Employees with occupational exposure to blood, body fluids, or other potentially infectious
materials must be offered, and should be encouraged to participate in, the free hepatitis
B vaccination program.
- Employee compliance with the Hepatitis B Vaccination program is monitored by Safety
and Risk Management.
- Employees must read the Hepatitis B Information and then sign EITHER the Hepatitis B Vaccination Consent OR the Hepatitis B Vaccination Declination and return their form to Safety and Risk Management.
- Supervisors must ensure that new employees meeting the criteria for occupational exposure
risk receive the required training and submit the Hepatitis B vaccination consent
or declination form to the Safety Office within 10 working days of initial assignment.
- The vaccination is administered by WCU's Health Services. Three doses are required
for immunity - an initial dose, a second dose 1 month later, and a third dose 6 months
from the date of the initial dose.
- The supervising department will be billed for the vaccination expense.
All exposure incidents shall be reported, investigated, and documented. Significant
exposure includes contamination by blood or other body fluids or high titers of cell-associated
or free virus via:
- percutaneous, e.g., needle stick, scalpel;
- permucosal, e.g., splash in the eye or mouth; or
- cutaneous exposure, e.g., non-intact skin, or involving large amounts of blood or
prolonged contact with blood, especially when exposed skin is chapped, abraded, or
afflicted with dermatitis.
All blood or body fluid exposures must be washed vigorously and then reported immediately
to the supervisor and Health Services.
The supervisor should submit the BBP Post Exposure Incident Report Form to the Safety and Risk Management Office within 24 hours of the incident.
Following an exposure incident, the exposed employee shall immediately receive (at
no cost to the employee) a confidential medical evaluation and follow-up, to include
the following elements:
- Documentation of the route of exposure and the circumstances under which the exposure
incident occurred. If the incident involves percutaneous injury from a contaminated
sharp, appropriate information shall be entered into the sharps injury log.
- Identification and documentation of the source individual, unless this is infeasible
or prohibited by law. The source individual’s blood shall be tested as soon as feasible,
and after consent is obtained, in order to determine HBV and HIV infectivity.
- The exposed employee’s blood shall be collected and tested as soon as feasible, and
after consent is obtained.
- The exposed employee shall have the opportunity to receive post-exposure prophylaxis
(HBV vaccination, etc.) as recommended by the U.S. Public Health Service and/or CDC.
Procedures for evaluating the circumstances surrounding an exposure incident
Supervisors must notify the Safety and Risk Management Office and provide details
about the incident within 24 hours. The Safety and Risk Management Office will review
the circumstances of all exposure incidents to determine:
- Engineering controls in use at the time of the incident
- Work practices and procedures being performed when the incident occurred
- The type of device being used
- Protective equipment used at the time of exposure (gloves, eye shield, etc.)
- Location of the incident
- Employee’s training status
The exposure will be reviewed. Hepatitis B virus (HBV), hepatitis C (HCV), and human
immunodeficiency virus (HIV) infection status of the source patient will be specifically
investigated. The presence of other bloodborne diseases will be evaluated and appropriate
protocols instituted, as needed.
Sharps Injury Log
An incident involving percutaneous injury from a contaminated sharp, must be documented
in the Sharps Injury Log maintained by the Safety and Risk Management Office. Information
collected includes the type, brand, and purpose of device involved in the incident
(if known), the location where the incident occurred, the occupation of the injured
employee, an explanation of how the injury occurred, and the source material’s infection
status (if available). The Safety Office will review the exposure. Other blood or
body fluid exposure protocols will be instituted, as indicated.
Employee training is provided by the Safety and Risk Management Office as an on-line
training module and “in-person” upon request. The Office of Safety and Risk Management
may be contacted at 828-227-7443 for assistance in implementing procedures or to provide
training for employees in Universal Precautions and the Bloodborne Pathogens Exposure
Target Population: All employees with routine, anticipated exposure to blood, body
fluids, and other potentially infectious materials (OPIMs).
- Understand the modes of transmission of bloodborne pathogens, and the philosophy behind
- Have a general understanding of the epidemiology and symptoms of bloodborne diseases.
- Be familiar with the Western Carolina University Exposure Control Plan and the means
by which the employee can obtain a copy of the written plan.
- Know the appropriate methods for recognizing tasks and other activities that may involve
exposure to blood and OPIM.
- Be familiar with the use and limitations of methods that will prevent or reduce exposure
including appropriate engineering controls, work practices, and personal protective
- Know the types, basis for selection, and proper use of personal protective equipment.
- Be informed about hepatitis B vaccine, including information on its efficacy, safety,
method of administration, the benefits of being vaccinated, and that the vaccination
will be offered free of charge to affected personnel.
- Be informed of the appropriate actions to take and persons to contact in an emergency
involving blood or OPIM.
- Know 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.
- Be informed on the post-exposure evaluation and follow-up that the employer is required
to provide for the employee following an exposure incident.
- Know the signs and labels and/or color-coding required by the standard.
- Be familiar with waste management, laundry, and housekeeping practices specific for
Western Carolina University.
- Understand his/her role and the University's role in the standard.
- Training is required for all employees with reasonable exposure risk within 10 working
days of initial assignment to the work area involving exposure prone tasks and at
least annually thereafter, or when changes in tasks/procedures result in a change
of the exposure potential.
- Departments who wish to provide area-specific or departmental training may do so upon
approval of training material by the Safety and Risk Management Office.
- Institutional employee training records will be maintained by the Safety and Risk
- Supervisors, training coordinators, and other persons responsible for providing training
to students should retain copies and have documentation available during a site audit.
- Records will be maintained for 3 years from the date of training.
- Training records will contain the following: Date of training session, contents or
a summary of the training session, name and qualifications of the trainer, and name
and 92# of all persons attending the session.