is any open skin lesion or dermatitis as these conditions increase the risk of infection.
  • Select disposable gloves that fit well and are easily replaced.
  • Damaged gloves must be replaced immediately.
  • Remove gloves after task completion (e.g. before handling telephones, performing office work and leaving the laboratory).
  • If a telephone is contaminated wipe thoroughly with 70% alcohol.
  • Gloves must be worn when working in a biological safety cabinet in PC2 certified facilities.
  • Gloves must be worn when working in PC3 certified facilities.

10.2 Face and eye protection

  • Facial protection such as safety glasses, P2 mask or face shield must be worn if there is a risk of splashing or spraying of blood or body fluids.
  • Eye protection should be worn when transferring blood or bodily fluids. A full-face shield provides the greatest degree of protection - see Guideline on Eye Protection in Laboratories.
  • Contact lenses will not protect the eyes from exposure and may absorb chemicals or biologicals.

10.3 Gowns and laboratory coats

  • Back opening or wrap around gowns should be worn in laboratories in preference to wearing a laboratory coat.
  • Gowns should be worn in laboratories at all times and removed or discarded on leaving the laboratory.
  • Disposable gowns should be used when working with infectious pathogens, high risk biologicals or cyto-toxic materials.
  • Ensure gowns have a closed, completely covered front.
  • Gowns should be discarded appropriately when soiled or contaminated.

10.4 Footwear

  • Closed shoes must be worn in the clinical and laboratory environment.
  • High heels are not appropriate in the clinical and laboratory environment.

11. Personal Hygiene

The following are important points which should, as appropriate, be included in local safe work instructions and on-site training.

11.1 Hand washing

Attention to hand washing is an essential part of good practice:

  • Hands should be washed thoroughly with soap and water immediately if contaminated with blood or other body fluids or if gloves have been torn or punctured.
  • All wounds should be covered with waterproof dressings.
  • Hands should be washed at completion of the workday or session.
  • Elbow or foot operated taps should be available.

11.2 Hand care

  • The use of moisturising cream is recommended where frequent hand washing is required.
  • Antimicrobial hand gels are available with moisturisers and these can reduce the drying effects of frequent hand washing.
  • Nails should be kept trimmed and clean.

11.3 Avoiding contact

Staff must avoid inadvertent contact with their skin or mucosal surface (e.g. eyes, mouth):

  • Mouth pipetting is prohibited.
  • Cosmetics must not be applied in the laboratory and long hair should be tied back.
  • Food and drink must not be kept in nor consumed in the laboratory.

11.4 Skin injury

  • All skin problems such as cuts, abrasions, exudations and exudative rashes should be covered by a waterproof dressing applied prior to entering the laboratory.

12. Additional Information

For additional information and links, refer to the UQ OHS website.

Custodians
Director, Occupational Health and Safety
Mr Jim Carmichael
Custodians
Director, Occupational Health and Safety
Mr Jim Carmichael