Download Dental Hygiene OSHA Manual

AUSTIN COMMUNITY COLLEGE
DEPARTMENT OF DENTAL HYGIENE
OSHA
REGULATORY COMPLIANCE
MANUAL
Austin Community College – Department of Dental Hygiene
Regulatory Compliance Manual
Table of Contents
General Information
Introduction .................................................................................................................................1
General Industry Standard on Personal Protective Equipment ..................................................2
General Industry Standard on Compressed Gases....................................................................5
General Industry Standard on Formaldehyde ............................................................................. 10
OSHA General Standard for Emergency Action Plans .............................................................14
OSHA Training and Records .....................................................................................................20
If ACC-DH Receives a Telephone Call or Letter from OSHA ...................................................22
Form A – Certificate of Hazard Assessment ............................................................................24
Form B – Certificate of Employee Training in PPE ..................................................................... 25
Appendices: General Information
A. OSHA Standards on General Requirements on Personal Protective
Equipment and Hand Protection.....................................................................................1
B. General Industry Standard on Compressed Gases .......................................................5
C. General Industry Standard on Formaldehyde .................................................................. 7
D. General Industry Standard on Emergency Action Plans ..............................................33
E. OSHA Fact Sheet – Formaldehyde ................................................................................. 35
F. OSHA Plans per State .................................................................................................. 37
G. Glossary of Terms and Abbreviations Used in the Compliance Manual ......................43
H. Emergency Action Plan Checklist................................................................................. 47
I.
01/2015
Sample Emergency Action Plan ...................................................................................... 49
I
Table of Contents
Bloodborne Pathogens
Exposure Control Plan for This Dental Setting ........................................................................1
Hepatitis B Vaccination/Postexposure Procedures...................................................................18
Labeling .....................................................................................................................................25
Training...................................................................................................................................................26
Recordkeeping ................................................................................................................................33
Appendices: Bloodborne Pathogens
A. Bloodborne Pathogens Standard ...................................................................................1
B. Summary of CDC’s Guidelines for Infections Control .................................................. 31
in Dental Health-Care Settings
C. Methods for Sterilizing and Disinfecting Patient-Care ..................................................35
Items and Environmental Surfaces
D. CDC Guidelines for Infection Control in Dental Health-Care Settings, 2003 ............... 37
E. ADA Statement on Infection Control in Dentistry..........................................................93
F. Updated US Public Health Service Guidelines for the Management ...........................95
of Occupational Exposures to Human Immunodeficiency Virus and
Recommendations for Postexposure Prophylaxis
G. Needlestick Safety and Prevention Act FAQ ....................................................................... 115
H. OSHA Standard on Access to Employee Exposure and ............................................ 119
Medical Records
Hazard Communications
Hazard Communication Program for ACC-DH .........................................................................1
List of Hazardous Chemicals ......................................................................................................3
Hazard CommunicationTraining Program ...................................................................................9
01/2015
2
Table of Contents
Appendices: Hazard Communications
A. Hazard Communication Standard ..................................................................................1
B. OSHA Quick Card: Hazard Communication Standard Pictogram ................................. 3
C. OSHA Quick Card: Hazard Communication Standard Labels ....................................... 5
D. OSHA Quick Card: Hazard Communication Safety Data Sheets .................................. 7
E. Hazard Communication Standard: Labeling of Chemicals.............................................9
Waste Management
ACC Hazardous Waste Management Program............................................................................. 1
Appendices
A. Medical Waste Tracking Form ........................................................................................1
B. Generator Shipment Log ................................................................................................3
C. ADA Directory of Dental Waste Recyclers .....................................................................5
D. ADA Best Management Practices for Amalgam Waste ................................................. 15
Other Regulatory Issues
Backflow Prevention ........................................................................................................................ 1
CDC Statement on Backflow Prevention ....................................................................................... 2
Radiation Safety ..........................................................................................................................6
Ergo Tips .....................................................................................................................................7
01/2015
3
Table of Contents
Austin Community College
Department of Dental Hygiene
Introduction
Austin Community College – Department of Dental Hygiene (known in this
manual as ACC-DH) is dedicated to providing a safe and healthful environment
for employees, students and patients, protecting the public and preserving our
assets and property.
At ACC-DH our most valuable resources are the people who work for us, the
students who attend our program and the patients who we treat in our clinic.
Injuries can be prevented. To achieve this objective, ACC-DH will make all
reasonable efforts to comply with all government regulations pertaining to safety
and health issues. An effective Safety and Health Program will be carried out
throughout our clinic.
The Safety and Health Program will assist management and non-supervisory
employees and students in controlling hazards and risks which will minimize
employee, student and patient injuries, damage to their property and damage or
destruction of ACC-DH property.
All employees and students will follow this program. This program is designed to
encourage all employees and students to promote the safety of their fellow
employees, students and patients. To accomplish our safety and health goals, all
members of management are responsible and accountable for implementing this
policy, and to insure it is followed.
ACC-DH is sincerely interested in the employee’s and student’s safety. The
policy of ACC-DH is to provide safe equipment, adequate tools and training, and
the necessary protective equipment. It is the employee’s and student’s
responsibility to follow the rules of safety as established for their protection and
the protection of others, and to use the protective devices, which ACC-DH
provides.
01/2015
1
General Information
General Industry Standard on Personal
Protective Equipment
OSHA’s general industry standards on personal protective equipment (PPE) impose compliance
obligations on dentists. The material on the following pages explains these obligations and what
you must do to comply if you are an employer with one or more employees.
As you know, the use of personal protective equipment to protect against bloodborne
pathogens (e.g., gloves, gowns, masks and eyewear) is already covered under OSHA’s
Bloodborne Pathogens Standard. These requirements are described in the section of this
Manual on Bloodborne Pathogens under the tab “Methods of Compliance.”
However, OSHA also has what are called “general industry standards” on personal protective
equipment that apply to other kinds of hazards. These standards would apply, for example, in
situations where employees handle hazardous chemicals or to employees who operate dental
equipment. They might require employees working with high viscosity silicone impression
material to wear gloves and protective eyewear or to wear safety glasses when operating
a dental lathe or model trimmer.
These rules require employers to:
• Conduct a formal hazard assessment to determine whether and what PPE is needed;
• Train employees in proper selection and use of PPE; and
• Certify that the assessment and training have been done.
General Requirements for Personal Protective Equipment
Portions of the standard on general requirements for personal protective equipment (PPE) can
be found in Appendix A of this section. However, the main idea of this document as it applies to
your office is outlined below. The full text is available at:
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_
id=13370 .
Additional information on this subject is available from OSHA in the free booklet, “Personal
Protective Equipment” (OSHA 3151). Dentists may request this publication from their area
OSHA office, or they may obtain a copy at www.osha.gov.
What the Standard (29 CFR §1910.132) Says:
• Personal protective equipment (PPE) must be provided, used and maintained in a sanitary
and reliable condition wherever it is needed to protect employees against chemical hazards,
radiological hazards or mechanical irritants.
Note: Employers must not only provide PPE, they must take reasonable steps to ensure that
employees use it. For example, OSHA might require an employer to periodically check on
employee compliance.
01/2015
2
General Information
• Employers must assess the hazards present in their workplaces and select the equipment
that will protect employees from any hazards they find. Guidelines for conducting the
assessment and selecting appropriate equipment are provided in non-mandatory Appendix
B to the standard (Appendix 1).
Note: This is a performance standard. Employers are required to select the equipment that
is appropriate in light of the tasks to be performed, the conditions present, the duration of
the use and the hazards and potential hazards identified. However, the selection guidelines
in Appendix B to the General Industry Standard (Appendix 1) should be helpful to dentists in
determining what is appropriate in their particular offices.
• Employers must communicate their selection decisions to affected employees.
Note: The rule does not specify how this information should be communicated. Perhaps
the best way would be as part of the required employee training program. Dentists would be
wise to document the discussion as part of their training record.
• Employers must select equipment that fits each affected employee (e.g., small gloves for
small hands, large glasses for wide faces.)
• Employers must certify in writing that the required hazard assessment has been performed.
• The certificate (which the employer must make available to OSHA upon request) must contain:
o The identity of the workplace;
o The identity of the person certifying that the evaluation was performed; and
o The date(s) of the evaluation.
The certificate must also state that it is a certificate of hazard assessment. A sample hazard
assessment certificate is included at the end of this summary. (Form A, page 29).
• Defective or damaged PPE may not be used (e.g., torn gloves or scratched glasses that
obscure the wearer’s vision).
• Employers must provide training to employees who are required by this section to use PPE.
Training in PPE required under the bloodborne pathogens standard is governed by that
standard, not this one.
• Employees must be trained to know:
o When PPE is necessary;
o What PPE is necessary;
o How to properly don, doff, adjust and wear PPE;
o The limitations of the PPE; and
o The proper care, maintenance, useful life and disposal of the PPE.
01/2015
3
General Information
Following the training, employees must be able to demonstrate they understood the
training and know how to use the PPE properly before using the PPE in actual practice.
Note: New employees should be trained before they begin work requiring the use of PPE.
Retraining is required when the employer has reason to believe an employee does not have the
understanding and skill to use PPE properly or when there are changes in the workplace or the
types of PPE used that make the previous training obsolete.
Employers must certify in writing that each affected employee has received and understood the
required training. The certificate (which must be made available to OSHA upon request) must
contain:
o The name of each employee trained; and
o The dates of training.
The certificate must also state that it is a training certificate.
What ACC-DH Has Done to Comply
A hazard assessment of the ACC-DH clinic was done to determine the need for PPE. A
certificate has been completed and is on file verifying that the evaluation was done.
Form A on page 24 is included for this purpose.
Employees and students are trained in the use of any PPE the ACC-DH clinic determines
is needed and required to demonstrate their understanding of what they have learned.
ACC-DH has completed and has on file a certificate verifying the training was done.
Form B on pages 25 – 30 is included for this purpose.
01/2015
4
General Information
General Industry Standard on Compressed Gases
A compressed gas is a gas or mixture of gases stored under pressure in cylinders. Examples
of compressed gases that may be found in a dental office include nitrous oxide and oxygen.
Dental staff should handle, maintain, and store compressed gases with caution. Possible
hazards include oxygen displacement, fires, explosions, and toxic gas exposures. When
damaged or broken off, regulators and cylinder valves could fly off, wounding someone with
the force of a bullet. Broken valves might also cause cylinders to pinwheel or become missilelike projectiles. Falling, heat, vibration, corrosion, or anything that may weaken or cause a
crack in the cylinder wall or shell can cause damage to cylinders. Maintenance and storage of
compressed gas cylinders is of the utmost importance for the safety of your office. Fortunately,
it is also relatively easy.
TYPICAL CYLINDER PRESSURE REGULATOR
The full text of the standard is available at:
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9747
This document is also included in its entirety in the appendices following this section.
What the Standard (29 CFR§1910.101) Says:
• Employers are responsible for visually inspecting their compressed gas cylinders to ensure
they are in a safe condition
• Handling, storage and use of all compressed gases in cylinders should be in accordance
with Compressed Gas Association Pamphlet P-1-1965.
Note: The contents of this pamphlet as they apply to the dental office are outlined below.
• Compressed gas cylinders will have pressure relief devices installed and maintained in
accordance with Compressed Gas Association Pamphlets S-1.1-1963 and 1965 addenda
and S-1.2-1963
Note: The maintenance requirements as they apply to the dental office are outlined below.
01/2015
5
General Information
Labeling
All compressed gas cylinders must be clearly labeled. Always check the labels of the cylinders
when they are delivered. The name of the gas should be stenciled or stamped on the cylinder
or on a label on the cylinder. Do not accept cylinders that are not identified with a legible label
of the contents. If you encounter this problem, return the cylinder to the supplier after marking it
with the label “contents unknown.”
Do not use a cylinder’s color as the basis for identifying the gas. Different suppliers may use
different colors. Also do not trust labels on a cylinder’s cap for identification because cylinder
caps are interchangeable.
You should also label the gas lines leading to the cylinder. The gas lines should be clearly
labeled with the name of the gas, the area served, and any possible hazards, such as
flammable, corrosive or toxic. Signs identifying the gas and noting these hazards should also
be posted in the area where the gas is used or stored.
Storage
Secure cylinders at all times to avoid jostling or tipping. Cylinders are heavy and may cause
serious injury if they fall on someone. Or if a cylinder falls over and a valve breaks off, high
pressure gas may escape, and the cylinder could become a projectile.
Cylinders may be secured with straps or chains connected to a wall bracket, or using special
racks or stands specifically designed for this purpose.
In addition to securing cylinders, there are several other considerations. Use the following
guidelines to ensure that cylinders are stored safely:
• Cylinders should always be stored in an upright position with cylinder valves in the closed
position and cylinder valve caps securely attached.
• Keep cylinders in a temperature-controlled area that is cool, dry, well-ventilated and isolated
from any potential fire or electrical hazards. The area should be free of corrosive materials.
• Do not store cylinders in hallways or other public areas.
• Separate cylinders by their contents.
• There are special considerations for oxygen cylinders. Oxygen cylinders must be stored at
least 20 feet from any cylinders containing other flammable gases or combustible materials.
Oxygen cylinders may also be separated by a noncombustible barrier with a height of at
least five feet and a fire-resistance rating of at least 30 minutes.
• Store empty and full cylinders separately.
01/2015
6
General Information
Transporting Cylinders
There are also special recommendations for transporting cylinders. Follow them to keep you
and your office staff safe:
• Cylinders should only be moved or transported using a cart or basket designed for this
purpose.
• Make sure that the cylinder valves are off and that valve caps are securely attached.
• Do not transport the cylinder with the regulator in place.
• Do not drop or strike a cylinder — this may cause an explosion.
• Do not try to lift a cylinder by its valve cover. The valve could become loose or come off.
• Never roll a cylinder on its side to move it.
• Make sure that the cylinder is secure before you attempt to transport it.
Using Compressed Gases
Only properly trained staff should use compressed gas cylinders.
• Before you use a compressed gas:
o Inspect all cylinders, valves, regulators, and hoses.
o Make sure all the connectors are free from oil and grease.
o Move the cylinder valve end into the up position.
o Before you attach any regulators, hoses or piping, vent the cylinder by slightly opening
the valve. Do not position yourself in front of the valve when you do this.
o Make sure the regulator is the correct one for the cylinder you are using. Do not force
connections that do not fit.
o Open all valves slowly.
• After you use a compressed gas:
o Close all cylinder valves. Make sure they are closed tightly.
o Remove the regulator, but only after you have closed the valves and released all the
pressure.
o When closing needle valves, make sure you only close them finger tight so you don’t
damage the valve or valve stem.
Leaks
If you suspect a cylinder may be leaking, take the following precautions, move the cylinder
to an isolated, well-ventilated area away from potentially flammable sources. Post warnings
around the area. Wait for the gas to discharge. Do not try to repair the cylinder. Contact the
supplier for further instructions.
01/2015
7
General Information
Disposal
Remove the cylinder to a storage area that is designated for empty cylinders. Do not store it
with cylinders that still hold compressed gas. Replace the cap on the cylinder. Label it with a
tag so that everyone will know it is empty. You can use chalk to mark it with the letters “MT”
and the date. Empty cylinders may still have residual pressure, so handle them as if they were
full. Never refill an empty cylinder
Personal Protective Equipment (PPE)
When using compressed gases, users should wear safety glasses or faceshields. This is
especially important when disconnecting regulators and lines.
Training
OSHA does not require any specific staff training on compressed gases. However, the more
your staff knows about handling cylinders correctly, the safer everyone will be. Additionally,
the General Industry Standard on Compressed Gases is also one of the most frequently cited
standards during OSHA inspections of dental offices.
The following questions can be used for discussion and action with dental staff:
Why do we take such careful precautions when handling compressed gases?
What are the compressed gases used in your office? Where are they stored?
Who are the suppliers and what is their contact information in case of an emergency?
(A worksheet is provided on the following page to document this information.)
Are the cylinders in your office labeled correctly and legibly? What would you do if
a supplier delivered a cylinder with no label or an illegible label? Where do you look
for a label?
Are the cylinders in your office stored upright in stands, racks, or secured with straps
and chains to a wall?
Are the cylinders stored away from potential fire or electrical hazards?
What special considerations are there for compressed oxygen?
What should you do if you suspect a cylinder is leaking gas?
What do you do with an empty cylinder?
What are some steps to take before you use a compressed gas?
What are some steps when you are done using a compressed gas?
An additional resource on compressed gas safety is available at:
www.wsmr.army.mil/PDF/compressedgassafety.PDF.
01/2015
8
General Information
Compressed Gases in this Office
What is the gas?
Where is it stored?
Supplier’s Name
Oxygen
8100.5 hallway closet
Precision Oxygen &
Supply
Nitrous Oxide
8100.5 hallway closet
Precision Oxygen &
Supply
01/2015
9
Supplier’s Contact
Information
4927 E. 5th St
Austin, TX 78702
512-385-2247
4927 E. 5th St
Austin, TX 78702
512-385-2247
General Information
General Industry Standard on Formaldehyde
Formaldehyde is a colorless gas with a strong, pungent smell. It is commonly found as part of
water-based solutions. Typical uses of formaldehyde-containing agents in a dental office include
Formalin for tissue fixation and formocresol for endodontic procedures. The National Institute of
Environmental Health Sciences (NIH-HHS) classifies formaldehyde as a known carcinogen.
However, you can train your staff to handle formaldehyde safely to limit their exposure.
Symptoms of exposure or overexposure to formaldehyde include:
•
•
•
•
•
Watery eyes
Burning sensations in the eyes, nose and throat
Coughing
Wheezing
Skin irritation
It is important to note that sensitivity to formaldehyde varies from person to person.
At the same exposure level, one person may experience an adverse reaction, while a
different person may not react at all.
The portions of the standard that apply to a dental office are summarized in the following
pages. The full text is available at:
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10075.
An OSHA factsheet is also available online at:
www.osha.gov/OshDoc/data_General_Facts/formaldehyde-factsheet.pdf
Both of these documents are included in their entirety in the appendices following this section.
What the Standard (29 CFR§1910.1048) Says:
• The permissible exposure limit for formaldehyde in the workplace for employees is 0.75 parts
formaldehyde per million (ppm) measured as an eight hour time-weighted average. The
short-term exposure limit is two parts per million allowed during a 15 minute time period.
• Employers must monitor employees to determine their exposure to formaldehyde.
• The employer will have regulated areas where concentration of airborne formaldehyde
exceeds the time-weighted average or the short-term exposure limit. Access will be limited to
employees who have been trained to recognize the hazards of formaldehyde. Signs with the
following language will be posted at all entrances and access areas:
DANGER!
FORMALDEHYDE MAY CAUSE CANCER.
CAUSES SKIN, EYE, AND RESPIRATORY IRRITATION
AUTHORIZED PERSONNEL ONLY.
01/2015
10
General Information
• Employers will use engineering controls and work practice controls to reduce and maintain
employee exposure to formaldehyde at or below the time weighted average of the short-term
exposure limit. If employers cannot reduce exposure at or below permissible exposure limits,
they must provide respirators to staff.
• All mixtures or solutions composed of greater than 0.1 percent formaldehyde and materials
capable of releasing formaldehyde into the air at concentrations reaching or exceeding
0.1 ppm must be labeled. For all materials capable of releasing formaldehyde at levels above
0.5 ppm during normal use, the label must contain the words “potential cancer hazard.”
• Employers must provide personal protective equipment (PPE) at no cost to employees and
make sure that employees use the equipment.
• Employers will regularly provide maintenance of equipment, including checking for leaks.
They will also provide provisions for spills, decontamination, and waste disposal in the work
areas where formaldehyde is used. Spills will be cleaned by trained employees who are
wearing the appropriate PPE.
• If an employee develops signs and symptoms of overexposure to formaldehyde, the employer
will provide examination and follow-up by a medical professional at no cost to the employee.
• The employer will provide training to all employees who are at risk possible exposure
to formaldehyde. The training will take place annually, when a new employee is hired or
assigned to a task with possible formaldehyde exposure, and whenever a new exposure
to formaldehyde is introduced in the workplace.
Engineering Controls
Examples of engineering controls and work practice controls include the following:
• Always use formaldehyde in areas with proper ventilation.
• Store formaldehyde in closed containers in well-ventilated areas
• Use a tray when working with formaldehyde to contain potential spills
• Clearly label formaldehyde containers with the proper health hazards
• Do not eat or drink where formaldehyde is handled, processed or stored
• Use only as much formaldehyde as is necessary to perform the task at hand
• Always wash hands thoroughly after using formaldehyde, even if you were wearing gloves
01/2015
11
General Information
Personal Protective Equipment (PPE)
Appropriate PPE for handling formaldehyde includes gloves, goggles and faceshields.
When using liquids than contain a percentage of formaldehyde that is one percent or greater,
impermeable gloves must be used. Latex gloves may be used only in instances of short-term,
incidental contact.
PPE and clothing that has been contaminated with formaldehyde must be laundered before it is
used again. Employers will provide a storage area for contaminated PPE and clothing, and will
label it with the following:
DANGER
FORMALDEHYDE-CONTAMINATED [CLOTHING] EQUIPMENT
MAY CAUSE CANCER
CAUSES SKIN, EYE, AND RESPIRATORY IRRITATION
DO NOT BREATHE VAPOR
DO NOT GET ON SKIN
Labeling
Label all mixtures or solutions composed of greater than 0.1 percent formaldehyde and
materials capable of releasing formaldehyde into the air at concentrations reaching or
exceeding 0.1 ppm. For all materials capable of releasing formaldehyde at levels above 0.5 ppm
during normal use, the label must contain the words “may cause cancer.” These label
requirements will be met by the chemical manufacturer. If you keep the formaldehyde product in
its original container and the original label remains intact, the original label should be sufficient.
Here is an example of a sample manufacturer’s label for Formalin, a product containing
formaldehyde:
Products containing formaldehyde may not be poured or used in any non-labeled containers.
Storage
Products containing formaldehyde should be kept in their original, labeled containers. They
should be stored in a dry, well-ventilated area that is temperature controlled. Keep these
products out of direct sunlight. They must also be kept away from heat; combustible and
flammable materials; and incompatible materials.
01/2015
12
General Information
Training
Training on the safe handling of formaldehyde should be conducted at least annually.
The following situations also require training:
• When you hire someone new whose duties include tasks with potential formaldehyde
exposure
• When a current employee’s duties expand to include tasks with potential formaldehyde
exposure
• When a new product with the risk of formaldehyde exposure is introduced into the office
The following checklist describes the information that should be included in your
training program:
A description of the health hazards of formaldehyde exposure, as well as the signs
and symptoms of formaldehyde exposure
Descriptions of how to safely work in an area where formaldehyde is present, as well
as the explanation of safe work practices to limit exposure to formaldehyde in each
job where it is used
The purpose and proper use of PPE when handling formaldehyde
Instructions on handling spills, emergencies, and clean-up procedures
An explanation of engineering and work practice controls and how to use them
A review of emergency procedures, including individual employee assignments in the
event of an emergency
Instructions for immediately reporting to the employer any signs or symptoms that
the employee suspects are due to formaldehyde exposure
A review of the Safety Data Sheets of products containing formaldehyde
The location of the training materials for future reference
01/2015
13
General Information
OSHA General Standard for Emergency Action Plans
OSHA requires an emergency action plan (EAP) for dental offices. Compliance is simple, and
can be easily accomplished in the steps outlined below.
The full text of the standard is available at:
www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=9726&p_table=STANDARDS
This document is also included in its entirety in the appendices following this section.
What the standard (29 CFR§1910.101) says:
• Employers must have an emergency action plan where OSHA requires one
• The emergency action plan must be kept in writing where it is accessible by employees.
However, if there are fewer than 10 employees, the emergency action plan can be
communicated orally.
• The emergency action plan must contain the following at a minimum:
o Procedures for reporting a fire or other emergency
o Procedures for emergency evacuation, including the evacuation type and exit route
assignments
o Procedures to be followed by employees who remain behind to operate critical
operations before they evacuate
o Procedures to account for each employee after evacuation
o Procedures to be followed by employees who perform rescue or medical duties
o The name and job title of every employee who may be contacted by employees who
need more information about the plan or an explanation of their duties under the plan
• An employer must have and maintain an employee alarm system. The employee system
must use a distinctive signal for each purpose
• An employer must designate and train employees to assist in a safe and orderly evacuation
of other employees
• An employer must review the emergency action plan with each covered employee when:
o The plan is developed or the employee is initially assigned to a job
o When an employee’s responsibilities under the plan change
o When the plan changes
01/2015
14
General Information
Developing an Emergency Action Plan
STEP 1: CONDUCT A WORKPLACE EVALUATION
The first step in developing an emergency action plan is to conduct a workplace evaluation.
According to OSHA, your workplace evaluation should include an assessment of the following:
• Design and construction requirements for exit routes
• Maintenance, safeguards and operational features for exit routes
• Your current emergency action plan
• Your fire prevention plan
• Fire extinguishing systems
o Portable extinguishers
o Fixed systems
• Fire detection systems
• Emergency alarm systems
STEP 2: GATHER STAFF INPUT
In order to have an effective emergency action plan, you must gather input from a diverse range
of staff, from the front desk staff to the clinical staff to the office management. You may be
surprised at the different concerns that each group has. Maybe the administrative staff is focused
on backing up data systems, while the clinical staff is more aware of securing equipment.
Discuss the types of emergencies that could occur in your area. Consider both natural and
manmade emergencies. For example, is your geographic region prone to earthquakes,
tornadoes, or other natural disasters? Is there a nuclear power plant near your town? What
types of precautions are necessary in your locale?
Also think about who may need extra help if an evacuation is necessary, as well as if anyone
will stay behind to operate critical plant operations prior to evacuating.
STEP 3: ASSIGN STAFF ROLES
• Who is in charge during an emergency?
• Who will account for each staff member after everyone has been evacuated?
• Who will stay behind to operate critical plant operations before evacuating?
• What are the names and job titles of people who can be contacted for further information on
the emergency action plan?
• Which employees will assist in the safe and orderly evacuation of other employees?
01/2015
15
General Information
• Who in the office has had CPR training and how can they be of assistance during an
emergency?
STEP 4: DECIDE HOW YOU WILL REPORT FIRES AND OTHER EMERGENCIES
Before an emergency occurs, decide how it will be reported. Often, calling 911 is enough to
alert the appropriate authorities.
STEP 5: TRAIN STAFF
OSHA does not require any special training on emergency action plans for office staff.
However, familiarizing your staff with the emergency action plan is a good idea to ensure
everyone’s safety. OSHA suggests including the following information in a general employee
training:
Clearly communicate who is in charge during an emergency. This will reduce confusion
if an emergency arises.
Assign individual roles and responsibilities. Your employees should know who is in
charge of what.
Discuss potential threats, hazards, and protective actions
Explain the notification, warning, and communications procedures you have in place
Review emergency response procedures
Talk about evacuation, shelter and accountability procedures
Go over the location and use of common emergency equipment
Examine the emergency shutdown procedures
In order for employees to retain the information you have provided, conducting an annual
emergency action plan training is ideal. Remember: though a yearly training is not required,
OSHA mandates that employers review the emergency action plan with each covered
employee when the plan is developed; when the plan changes; when an employee is initially
assigned to a job; or when an employee’s responsibilities change under the plan.
01/2015
16
General Information
Emergency Action Plan Training Log
Date of Training
Employee Name
Employee Signature
Reason for Training
(Annual training, training for
updated EAP, new employee
training, training for new
responsibilities, etc.)
08/25/2015
Renee Cornett
Annual Training
08/25/2015
Kellie Murphree
Annual Training
08/25/2015
Gary Wright
Annual Training
08/25/2015
Michelle Landrum
Annual Training
08/25/2015
Kate Goin
Annual Training
08/25/2015
Kimberly McDougall
Annual Training
08/25/2015
Sima Sohrabi
Annual Training
08/25/2015
Debra Segen
Annual Training
08/25/2015
Rita Snodell
Annual Training
08/25/2015
David Reeves
Annual Training
08/25/2015
Tina Stein
New employee training
08/25/2015
Andrea Kovarik
New employee training
01/2015
17
General Information
Emergency Action Plan Training Log
Date of Training
Student Name
Reason for Training (Annual
training, training for updated EAP,
new employee training, training for
new responsibilities, etc.)
08/29/2016
Monique Alarcon
New student training
08/29/2016
Rachel Dickens
New student training
08/29/2016
Sunena Gagneja
New student training
08/29/2016
Lacie Herrin
New student training
08/29/2016
Dylon Hopper
New student training
08/29/2016
Cydnie Johnson
New student training
08/29/2016
Julia Levitt
New student training
08/29/2016
Stephanie Liu
New student training
08/29/2016
Kristi Madrid
New student training
08/29/2016
Katie Natale
New student training
08/29/2016
Aneesa Patel
New student training
08/29/2016
Lee Pepe
New student training
08/29/2016
Jennifer Rice
New student training
08/29/2016
Shaunda Talamantez
New student training
08/29/2016
Yulia Voznesenskaya
New student training
08/29/2016
Jeremiah Wallace
New student training
08/29/2016
Allyson Walter
New student training
08/2016
18
General Information
Emergency Action Plan Training Log
Date of Training
Employee Name
Student Signature
Reason for Training
(Annual training, training for
updated EAP, new employee
training, training for new
responsibilities, etc.)
08/24/2015
Jason Blunck
New student training
08/24/2015
Wendy Bushman
New student training
08/24/2015
Josette Chen
New student training
08/24/2015
Amy Deng
New student training
08/24/2015
Becca Eiserer
New student training
08/24/2015
Zainab Jabr
New student training
08/24/2015
Laura Jaimes
New student training
08/24/2015
Whitney Jones
New student training
08/24/2015
Molly Keith
New student training
08/24/2015
Shari Langerhans
New student training
08/24/2015
Jessica Lee
New student training
08/24/2015
Carrie Nunnally
New student training
08/24/2015
Jess Ross
New student training
08/24/2015
Azadeh Samani
New student training
08/24/2015
Elya Singler
New student training
08/24/2015
Allyson Walter
New student training
08/24/2015
Stacy Weiner
New student training
08/24/2015
Jason Whittley
New student training
08/2015
19
General Information
OSHA Training and Records
Below is a list of the ACC-DH policies for training and keeping records up-to-date to fully
comply with OSHA standards.
When a New Employee is Hired or a New Class of Students Enter the
Program
• It is determined whether the employee or student has “occupational exposure” to bloodborne
pathogens and any necessary changes in the written exposure determination are made.
• A confidential medical record for the employee or student is created, to include the
employee’s or student’s name, social security number and hepatitis B vaccination status; the
employee or student is informed of their right of access to this record and how to exercise
that right.
• The level of training already obtained in prior employment is determined.
• Required training depending on the specific hazards in our office to which the employee or
student is exposed (e.g., bloodborne pathogens, hazardous chemicals, fire, etc.) is
provided; a written record of all training is maintained.
When There is a Change in Office Procedure
Sometimes employees or students take on new responsibilities, a change occurs in office
tasks or procedures (e.g., we switch from a one-handed “scoop” method of recapping
needles to a mechanical device) or a new hazard is introduced in the work place (e.g., a
new product containing a hazardous chemical). When this happens:
• The relevant plan (e.g., exposure control, hazard communication) is updated
• Training of affected employees or students is updated
When an Accident or Illness Occurs
• A record of any “exposure incident,” e.g., a needlestick is made; the incident is evaluated
to determine if the employee or student needs additional training (all of the other steps
required for post-exposure evaluation and follow-up are completed and documented).
• A copy of the incident report and the health care professional’s written report (if any) is
filed in the employee’s or student’s medical record.
• As of January 1, 2015, new reporting requirements went into effect for the following
situations:
o Fatalities
o In-patient hospitalization
o Loss of an eye
o Amputations
01/2015
20
General Information
Work-related fatalities must be reported to OSHA within eight hours of the event.
Work-related in-patient hospitalizations, loss of an eye, or amputations must be reported
within 24 hours of the incident.
We can report the incident to OSHA by phone or online:
o Call the 24-hour OSHA hotline at 1.800.321.OSHA
o Report the incident online at www.osha.gov/report_online
Once a Year
• The exposure control plan is reviewed and updated. This includes documentation that we
have evaluated safer needle devices and that representative exposed employees were
involved in the process. For information and forms to help us evaluate devices, see the
CDC’s web page at www.cdc.gov/OralHealth/infectioncontrol/forms.htm.
• Bloodborne pathogens training and a refresher on hazard communication and other
OSHA standards, too are provided.
• Employees and students are reminded they have right of access to their medical records
and a record that we did so is kept.
• Any employees or students who are expected to use fire extinguishers are trained in their use.
• A maintenance check for any portable fire extinguishers is provided and the
maintenance date is recorded.
Monthly
• Any portable fire extinguishers are visually inspected; a record of the inspection is
maintained.
Periodically
• A periodic mock inspection of our own dental clinic is conducted, using the ADA’s OSHA
checklist as a guide for compliance with OSHA’s most significant requirements. The mock
inspection is also used to check for other potentially unsafe conditions, such as torn
carpeting or loose handrails, which are not specifically covered in the checklist.
01/2015
21
General Information
If ACC-DH Receives a Telephone Call or Letter from
OSHA
In an effort to streamline the inspection process, OSHA inspectors may investigate certain
complaints by telephone or by letter. ACC-DH has developed an office protocol for dealing
with either such contact.
Background
OSHA separates complaints into two categories: formal and nonformal. A formal complaint must:
1. Be in writing
2. Allege that an imminent danger or a violation threatening physical harm exists
(i.e., a complaint of a recordkeeping violation would not meet this requirement)
3. Set forth with reasonable particularity the grounds on which the complaint is based
4. Be signed by at least one current employee, a representative of an employee (such as
unions, attorneys, elected representatives, and family members), or present employee
of another company if that employee is exposed to the hazards of the complained-about
workplace (former employees can only submit nonformal complaints)
A nonformal complaint is any complaint that does not meet the requirements of a formal
complaint, e.g. unsigned or oral complaints by current employees, written and oral complaints
by most nonemployees or former employees.
Letters from OSHA
OSHA’s procedure has been to conduct an unannounced workplace inspection in response
to a formal complaint. When OSHA receives a nonformal complaint, it typically sends the
employer a letter, informing him/her of the alleged violations and asking the employer to
investigate and respond within a specified time. The language of the letter is usually the same;
only the list of alleged violations varies. More dentists will receive a letter from OSHA than will
ever see an inspector.
OSHA will usually share a copy of the response with the complainant and ask him or her to
comment. If it appears that no violation exists, or that the employer has taken appropriate
corrective action, OSHA will usually close the file with no further action. In one out of 10 cases,
OSHA will conduct a follow-up inspection to verify the information provided. OSHA selects
these cases on a random basis from a pool consisting of all employers, not just dentists.
OSHA will always conduct an inspection if the employer fails to respond or his or her response
is inadequate.
Phone Calls from OSHA
Under an alternative procedure, an investigation of a nonformal complaint may be conducted
by telephone, as well as by letter, if the complaint alleges a condition that is not serious and can
be satisfactorily resolved in this manner.
01/2015
22
General Information
ACC-DH Office Protocol
1. Only the Dental Hygiene Department Chair (known as the DHDC) will answer telephone
inquiries from an OSHA inspector. Office staff who may answer the phone are instructed to
immediately contact the DHDC if an OSHA inspector calls. If the DHDC is not in the office, staff
are instructed to tell the inspector that the DHDC will call the inspector back.
2. Take the inspector’s name and the name of the OSHA area office from which the inspector
is calling. Verify the phone number of the area office from directory assistance and then
the DHDC will call the inspector back. The caller should be informed that this precaution is
being taken as a necessary step to avoid scams. Unscrupulous suppliers have been
known to identify themselves as OSHA officials in order to gain access to dental offices.
3. When the DHDC has verified the identity of the caller, find out whether the call is in
response to a formal complaint or a nonformal complaint.
4. Ask the inspector to send a copy of the complaint or, in the case of an unwritten
complaint, a list of the alleged violations. This will allow careful review of the
allegations and time to conduct any necessary investigation before responding. (If
you receive a copy of a complaint, the complainant’s name will be deleted.)
5. As with responses to OSHA letters, the conversation will be confined to the violations
alleged in the complaint. Each alleged violation will be discussed in turn.
6. If the inspector’s questions start to go beyond the scope of the complaint, the DHDC
will object, courteously but firmly.
7. The DHDC will not get into an argument with the inspector. If the inspector is being
difficult, ask to speak to his or her supervisor.
8. The DHDC will be truthful. OSHA will verify information provided and will inform the
complainant of the response.
9. The DHDC will not make any disparaging comments about the person suspected of filing
the complaint. OSHA’s mission is to protect employees. Comments which OSHA interprets
as broadly anti-employee could make a bad impression.
10. Upon request, send the inspector documentary evidence that is relevant to the violations
alleged in the complaint. Examples might be invoices for glove purchases or copies of
training records. Again, know where to stop. Anything that does not relate specifically
to the violations complained of should not be provided. Photographs are particularly
tricky in this regard, because it is difficult to keep extraneous material out.
01/2015
23
General Information
Form A
Certificate of Hazard Assessment
Pursuant to 29 CFR § 1910.132
I, Kate Goin, BA, RDH,
certify that the dental office of:
Austin Community College, Department of Dental Hygiene
was evaluated on:
09/14/2016
for hazards which are present, or are likely to be present, which necessitate the use
of personal protective equipment.
(signature)
09/14/2016
(date)
01/2015
24
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 09/04/2012
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Renee Cornett, RDH
2. Kellie Murphree, RDH
3. Joe Wright, DDS
4. David Reeves, DMD
5. Michelle Landrum, RDH
6. Sima Sohrabi, RDH
7. Debra Segen, RDH
8. Rita Snodell, RDH
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
05/26/2015
(date)
01/2015
25
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 08/31/2015
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Kimberly McDougall, RDH
2. Tina Stein, RDH
3. Andrea Kovarik, RDH
4. Veronica Ledesma, RDH on 9/7/2016 as new employee
5. Teri Frank, CDA on 9/13/2016 as new employee
6.
7.
8.
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
09/10/2015
(date)
01/2015
26
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 09/07/2016
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Monique Alarcon
2. Rachel Dickens
3. Sunena Gagneja
4. Lacie Herrin
5. Dylon Hopper
6. Cydnie Johnson
7. Julia Levitt
8. Stephanie Liu
9. Kristi Madrid
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
09/13/2016
(date)
09/2015
27
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 09/07/2016
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Katie Natale
2. Aneesa Patel
3. Lee Pepe
4. Jennifer Rice
5. Shaunda Talamantez
6. Yulia Voznesenskaya
7. Jeremiah Wallace
8. Allyson Walter
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
09/13/2016
(date)
09/2015
28
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 08/31/2015
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Jason Blunck
2. Wendy Bushman
3. Josette Chen
4. Amy Deng
5. Becca Eiserer
6. Zainab Jabr
7. Laura Jaimes
8. Whitney Jones
9. Molly Keith
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
09/10/2015
(date)
09/2015
29
General Information
Form B
Certificate of Employee Training in PPE
Use Pursuant to 29 CFR § 1910.132
I, Kate Goin, RDH
certify that on 08/31/2015
the following employees/students received the training required under OSHA’s standard on
personal protective equipment
1. Shari Langerhans
2. Jessica Lee
3. Carrie Nunnally
4. Jess Ross
5. Azadeh Samani
6. Elya Singler
7. Allyson Walter
8. Stacy Weiner
9. Jason Whittley
As part of this training, employees were informed about the safe and proper use of
personal protective equipment selected by this office.
I further certify that each employee listed above has demonstrated his/her understanding
of this training.
(signature)
09/10/2015
(date)
09/2015
30
General Information
Appendix A: Standards on General Requirements on Personal
Protective Equipment and Hand Protection
U.S. Department of Labor
Occupational Safety & Health Administration
www.osha.gov
[skip navigational links]
Search
Advanced Search
Regulations (Standards - 29 CFR)
General requirements. - 1910.132
Regulations (Standards - 29 CFR) - Table of Contents
•
•
•
•
•
•
Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:
1910
Occupational Safety and Health Standards
I
Personal Protective Equipment
1910.132
General requirements.
1910.132(a)
$SSOLFDWLRQ3URWHFWLYHHTXLSPHQWLQFOXGLQJSHUVRQDOSURWHFWLYHHTXLSPHQWIRUH\HVIDFH
KHDGDQGH[WUHPLWLHVSURWHFWLYHFORWKLQJUHVSLUDWRU\GHYLFHVDQGSURWHFWLYHVKLHOGVDQG
EDUULHUVVKDOOEHSURYLGHGXVHGDQGPDLQWDLQHGLQDVDQLWDU\DQGUHOLDEOHFRQGLWLRQZKHUHYHU
LWLVQHFHVVDU\E\UHDVRQRIKD]DUGVRISURFHVVHVRUHQYLURQPHQWFKHPLFDOKD]DUGV
UDGLRORJLFDOKD]DUGVRUPHFKDQLFDOLUULWDQWVHQFRXQWHUHGLQDPDQQHUFDSDEOHRIFDXVLQJ
LQMXU\RULPSDLUPHQWLQWKHIXQFWLRQRIDQ\SDUWRIWKHERG\WKURXJKDEVRUSWLRQLQKDODWLRQRU
SK\VLFDOFRQWDFW
1910.132(b)
(PSOR\HHRZQHGHTXLSPHQW:KHUHHPSOR\HHVSURYLGHWKHLURZQSURWHFWLYHHTXLSPHQWWKH
HPSOR\HUVKDOOEHUHVSRQVLEOHWRDVVXUHLWVDGHTXDF\LQFOXGLQJSURSHUPDLQWHQDQFHDQG
VDQLWDWLRQRIVXFKHTXLSPHQW
1910.132(c)
'HVLJQ$OOSHUVRQDOSURWHFWLYHHTXLSPHQWVKDOOEHRIVDIHGHVLJQDQGFRQVWUXFWLRQIRUWKH
ZRUNWREHSHUIRUPHG
..1910.132(d)
1910.132(d)
+D]DUGDVVHVVPHQWDQGHTXLSPHQWVHOHFWLRQ
1910.132(d)(1)
7KHHPSOR\HUVKDOODVVHVVWKHZRUNSODFHWRGHWHUPLQHLIKD]DUGVDUHSUHVHQWRUDUHOLNHO\WR
EHSUHVHQWZKLFKQHFHVVLWDWHWKHXVHRISHUVRQDOSURWHFWLYHHTXLSPHQW33(,IVXFKKD]DUGV
DUHSUHVHQWRUOLNHO\WREHSUHVHQWWKHHPSOR\HUVKDOO
1910.132(d)(1)(i)
6HOHFWDQGKDYHHDFKDIIHFWHGHPSOR\HHXVHWKHW\SHVRI33(WKDWZLOOSURWHFWWKHDIIHFWHG
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[$
*HQHUDOUHTXLUHPHQWV
3DJH RI
HPSOR\HHIURPWKHKD]DUGVLGHQWLILHGLQWKHKD]DUGDVVHVVPHQW
1910.132(d)(1)(ii)
&RPPXQLFDWHVHOHFWLRQGHFLVLRQVWRHDFKDIIHFWHGHPSOR\HHDQG
1910.132(d)(1)(iii)
6HOHFW33(WKDWSURSHUO\ILWVHDFKDIIHFWHGHPSOR\HH1RWH1RQPDQGDWRU\$SSHQGL[%
FRQWDLQVDQH[DPSOHRISURFHGXUHVWKDWZRXOGFRPSO\ZLWKWKHUHTXLUHPHQWIRUDKD]DUG
DVVHVVPHQW
1910.132(d)(2)
7KHHPSOR\HUVKDOOYHULI\WKDWWKHUHTXLUHGZRUNSODFHKD]DUGDVVHVVPHQWKDVEHHQSHUIRUPHG
WKURXJKDZULWWHQFHUWLILFDWLRQWKDWLGHQWLILHVWKHZRUNSODFHHYDOXDWHGWKHSHUVRQFHUWLI\LQJ
WKDWWKHHYDOXDWLRQKDVEHHQSHUIRUPHGWKHGDWHVRIWKHKD]DUGDVVHVVPHQWDQGZKLFK
LGHQWLILHVWKHGRFXPHQWDVDFHUWLILFDWLRQRIKD]DUGDVVHVVPHQW
1910.132(e)
'HIHFWLYHDQGGDPDJHGHTXLSPHQW'HIHFWLYHRUGDPDJHGSHUVRQDOSURWHFWLYHHTXLSPHQW
VKDOOQRWEHXVHG
..1910.132(f)
1910.132(f)
7UDLQLQJ
1910.132(f)(1)
7KHHPSOR\HUVKDOOSURYLGHWUDLQLQJWRHDFKHPSOR\HHZKRLVUHTXLUHGE\WKLVVHFWLRQWRXVH
33((DFKVXFKHPSOR\HHVKDOOEHWUDLQHGWRNQRZDWOHDVWWKHIROORZLQJ
1910.132(f)(1)(i)
:KHQ33(LVQHFHVVDU\
1910.132(f)(1)(ii)
:KDW33(LVQHFHVVDU\
1910.132(f)(1)(iii)
+RZWRSURSHUO\GRQGRIIDGMXVWDQGZHDU33(
1910.132(f)(1)(iv)
7KHOLPLWDWLRQVRIWKH33(DQG
1910.132(f)(1)(v)
7KHSURSHUFDUHPDLQWHQDQFHXVHIXOOLIHDQGGLVSRVDORIWKH33(
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[$
*HQHUDOUHTXLUHPHQWV
3DJH RI
1910.132(f)(2)
(DFKDIIHFWHGHPSOR\HHVKDOOGHPRQVWUDWHDQXQGHUVWDQGLQJRIWKHWUDLQLQJVSHFLILHGLQ
SDUDJUDSKIRIWKLVVHFWLRQDQGWKHDELOLW\WRXVH33(SURSHUO\EHIRUHEHLQJDOORZHGWR
SHUIRUPZRUNUHTXLULQJWKHXVHRI33(
1910.132(f)(3)
:KHQWKHHPSOR\HUKDVUHDVRQWREHOLHYHWKDWDQ\DIIHFWHGHPSOR\HHZKRKDVDOUHDG\EHHQ
WUDLQHGGRHVQRWKDYHWKHXQGHUVWDQGLQJDQGVNLOOUHTXLUHGE\SDUDJUDSKIRIWKLVVHFWLRQ
WKHHPSOR\HUVKDOOUHWUDLQHDFKVXFKHPSOR\HH&LUFXPVWDQFHVZKHUHUHWUDLQLQJLVUHTXLUHG
LQFOXGHEXWDUHQRWOLPLWHGWRVLWXDWLRQVZKHUH
1910.132(f)(3)(i)
&KDQJHVLQWKHZRUNSODFHUHQGHUSUHYLRXVWUDLQLQJREVROHWHRU
..1910.132(f)(3)(ii)
1910.132(f)(3)(ii)
&KDQJHVLQWKHW\SHVRI33(WREHXVHGUHQGHUSUHYLRXVWUDLQLQJREVROHWHRU
1910.132(f)(3)(iii)
,QDGHTXDFLHVLQDQDIIHFWHGHPSOR\HH
VNQRZOHGJHRUXVHRIDVVLJQHG33(LQGLFDWHWKDWWKH
HPSOR\HHKDVQRWUHWDLQHGWKHUHTXLVLWHXQGHUVWDQGLQJRUVNLOO
1910.132(f)(4)
7KHHPSOR\HUVKDOOYHULI\WKDWHDFKDIIHFWHGHPSOR\HHKDVUHFHLYHGDQGXQGHUVWRRGWKH
UHTXLUHGWUDLQLQJWKURXJKDZULWWHQFHUWLILFDWLRQWKDWFRQWDLQVWKHQDPHRIHDFKHPSOR\HH
WUDLQHGWKHGDWHVRIWUDLQLQJDQGWKDWLGHQWLILHVWKHVXEMHFWRIWKHFHUWLILFDWLRQ
1910.132(g)
3DUDJUDSKVGDQGIRIWKLVVHFWLRQDSSO\RQO\WRDQG
3DUDJUDSKVGDQGIRIWKLVVHFWLRQGRQRWDSSO\WRDQG
>)5-XQHDVDPHQGHGDW)5$SULO)5-XO\
)5-XO\@
Next Standard (1910.133)
Regulations (Standards - 29 CFR) - Table of Contents
Back to Top
www.osha.gov
www
Contact Us | Freedom of Information Act | Customer Survey
Privacy and Security Statement | Disclaimers
Occupational Safety & Health Administration
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[$
+DQG3URWHFWLRQ
3DJH RI
U.S. Department of Labor
Occupational Safety & Health Administration
www.osha.gov
Search
[skip navigational links]
Advanced Search_A-Z Inde
Regulations (Standards - 29 CFR)
Hand Protection. - 1910.138
Regulations (Standards - 29 CFR) - Table of Contents
•
•
•
•
•
•
Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:
1910
Occupational Safety and Health Standards
I
Personal Protective Equipment
1910.138
Hand Protection.
1910.138(a)
*HQHUDOUHTXLUHPHQWV(PSOR\HUVVKDOOVHOHFWDQGUHTXLUHHPSOR\HHVWRXVHDSSURSULDWHKDQG
SURWHFWLRQZKHQHPSOR\HHV
KDQGVDUHH[SRVHGWRKD]DUGVVXFKDVWKRVHIURPVNLQDEVRUSWLRQ
RIKDUPIXOVXEVWDQFHVVHYHUHFXWVRUODFHUDWLRQVVHYHUHDEUDVLRQVSXQFWXUHVFKHPLFDO
EXUQVWKHUPDOEXUQVDQGKDUPIXOWHPSHUDWXUHH[WUHPHV
1910.138(b)
6HOHFWLRQ(PSOR\HUVVKDOOEDVHWKHVHOHFWLRQRIWKHDSSURSULDWHKDQGSURWHFWLRQRQDQ
HYDOXDWLRQRIWKHSHUIRUPDQFHFKDUDFWHULVWLFVRIWKHKDQGSURWHFWLRQUHODWLYHWRWKHWDVNVWR
EHSHUIRUPHGFRQGLWLRQVSUHVHQWGXUDWLRQRIXVHDQGWKHKD]DUGVDQGSRWHQWLDOKD]DUGV
LGHQWLILHG
>)5$SULO@
Next Standard (1910 Subpart I App A)
Regulations (Standards - 29 CFR) - Table of Contents
www.osha.gov
Back to Top
www
Contact Us | Freedom of Information Act | Customer Survey
Privacy and Security Statement | Disclaimers
Occupational Safety & Health Administration
200 Constitution Avenue, NW
Washington, DC 20210
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[$
General Information Appendix B:
General Industry Standard on Compressed Gases
1/16/2014
Compressed gases (general requirements). - 1910.101
$ WR = ,QGH[ _ (Q HVSDxRO _ &RQWDFW 8V _ )$4V _ $ERXW 26+$
26+$
1HZVOHWWHU
566 )HHGV
3ULQW 7KLV 3DJH
7H[W 6L]H
:DV WKLV SDJH KHOSIXO"
:KDW
V 1HZ _ 2IILFHV
+RPH
:RUNHUV
5HJXODWLRQV
(QIRUFHPHQW
'DWD 6WDWLVWLFV
7UDLQLQJ
3XEOLFDWLRQV
1HZVURRP
6PDOO %XVLQHVV
5HJXODWLRQV 6WDQGDUGV &)5 7DEOH RI &RQWHQWV
‡ 3DUW 1XPEHU
‡ 3DUW 7LWOH
‡ 6XESDUW
‡ 6XESDUW 7LWOH
‡ 6WDQGDUG 1XPEHU
‡ 7LWOH
2FFXSDWLRQDO 6DIHW\ DQG +HDOWK 6WDQGDUGV
+
+D]DUGRXV 0DWHULDOV
&RPSUHVVHG JDVHV JHQHUDO UHTXLUHPHQWV
D
,QVSHFWLRQ RI FRPSUHVVHG JDV F\OLQGHUV (DFK HPSOR\HU VKDOO GHWHUPLQH WKDW FRPSUHVVHG JDV F\OLQGHUV XQGHU KLV FRQWURO DUH LQ D VDIH
FRQGLWLRQ WR WKH H[WHQW WKDW WKLV FDQ EH GHWHUPLQHG E\ YLVXDO LQVSHFWLRQ 9LVXDO DQG RWKHU LQVSHFWLRQV VKDOO EH FRQGXFWHG DV SUHVFULEHG LQ WKH
+D]DUGRXV 0DWHULDOV 5HJXODWLRQV RI WKH 'HSDUWPHQW RI 7UDQVSRUWDWLRQ &)5 SDUWV DQG &)5 SDUW :KHUH WKRVH
UHJXODWLRQV DUH QRW DSSOLFDEOH YLVXDO DQG RWKHU LQVSHFWLRQV VKDOO EH FRQGXFWHG LQ DFFRUGDQFH ZLWK &RPSUHVVHG *DV $VVRFLDWLRQ 3DPSKOHWV
& DQG & ZKLFK LV LQFRUSRUDWHG E\ UHIHUHQFH DV VSHFLILHG LQ 6HF E
&RPSUHVVHG JDVHV 7KH LQSODQW KDQGOLQJ VWRUDJH DQG XWLOL]DWLRQ RI DOO FRPSUHVVHG JDVHV LQ F\OLQGHUV SRUWDEOH WDQNV UDLO WDQNFDUV RU
PRWRU YHKLFOH FDUJR WDQNV VKDOO EH LQ DFFRUGDQFH ZLWK &RPSUHVVHG *DV $VVRFLDWLRQ 3DPSKOHW 3 ZKLFK LV LQFRUSRUDWHG E\ UHIHUHQFH
DV VSHFLILHG LQ 6HF F
F
6DIHW\ UHOLHI GHYLFHV IRU FRPSUHVVHG JDV FRQWDLQHUV &RPSUHVVHG JDV F\OLQGHUV SRUWDEOH WDQNV DQG FDUJR WDQNV VKDOO KDYH SUHVVXUH UHOLHI
GHYLFHV LQVWDOOHG DQG PDLQWDLQHG LQ DFFRUGDQFH ZLWK &RPSUHVVHG *DV $VVRFLDWLRQ 3DPSKOHWV 6 DQG DGGHQGD DQG 6
ZKLFK LV LQFRUSRUDWHG E\ UHIHUHQFH DV VSHFLILHG LQ 6HF > )5 0DUFK @
1H[W 6WDQGDUG 5HJXODWLRQV 6WDQGDUGV &)5 7DEOH RI &RQWHQWV
)UHHGRP RI ,QIRUPDWLRQ $FW _ 3ULYDF\ 6HFXULW\ 6WDWHPHQW _ 'LVFODLPHUV _ ,PSRUWDQW :HE 6LWH 1RWLFHV _ ,QWHUQDWLRQDO _ &RQWDFW 8V
86 'HSDUWPHQW RI /DERU _ 2FFXSDWLRQDO 6DIHW\ +HDOWK $GPLQLVWUDWLRQ _ &RQVWLWXWLRQ $YH 1: :DVKLQJWRQ '& 7HOHSKRQH 26+$ _ 77< ZZZ26+$JRY
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[%
General Information Appendix C:
General Industry Standard on Formaldehyde
Occupational Safety and Health Admin., Labor
potentials, other organic compounds may be
ionized. The lower the lamp energy, the better the selectivity. As a continuous monitor,
photoionization detection can be useful for
locating high concentration pockets, in leak
detection, and continuous ambient air monitoring. Both portable and stationary gas
chromatographs are available with various
types of detectors, including photoionization
detectors. A gas chromatograph with a
photoionization
detector
retains
the
photionization sensitivity, but minimizes or
eliminates interferences. For several GC/PID
units, the sensitivity is in the 0.1–0.2 ppm
EtO range. The GC/PID with microprocessors
can sample up to 20 sample points sequentially, calculate and record data, and activate alarms or ventilation systems. Many
are quite flexible and can be configured to
meet the specific analysis needs for the
workplace.
DuPont presented their laboratory validation data of the accuracy of the QaziKetcham charcoal tube, the PCB charcoal
tube, Miran 103 IR analyzer, 3M #3550 monitor and the Du Pont C–70 badge. Quoting Elbert V. Kring:
We also believe that OSHA’s proposed accuracy in this standard is appropriate. At
plus or minus 25 percent at one part per million, and plus or minus 35 percent below
that. And, our data indicates there’s only
one monitoring method, right now, that
we’ve tested thoroughly, that meets that accuracy requirements. That is the Du Pont
Pro-Tek badge* * *. We also believe that this
kind of data should be confirmed by another
independent laboratory, using the same type
dynamic chamber testing (Tr. 1470)
erowe on DSK5CLS3C1PROD with CFR
Additional data by an independent laboratory following their exact protocol was not
submitted. However, information was submitted on comparisons and precision and accuracy of those monitoring procedures which
indicate far better precision and accuracy of
those monitoring procedures than that obtained by Du Pont (Ex. 4–20, 130, 11–68, 11–133,
130, 135A).
The accuracy of any method depends to a
large degree upon the skills and experience
of those who not only collect the samples
but also those who analyze the samples.
Even for methods that are collaboratively
tested, some laboratories are closer to the
true values than others. Some laboratories
may meet the precision and accuracy requirements of the method; others may con-
§ 1910.1048
sistently far exceed them for the same method.
[49 FR 25796, June 22, 1984, as amended at 50
FR 9801, Mar. 12, 1985; 50 FR 41494, Oct. 11,
1985; 51 FR 25053, July 10, 1986; 53 FR 11436,
11437, Apr. 6, 1988; 53 FR 27960, July 26, 1988;
54 FR 24334, June 7, 1989; 61 FR 5508, Feb. 13,
1996; 63 FR 1292, Jan. 8, 1998; 67 FR 67965, Nov.
7, 2002; 70 FR 1143, Jan. 5, 2005; 71 FR 16672,
16673, Apr. 3, 2006; 71 FR 50190, Aug. 24, 2006;
73 FR 75586, Dec. 12, 2008]
§ 1910.1048 Formaldehyde.
(a) Scope and application. This standard applies to all occupational exposures to formaldehyde, i.e. from formaldehyde gas, its solutions, and materials that release formaldehyde.
(b) Definitions. For purposes of this
standard, the following definitions
shall apply:
Action level means a concentration of
0.5 part formaldehyde per million parts
of air (0.5 ppm) calculated as an eight
(8)-hour time-weighted average (TWA)
concentration.
Assistant Secretary means the Assistant Secretary of Labor for the Occupational Safety and Health Administration, U.S. Department of Labor, or designee.
Authorized person means any person
required by work duties to be present
in regulated areas, or authorized to do
so by the employer, by this section, or
by the OSH Act of 1970.
Director means the Director of the
National Institute for Occupational
Safety and Health, U.S. Department of
Health and Human Services, or designee.
Emergency is any occurrence, such as
but not limited to equipment failure,
rupture of containers, or failure of control equipment that results in an uncontrolled release of a significant
amount of formaldehyde.
Employee exposure means the exposure to airborne formaldehyde which
would occur without corrections for
protection provided by any respirator
that is in use.
Formaldehyde means the chemical
substance, HCHO, Chemical Abstracts
Service Registry No. 50–00–0.
(c) Permissible Exposure Limit (PEL)—
(1) TWA: The employer shall assure
that no employee is exposed to an airborne concentration of formaldehyde
which exceeds 0.75 parts formaldehyde
357
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
09:15 Aug 28, 2009 Jkt 217114 PO 00000 Frm 00367 Fmt 8010
Sfmt 8010 Y:\SGML\217114.XXX 217114 *HQHUDO,QIRUPDWLRQ$SSHQGL[&
3DJH
VerDate
Nov<24>2008
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
per million parts of air (0.75 ppm) as an
8-hour TWA.
(2) Short Term Exposure Limit (STEL):
The employer shall assure that no employee is exposed to an airborne concentration of formaldehyde which exceeds two parts formaldehyde per million parts of air (2 ppm) as a 15-minute
STEL.
(d) Exposure monitoring—(1) General.
(i) Each employer who has a workplace
covered by this standard shall monitor
employees to determine their exposure
to formaldehyde.
(ii) Exception. Where the employer
documents, using objective data, that
the presence of formaldehyde or formaldehyde-releasing products in the
workplace cannot result in airborne
concentrations of formaldehyde that
would cause any employee to be exposed at or above the action level or
the STEL under foreseeable conditions
of use, the employer will not be required to measure employee exposure
to formaldehyde.
(iii) When an employee’s exposure is
determined from representative sampling, the measurements used shall be
representative of the employee’s full
shift or short-term exposure to formaldehyde, as appropriate.
(iv) Representative samples for each
job classification in each work area
shall be taken for each shift unless the
employer can document with objective
data that exposure levels for a given
job classification are equivalent for different work shifts.
(2) Initial monitoring. The employer
shall identify all employees who may
be exposed at or above the action level
or at or above the STEL and accurately determine the exposure of each
employee so identified.
(i) Unless the employer chooses to
measure the exposure of each employee
potentially exposed to formaldehyde,
the employer shall develop a representative sampling strategy and measure
sufficient exposures within each job
classification for each workshift to
correctly characterize and not underestimate the exposure of any employee
within each exposure group.
(ii) The initial monitoring process
shall be repeated each time there is a
change in production, equipment, process, personnel, or control measures
which may result in new or additional
exposure to formaldehyde.
(iii) If the employer receives reports
of signs or symptoms of respiratory or
dermal conditions associated with
formaldehyde exposure, the employer
shall promptly monitor the affected
employee’s exposure.
(3) Periodic monitoring. (i) The employer shall periodically measure and
accurately determine exposure to
formaldehyde for employees shown by
the initial monitoring to be exposed at
or above the action level or at or above
the STEL.
(ii) If the last monitoring results reveal employee exposure at or above the
action level, the employer shall repeat
monitoring of the employees at least
every 6 months.
(iii) If the last monitoring results reveal employee exposure at or above the
STEL, the employer shall repeat monitoring of the employees at least once a
year under worst conditions.
(4) Termination of monitoring. The employer may discontinue periodic monitoring for employees if results from
two consecutive sampling periods
taken at least 7 days apart show that
employee exposure is below the action
level and the STEL. The results must
be statistically representative and consistent with the employer’s knowledge
of the job and work operation.
(5) Accuracy of monitoring. Monitoring
shall be accurate, at the 95 percent
confidence level, to within plus or
minus 25 percent for airborne concentrations of formaldehyde at the
TWA and the STEL and to within plus
or minus 35 percent for airborne concentrations of formaldehyde at the action level.
(6) Employee notification of monitoring
results. The employer must, within 15
working days after the receipt of the
results of any monitoring performed
under this section, notify each affected
employee of these results either individually in writing or by posting the
results in an appropriate location that
is accessible to employees. If employee
exposure is above the PEL, affected
employees shall be provided with a description of the corrective actions
being taken by the employer to decrease exposure.
358
VerDate Nov4>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00368
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
(7) Observation of monitoring. (i) The
employer shall provide affected employees or their designated representatives an opportunity to observe any
monitoring of employee exposure to
formaldehyde required by this standard.
(ii) When observation of the monitoring of employee exposure to formaldehyde requires entry into an area
where the use of protective clothing or
equipment is required, the employer
shall provide the clothing and equipment to the observer, require the observer to use such clothing and equipment, and assure that the observer
complies with all other applicable safety and health procedures.
(e) Regulated areas. (1) The employer
shall establish regulated areas where
the concentration of airborne formaldehyde exceeds either the TWA or
the STEL and post all entrances and
accessways with signs bearing the following information:
erowe on DSK5CLS3C1PROD with CFR
DANGER
FORMALDEHYDE
IRRITANT AND POTENTIAL CANCER
HAZARD
AUTHORIZED PERSONNEL ONLY
(2) The employer shall limit access to
regulated areas to authorized persons
who have been trained to recognize the
hazards of formaldehyde.
(3) An employer at a multiemployer
worksite who establishes a regulated
area shall communicate the access restrictions and locations of these areas
to other employers with work operations at that worksite.
(f) Methods of compliance—(1) Engineering controls and work practices. The
employer shall institute engineering
and work practice controls to reduce
and maintain employee exposures to
formaldehyde at or below the TWA and
the STEL.
(2) Exception. Whenever the employer
has established that feasible engineering and work practice controls cannot
reduce employee exposure to or below
either of the PELs, the employer shall
apply these controls to reduce employee exposures to the extent feasible
and shall supplement them with respirators which satisfy this standard.
(g) Respiratory protection—(1) General.
For employees who use respirators required by this section, the employer
§ 1910.1048
must provide each employee an appropriate respirator that complies with
the requirements of this paragraph.
Respirators must be used during:
(i) Periods necessary to install or implement feasible engineering and workpractice controls.
(ii) Work operations, such as maintenance and repair activities or vessel
cleaning, for which the employer establishes that engineering and work-practice controls are not feasible.
(iii) Work operations for which feasible engineering and work-practice
controls are not yet sufficient to reduce employee exposure to or below the
PELs.
(iv) Emergencies.
(2) Respirator program. (i) The employer must implement a respiratory
protection program in accordance with
§ 1910.134(b)
through
(d)
(except
(d)(1)(iii), (d)(3)(iii)(b)(1), and (2)), and
(f) through (m), which covers each employee required by this section to use a
respirator.
(ii) When employees use air-purifying
respirators with chemical cartridges or
canisters that do not contain end-ofservice-life indicators approved by the
National Institute for Occupational
Safety and Health, employers must replace these cartridges or canisters as
specified by paragraphs (d)(3)(iii)(B)(1)
and (B)(2) of 29 CFR 1910.134, or at the
end of the workshift, whichever condition occurs first.
(3) Respirator selection. (i) Employers
must:
(A) Select, and provide to employees,
the appropriate respirators specified in
paragraph (d)(3)(i)(A) of 29 CFR
1910.134.
(B) Equip each air-purifying, full
facepiece respirator with a canister or
cartridge approved for protection
against formaldehyde.
(C) For escape, provide employees
with one of the following respirator options: A self-contained breathing apparatus operated in the demand or pressure-demand mode; or a full facepiece
respirator having a chin-style, or a
front-or back-mounted industrial-size,
canister or cartridge approved for protection against formaldehyde.
(ii) Employers may substitute an airpurifying, half mask respirator for an
air-purifying, full facepiece respirator
359
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00369
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
when they equip the half mask respirator with a cartridge approved for
protection against formaldehyde and
provide the affected employee with effective gas-proof goggles.
(iii) Employers must provide employees who have difficulty using negative
pressure respirators with powered airpurifying respirators permitted for use
under paragraph (g)(3)(i)(A) of this
standard and that affords adequate protection against formaldehyde exposures.
(h) Protective equipment and clothing.
Employers shall comply with the provisions of 29 CFR 1910.132 and 29 CFR
1910.133. When protective equipment or
clothing is provided under these provisions, the employer shall provide these
protective devices at no cost to the employee and assure that the employee
wears them.
(1) Selection. The employer shall select protective clothing and equipment
based upon the form of formaldehyde
to be encountered, the conditions of
use, and the hazard to be prevented.
(i) All contact of the eyes and skin
with liquids containing 1 percent or
more formaldehyde shall be prevented
by the use of chemical protective
clothing made of material impervious
to formaldehyde and the use of other
personal protective equipment, such as
goggles and face shields, as appropriate
to the operation.
(ii) Contact with irritating or sensitizing materials shall be prevented to
the extent necessary to eliminate the
hazard.
(iii) Where a face shield is worn,
chemical safety goggles are also required if there is a danger of formaldehyde reaching the area of the eye.
(iv) Full body protection shall be
worn for entry into areas where concentrations exceed 100 ppm and for
emergency reentry into areas of unknown concentration.
(2) Maintenance of protective equipment
and clothing. (i) The employer shall assure that protective equipment and
clothing that has become contaminated with formaldehyde is cleaned or
laundered before its reuse.
(ii) When ventilating formaldehydecontaminated clothing and equipment,
the employer shall establish a storage
area so that employee exposure is
minimized. Containers for contaminated clothing and equipment and storage areas shall have labels and signs
containing the following information:
DANGER
FORMALDEHYDE-CONTAMINATED
[CLOTHING] EQUIPMENT
AVOID INHALATION AND SKIN CONTACT
(iii) The employer shall assure that
only persons trained to recognize the
hazards of formaldehyde remove the
contaminated material from the storage area for purposes of cleaning, laundering, or disposal.
(iv) The employer shall assure that
no employee takes home equipment or
clothing that is contaminated with
formaldehyde.
(v) The employer shall repair or replace all required protective clothing
and equipment for each affected employee as necessary to assure its effectiveness.
(vi) The employer shall inform any
person who launders, cleans, or repairs
such
clothing
or
equipment
of
formaldehyde’s potentially harmful effects and of procedures to safely handle
the clothing and equipment.
(i) Hygiene protection. (1) The employer shall provide change rooms, as
described in 29 CFR 1910.141 for employees who are required to change from
work clothing into protective clothing
to prevent skin contact with formaldehyde.
(2) If employees’ skin may become
spashed with solutions containing 1
percent or greater formaldehyde, for
example, because of equipment failure
or improper work practices, the employer shall provide conveniently located quick drench showers and assure
that affected employees use these facilities immediately.
(3) If there is any possibility that an
employee’s eyes may be splashed with
solutions containing 0.1 percent or
greater formaldehyde, the employer
shall provide acceptable eyewash facilities within the immediate work area
for emergency use.
(j) Housekeeping. For operations involving formaldehyde liquids or gas,
the employer shall conduct a program
to detect leaks and spills, including
regular visual inspections.
(1) Preventative maintenance of
equipment, including surveys for leaks,
360
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00370
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
Occupational Safety and Health Admin., Labor
shall be undertaken at regular intervals.
(2) In work areas where spillage may
occur, the employer shall make provisions to contain the spill, to decontaminate the work area, and to dispose
of the waste.
(3) The employer shall assure that all
leaks are repaired and spills are
cleaned promptly by employees wearing suitable protective equipment and
trained in proper methods for cleanup
and decontamination.
(4)
Formaldehyde-contaminated
waste and debris resulting from leaks
or spills shall be placed for disposal in
sealed containers bearing a label warning of formaldehyde’s presence and of
the hazards associated with formaldehyde.
(k) Emergencies. For each workplace
where there is the possibility of an
emergency involving formaldehyde, the
employer shall assure appropriate procedures are adopted to minimize injury
and loss of life. Appropriate procedures
shall be implemented in the event of an
emergency.
(l) Medical surveillance—(1) Employees
covered. (i) The employer shall institute medical surveillance programs for
all employees exposed to formaldehyde
at concentrations at or exceeding the
action level or exceeding the STEL.
(ii) The employer shall make medical
surveillance available for employees
who develop signs and symptoms of
overexposure to formaldehyde and for
all employees exposed to formaldehyde
in emergencies. When determining
whether an employee may be experiencing signs and symptoms of possible
overexposure to formaldehyde, the employer may rely on the evidence that
signs and symptoms associated with
formaldehyde exposure will occur only
in exceptional circumstances when airborne exposure is less than 0.1 ppm and
when formaldehyde is present in material in concentrations less than 0.1 percent.
(2) Examination by a physician. All
medical procedures, including administration of medical disease questionnaires, shall be performed by or under
the supervision of a licensed physician
and shall be provided without cost to
the employee, without loss of pay, and
at a reasonable time and place.
§ 1910.1048
(3) Medical disease questionnaire. The
employer shall make the following
medical surveillance available to employees prior to assignment to a job
where formaldehyde exposure is at or
above the action level or above the
STEL and annually thereafter. The employer shall also make the following
medical surveillance available promptly upon determining that an employee
is experiencing signs and symptoms indicative of possible overexposure to
formaldehyde.
(i) Administration of a medical disease questionnaire, such as in appendix
D, which is designed to elicit information on work history, smoking history,
any evidence of eye, nose, or throat irritation; chronic airway problems or
hyperreactive airway disease: allergic
skin conditions or dermatitis; and
upper or lower respiratory problems.
(ii) A determination by the physician, based on evaluation of the medical disease questionnaire, of whether a
medical examination is necessary for
employees not required to wear respirators to reduce exposure to formaldehyde.
(4) Medical examinations. Medical examinations shall be given to any employee who the physician feels, based
on information in the medical disease
questionnaire, may be at increased risk
from exposure to formaldehyde and at
the time of initial assignment and at
least annually thereafter to all employees required to wear a respirator to
reduce exposure to formaldehyde. The
medical examination shall include:
(i) A physical examination with emphasis on evidence of irritation or sensitization of the skin and respiratory
system, shortness of breath, or irritation of the eyes.
(ii) Laboratory examinations for respirator wearers consisting of baseline
and annual pulmonary function tests.
As a minimum, these tests shall consist of forced vital capacity (FVC),
forced expiratory volume in one second
(FEV1), and forced expiratory flow
(FEF).
(iii) Any other test which the examining physician deems necessary to
complete the written opinion.
361
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00371
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
(iv) Counseling of employees having
medical conditions that would be directly or indirectly aggravated by exposure to formaldehyde on the increased risk of impairment of their
health.
(5) Examinations for employees exposed
in an emergency. The employer shall
make medical examinations available
as soon as possible to all employees
who have been exposed to formaldehyde in an emergency.
(i) The examination shall include a
medical and work history with emphasis on any evidence of upper or lower
respiratory problems, allergic conditions,
skin
reaction
or
hypersensitivity, and any evidence of eye,
nose, or throat irritation.
(ii) Other examinations shall consist
of those elements considered appropriate by the examining physician.
(6) Information provided to the physician. The employer shall provide the
following information to the examining physician:
(i) A copy of this standard and appendix A, C, D, and E;
(ii) A description of the affected employee’s job duties as they relate to the
employee’s exposure to formaldehyde;
(iii) The representative exposure
level for the employee’s job assignment;
(iv) Information concerning any personal protective equipment and respiratory protection used or to be used
by the employee; and
(v) Information from previous medical examinations of the affected employee within the control of the employer.
(vi) In the event of a nonroutine examination because of an emergency,
the employer shall provide to the physician as soon as possible: A description of how the emergency occurred
and the exposure the victim may have
received.
(7) Physician’s written opinion. (i) For
each examination required under this
standard, the employer shall obtain a
written opinion from the examining
physician. This written opinion shall
contain the results of the medical examination except that it shall not reveal specific findings or diagnoses unrelated to occupational exposure to
formaldehyde. The written opinion
shall include:
(A) The physician’s opinion as to
whether the employee has any medical
condition that would place the employee at an increased risk of material
impairment of health from exposure to
formaldehyde;
(B) Any recommended limitations on
the employee’s exposure or changes in
the use of personal protective equipment, including respirators;
(C) A statement that the employee
has been informed by the physician of
any medical conditions which would be
aggravated by exposure to formaldehyde, whether these conditions may
have resulted from past formaldehyde
exposure or from exposure in an emergency, and whether there is a need for
further examination or treatment.
(ii) The employer shall provide for retention of the results of the medical
examination and tests conducted by
the physician.
(iii) The employer shall provide a
copy of the physician’s written opinion
to the affected employee within 15 days
of its receipt.
(8) Medical removal. (i) The provisions
of paragraph (l)(8) apply when an employee reports significant irritation of
the mucosa of the eyes or the upper
airways, respiratory sensitization, dermal irritation, or dermal sensitization
attributed to workplace formaldehyde
exposure. Medical removal provisions
do not apply in the case of dermal irritation or dermal sensitization when
the product suspected of causing the
dermal condition contains less than
0.05% formaldehyde.
(ii) An employee’s report of signs or
symptoms of possible overexposure to
formaldehyde shall be evaluated by a
physician selected by the employer
pursuant to paragraph (l)(3). If the physician determines that a medical examination is not necessary under paragraph (l)(3)(ii), there shall be a twoweek evaluation and remediation period to permit the employer to ascertain whether the signs or symptoms
subside untreated or with the use of
creams, gloves, first aid treatment or
personal protective equipment. Industrial hygiene measures that limit the
employee’s exposure to formaldehyde
may also be implemented during this
362
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00372
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
Occupational Safety and Health Admin., Labor
period. The employee shall be referred
immediately to a physician prior to expiration of the two-week period if the
signs or symptoms worsen. Earnings,
seniority and benefits may not be altered during the two-week period by
virtue of the report.
(iii) If the signs or symptoms have
not subsided or been remedied by the
end of the two-week period, or earlier if
signs or symptoms warrant, the employee shall be examined by a physician selected by the employer. The
physician shall presume, absent contrary evidence, that observed dermal
irritation or dermal sensitization are
not attributable to formaldehyde when
products to which the affected employee is exposed contain less than
0.1% formaldehyde.
(iv) Medical examinations shall be
conducted in compliance with the requirements of paragraph (l)(5) (i) and
(ii). Additional guidelines for conducting medical exams are contained
in appendix C.
(v) If the physician finds that significant irritation of the mucosa of the
eyes or of the upper airways, respiratory sensitization, dermal irritation, or dermal sensitization result
from workplace formaldehyde exposure
and recommends restrictions or removal, the employer shall promptly
comply with the restrictions or recommendation of removal. In the event
of a recommendation of removal, the
employer shall remove the effected employee from the current formaldehyde
exposure and if possible, transfer the
employee to work having no or significantly less exposure to formaldehyde.
(vi) When an employee is removed
pursuant to paragraph (l)(8)(v), the employer shall transfer the employee to
comparable work for which the employee is qualified or can be trained in
a short period (up to 6 months), where
the formaldehyde exposures are as low
as possible, but not higher than the action level. The employeer shall maintain the employee’s current earnings,
seniority, and other benefits. If there is
no such work available, the employer
shall maintain the employee’s current
earnings, seniority and other benefits
until such work becomes available,
until the employee is determined to be
unable to return to workplace form-
§ 1910.1048
aldehyde exposure, until the employee
is determined to be able to return to
the original job status, or for six
months, whichever comes first.
(vii) The employer shall arrange for a
follow-up medical examination to take
place within six months after the employee is removed pursuant to this
paragraph. This examination shall determine if the employee can return to
the original job status, or if the removal is to be permanent. The physician shall make a decision within six
months of the date the employee was
removed as to whether the employee
can be returned to the original job status, or if the removal is to be permanent.
(viii) An employer’s obligation to
provide earnings, seniority and other
benefits to a removed employee may be
reduced to the extent that the employee receives compensation for earnings lost during the period of removal
either from a publicly or employerfunded compensation program or from
employment with another employer
made possible by virtue of the employee’s removal.
(ix) In making determinations of the
formaldehyde content of materials
under this paragraph the employer
may rely on objective data.
(9) Multiple physician review. (i) After
the employer selects the initial physician who conducts any medical examination or consultation to determine
whether medical removal or restriction
is appropriate, the employee may designate a second physician to review
any findings, determinations or recommendations of the initial physician
and to conduct such examinations, consultations, and laboratory tests as the
second physician deems necessary and
appropriate to evaluate the effects of
formaldehyde exposure and to facilitate this review.
(ii) The employer shall promptly notify an employee of the right to seek a
second medical opinion after each occasion that an initial physician conducts a medical examination or consultation for the purpose of medical removal or restriction.
(iii) The employer may condition its
participation in, and payment for, the
multiple physician review mechanism
upon the employee doing the following
363
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00373
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
within fifteen (15) days after receipt of
the notification of the right to seek a
second medical opinion, or receipt of
the initial physician’s written opinion,
whichever is later;
(A) The employee informs the employer of the intention to seek a second
medical opinion, and
(B) The employee initiates steps to
make an appointment with a second
physician.
(iv) If the findings, determinations or
recommendations of the second physician differ from those of the initial
physician, then the employer and the
employee shall assure that efforts are
made for the two physicians to resolve
the disagreement. If the two physicians
are unable to quickly resolve their disagreement, then the employer and the
employee through their respective physicians shall designate a third physician who shall be a specialist in the
field at issue:
(A) To review the findings, determinations or recommendations of the
prior physicians; and
(B) To conduct such examinations,
consultations, laboratory tests and discussions with the prior physicians as
the third physician deems necessary to
resolve the disagreement of the prior
physicians.
(v) In the alternative, the employer
and the employee or authorized employee representative may jointly designate such third physician.
(vi) The employer shall act consistent with the findings, determinations and recommendations of the
third physician, unless the employer
and the employee reach an agreement
which is otherwise consistent with the
recommendations of at least one of the
three physicians.
(m) Hazard communication—(1) General. Communication of the hazards associated with formaldehyde in the
workplace shall be governed by the requirements of paragraph (m). The definitions of 29 CFR 1910.1200(c) shall
apply under this paragraph.
(i) The following shall be subject to
the hazard communication requirements of this paragraph: Formaldehyde
gas, all mixtures or solutions composed
of greater than 0.1 percent formaldehyde, and materials capable of releasing formaldehyde into the air, under
reasonably foreseeable conditions of
use, at concentrations reaching or exceeding 0.1 ppm.
(ii) As a minimum, specific health
hazards that the employer shall address are: Cancer, irritation and sensitization of the skin and respiratory
system, eye and throat irritation, and
acute toxicity.
(2) Manufacturers and importers who
produce or import formaldehyde or
formaldehyde-containing
products
shall provide downstream employers
using or handling these products with
an objective determination through the
required labels and MSDSs if these
items may constitute a health hazard
within the meaning of 29 CFR
1910.1200(d) under normal conditions of
use.
(3) Labels. (i) The employer shall assure that hazard warning labels complying with the requirements of 29 CFR
1910.1200(f) are affixed to all containers
of materials listed in paragraph
(m)(1)(i), except to the extent that 29
CFR 1910.1200(f) is inconsistent with
this paragraph.
(ii) Information on labels. As a minimum, for all materials listed in paragraph (m)(1)(i) capable of releasing
formaldehyde at levels of 0.1 ppm to 0.5
ppm, labels shall identify that the
product contains formaldehyde; list the
name and address of the responsible
party; and state that physical and
health hazard information is readily
available from the employer and from
material safety data sheets.
(iii) For materials listed in paragraph (m)(1)(i) capable of releasing
formaldehyde at levels above 0.5 ppm,
labels shall appropriately address all
hazards
as
defined
in
29
CFR
1910.1200(d) and 29 CFR 1910.1200 appendices A and B, including respiratory
sensitization, and shall contain the
words ‘‘Potential Cancer Hazard.’’
(iv) In making the determinations of
anticipated levels of formaldehyde release, the employer may rely on objective data indicating the extent of potential formaldehyde release under reasonably foreseeable conditions of use.
(v) Substitute warning labels. The employer may use warning labels required
364
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00374
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
Occupational Safety and Health Admin., Labor
by other statutes, regulations, or ordinances which impart the same information as the warning statements required by this paragraph.
(4) Material safety data sheets. (i) Any
employer who uses formaldehyde-containing materials listed in paragraph
(m)(1)(i) shall comply with the requirements of 29 CFR 1910.1200(g) with regard to the development and updating
of material safety data sheets.
(ii) Manufacturers, importers, and
distributors
of
formaldehyde-containing materials listed in paragraph
(m)(1)(i) shall assure that material
safety data sheets and updated information are provided to all employers
purchasing such materials at the time
of the initial shipment and at the time
of the first shipment after a material
safety data sheet is updated.
(5) Written hazard communication program. The employer shall develop, implement, and maintain at the workplace, a written hazard communication
program for formaldehyde exposures in
the workplace, which at a minimum
describes how the requirements specified in this paragraph for labels and
other forms of warning and material
safety data sheets, and paragraph (n)
for employee information and training,
will be met. Employers in multi-employer workplaces shall comply with
the
requirements
of
29
CFR
1910.1200(e)(2).
(n) Employee information and training—(1) Participation. The employer
shall assure that all employees who are
assigned to workplaces where there is
exposure to formaldehyde participate
in a training program, except that
where the employer can show, using
objective data, that employees are not
exposed to formaldehyde at or above 0.1
ppm, the employer is not required to
provide training.
(2) Frequency. Employers shall provide such information and training to
employees at the time of initial assignment, and whenever a new exposure to
formaldehyde is introduced into the
work area. The training shall be repeated at least annually.
(3) Training program. The training
program shall be conducted in a manner which the employee is able to understand and shall include:
§ 1910.1048
(i) A discussion of the contents of
this regulation and the contents of the
Material Safety Data Sheet.
(ii) The purpose for and a description
of the medical surveillance program required by this standard, including:
(A) A description of the potential
health hazards associated with exposure to formaldehyde and a description
of the signs and symptoms of exposure
to formaldehyde.
(B) Instructions to immediately report to the employer the development
of any adverse signs or symptoms that
the employee suspects is attributable
to formaldehyde exposure.
(iii) Description of operations in the
work area where formaldehyde is
present and an explanation of the safe
work practices appropriate for limiting
exposure to formaldehyde in each job;
(iv) The purpose for, proper use of,
and limitations of personal protective
clothing and equipment;
(v) Instructions for the handling of
spills, emergencies, and clean-up procedures;
(vi) An explanation of the importance
of engineering and work practice controls for employee protection and any
necessary instruction in the use of
these controls; and
(vii) A review of emergency procedures including the specific duties or
assignments of each employee in the
event of an emergency.
(4) Access to training materials. (i) The
employer shall inform all affected employees of the location of written
training materials and shall make
these materials readily available, without cost, to the affected employees.
(ii) The employer shall provide, upon
request, all training materials relating
to the employee training program to
the Assistant Secretary and the Director.
(o) Recordkeeping—(1) Exposure measurements. The employer shall establish
and maintain an accurate record of all
measurements taken to monitor employee exposure to formaldehyde. This
record shall include:
(i) The date of measurement;
(ii) The operation being monitored;
(iii) The methods of sampling and
analysis and evidence of their accuracy
and precision;
365
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00375
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
(iv) The number, durations, time, and
results of samples taken;
(v) The types of protective devices
worn; and
(vi) The names, job classifications,
social security numbers, and exposure
estimates of the employees whose exposures are represented by the actual
monitoring results.
(2) Exposure determinations. Where the
employer has determined that no monitoring is required under this standard,
the employer shall maintain a record
of the objective data relied upon to
support the determination that no employee is exposed to formaldehyde at or
above the action level.
(3) Medical surveillance. The employer
shall establish and maintain an accurate record for each employee subject
to medical surveillance under this
standard. This record shall include:
(i) The name and social security
number of the employee;
(ii) The physician’s written opinion;
(iii) A list of any employee health
complaints that may be related to exposure to formaldehyde; and
(iv) A copy of the medical examination results, including medical disease
questionnaires and results of any medical tests required by the standard or
mandated by the examining physician.
(4) Respirator fit testing. (i) The employer shall establish and maintain accurate records for employees subject to
negative pressure respirator fit testing
required by this standard.
(ii) This record shall include:
(A) A copy of the protocol selected
for respirator fit testing.
(B) A copy of the results of any fit
testing performed.
(C) The size and manufacturer of the
types of respirators available for selection.
(D) The date of the most recent fit
testing, the name and social security
number of each tested employee, and
the respirator type and facepiece selected.
(5) Record retention. The employer
shall retain records required by this
standard for at least the following periods:
(i) Exposure records and determinations shall be kept for at least 30 years.
(ii) Medical records shall be kept for
the duration of employment plus 30
years.
(iii) Respirator fit testing records
shall be kept until replaced by a more
recent record.
(6) Availability of records. (i) Upon request, the employer shall make all
records maintained as a requirement of
this standard available for examination
and copying to the Assistant Secretary
and the Director.
(ii) The employer shall make employee exposure records, including estimates made from representative monitoring and available upon request for
examination, and copying to the subject employee, or former employee, and
employee representatives in accordance with 29 CFR 1910.1020 (a)–(e) and
(g)–(i).
(iii) Employee medical records required by this standard shall be provided upon request for examination and
coying, to the subject employee or
former employee or to anyone having
the specific written consent of the subject employee or former employee in
accordance with 29 CFR 1910.1020 (a)–(e)
and (g)–(i).
APPENDIX A TO § 1910.1048—SUBSTANCE
TECHNICAL GUIDELINES FOR FORMALIN
The following Substance Technical Guideline for Formalin provides information on
uninhibited formalin solution (37% formaldehyde, no methanol stabilizer). It is designed
to inform employees at the production level
of their rights and duties under the formaldehyde standard whether their job title defines them as workers or supervisors. Much
of the information provided is general; however, some information is specific for formalin. When employee exposure to formaldehyde is from resins capable of releasing
formaldehyde, the resin itself and other impurities or decomposition products may also
be toxic, and employers should include this
information as well when informing employees of the hazards associated with the materials they handle. The precise hazards associated with exposure to formaldehyde depend
both on the form (solid, liquid, or gas) of the
material and the concentration of formaldehyde present. For example, 37–50 percent solutions of formaldehyde present a much
greater hazard to the skin and eyes from
spills or splashes than solutions containing
less than 1 percent formaldehyde. Individual
Substance Technical Guidelines used by the
employer for training employees should be
modified to properly give information on the
material actually being used.
366
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00376
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
Substance Identification
Chemical Name: Formaldehyde
Chemical Family: Aldehyde
Chemical Formula: HCHO
Molecular Weight: 30.03
Chemical Abstracts Service Number (CAS Number): 50–00–0
Synonyms: Formalin; Formic Aldehyde;
Paraform; Formol; Formalin (Methanolfree); Fyde; Formalith; Methanal; Methyl
Aldehyde; Methylene Glycol; Methylene
Oxide;
Tetraoxymethalene;
Oxomethane;
Oxymethylene
Components and Contaminants
Percent: 37.0 Formaldehyde
Percent: 63.0 Water
(Note—Inhibited solutions
anol.)
contain
meth-
National Fire Protection Association Section
325M Designation:
Health: 2—Materials hazardous to health,
but areas may be entered with full-faced
mask self-contained breathing apparatus
which provides eye protection.
Flammability: 2—Materials which must be
moderately heated before ignition will occur.
Water spray may be used to extinguish the
fire because the material can be cooled below
its flash point.
Reactivity: D—Materials which (in themselves) are normally stable even under fire
exposure conditions and which are not reactive with water. Normal fire fighting procedures may be used.
Reactivity
Description: Colorless liquid, pungent odor
Boiling point: 214 °F (101 °C)
Specific Gravity: 1.08 (H2 O=1 @ 20 °C)
pH: 2.8–4.0
Solubility in Water: Miscible
Solvent Solubility: Soluble in alcohol and acetone
Vapor Density: 1.04 (Air=1 @ 20 °C)
Odor Threshold: 0.8–1 ppm
Stability: Formaldehyde solutions may selfpolymerize to form paraformaldehyde which
precipitates.
Incompatibility (Materials to Avoid): Strong
oxidizing agents, caustics, strong alkalies,
isocyanates, anhydrides, oxides, and inorganic acids. Formaldehyde reacts with hydrochloric acid to form the potent carcinogen, bis-chloromethyl ether. Formaldehyde
reacts
with
nitrogen
dioxide,
nitromethane, perchloric acid and aniline, or
peroxyformic acid to yield explosive compounds. A violent reaction occurs when
formaldehyde is mixed with strong oxidizers.
Hazardous Combustion or Decomposition
Products: Oxygen from the air can oxidize
formaldehyde to formic acid, especially when
heated. Formic acid is corrosive.
Fire and Explosion Hazard
Health Hazard Data
Moderate fire and explosion hazard when
exposed to heat or flame.
The flash point of 37% formaldehyde solutions is above normal room temperature, but
the explosion range is very wide, from 7 to
73% by volume in air.
Reaction of formaldehyde with nitrogen dioxide, nitromethane, perchloric acid and aniline, or peroxyformic acid yields explosive
compounds.
Flash Point: 185 °F (85 °C) closed cup
Lower Explosion Limit: 7%
Upper Explosion Limit: 73%
Autoignition Temperature: 806 °F (430 °C)
Flammability Class (OSHA): III A
Extinguishing Media: Use dry chemical,
‘‘alcohol foam’’, carbon dioxide, or water in
flooding amounts as fog. Solid streams may
not be effective. Cool fire-exposed containers
with water from side until well after fire is
out.
Use of water spray to flush spills can also
dilute the spill to produce nonflammable
mixtures. Water runoff, however, should be
contained for treatment.
Ingestion (Swallowing): Liquids containing
10 to 40% formaldehyde cause severe irritation and inflammation of the mouth, throat,
and stomach. Severe stomach pains will follow ingestion with possible loss of consciousness and death. Ingestion of dilute formaldehyde solutions (0.03–0.04%) may cause discomfort in the stomach and pharynx.
Inhalation (Breathing): Formaldehyde is
highly irritating to the upper respiratory
tract and eyes. Concentrations of 0.5 to 2.0
ppm may irritate the eyes, nose, and throat
of some individuals. Concentrations of 3 to 5
ppm also cause tearing of the eyes and are
intolerable to some persons. Concentrations
of 10 to 20 ppm cause difficulty in breathing,
burning of the nose and throat, cough, and
heavy tearing of the eyes, and 25 to 30 ppm
causes severe respiratory tract injury leading to pulmonary edema and pneumonitis. A
concentration of 100 ppm is immediately
dangerous to life and health. Deaths from accidental exposure to high concentrations of
formaldehyde have been reported.
Other Contaminants: Formic acid (alcohol
free)
Exposure Limits:
OSHA TWA—0.75 ppm
OSHA STEL—2 ppm
Physical Data
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
Acute Effects of Exposure
367
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00377
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
Skin (Dermal): Formalin is a severe skin irritant and a sensitizer. Contact with formalin causes white discoloration, smarting,
drying, cracking, and scaling. Prolonged and
repeated contact can cause numbness and a
hardening or tanning of the skin. Previously
exposed persons may react to future exposure with an allergic eczematous dermatitis
or hives.
Eye
Contact:
Formaldehyde
solutions
splashed in the eye can cause injuries ranging from transient discomfort to severe, permanent corneal clouding and loss of vision.
The severity of the effect depends on the
concentration of formaldehyde in the solution and whether or not the eyes are flushed
with water immediately after the accident.
NOTE. The perception of formaldehyde by
odor and eye irritation becomes less sensitive with time as one adapts to formaldehyde. This can lead to overexposure if a
worker is relying on formaldehyde’s warning
properties to alert him or her to the potential for exposure.
Acute Animal Toxicity:
Oral, rats: LD50=800 mg/kg
Oral, mouse: LD50=42 mg/kg
Inhalation, rats: LCLo=250 mg/kg
Inhalation, mouse: LCLo=900 mg/kg
Inhalation, rats: LC50=590 mg/kg
Chronic Effects of Exposure
Carcinogenicity: Formaldehyde has the potential to cause cancer in humans. Repeated
and prolonged exposure increases the risk.
Various animal experiments have conclusively shown formaldehyde to be a carcinogen in rats. In humans, formaldehyde exposure has been associated with cancers of
the lung, nasopharynx and oropharynx, and
nasal passages.
Mutagenicity: Formaldehyde is genotoxic in
several in vitro test systems showing properties of both an initiator and a promoter.
Toxicity: Prolonged or repeated exposure to
formaldehyde may result in respiratory impairment. Rats exposed to formaldehyde at 2
ppm developed benign nasal tumors and
changes of the cell structure in the nose as
well as inflamed mucous membranes of the
nose. Structural changes in the epithelial
cells in the human nose have also been observed. Some persons have developed asthma
or bronchitis following exposure to formaldehyde, most often as the result of an accidental spill involving a single exposure to a
high concentration of formaldehyde.
erowe on DSK5CLS3C1PROD with CFR
Emergency and First Aid Procedures
Ingestion (Swallowing): If the victim is conscious, dilute, inactivate, or absorb the ingested formaldehyde by giving milk, activated charcoal, or water. Any organic material will inactivate formaldehyde. Keep affected person warm and at rest. Get medical
attention immediately. If vomiting occurs,
keep head lower than hips.
Inhalation (Breathing): Remove the victim
from the exposure area to fresh air immediately. Where the formaldehyde concentration may be very high, each rescuer must
put on a self-contained breathing apparatus
before attempting to remove the victim, and
medical personnel should be informed of the
formaldehyde exposure immediately. If
breathing has stopped, give artificial respiration. Keep the affected person warm and at
rest. Qualified first-aid or medical personnel
should administer oxygen, if available, and
maintain the patient’s airways and blood
pressure until the victim can be transported
to a medical facility. If exposure results in a
highly irritated upper respiratory tract and
coughing continues for more than 10 minutes, the worker should be hospitalized for
observation and treatment.
Skin Contact: Remove contaminated clothing (including shoes) immediately. Wash the
affected area of your body with soap or mild
detergent and large amounts of water until
no evidence of the chemical remains (at least
15 to 20 minutes). If there are chemical
burns, get first aid to cover the area with
sterile, dry dressing, and bandages. Get medical attention if you experience appreciable
eye or respiratory irritation.
Eye Contact: Wash the eyes immediately
with large amounts of water occasionally
lifting lower and upper lids, until no evidence of chemical remains (at least 15 to 20
minutes). In case of burns, apply sterile bandages loosely without medication. Get medical attention immediately. If you have experienced appreciable eye irritation from a
splash or excessive exposure, you should be
referred promptly to an opthamologist for
evaluation.
Emergency Procedures
Emergencies: If you work in an area where
a large amount of formaldehyde could be released in an accident or from equipment failure, your employer must develop procedures
to be followed in event of an emergency. You
should be trained in your specific duties in
the event of an emergency, and it is important that you clearly understand these duties. Emergency equipment must be accessible and you should be trained to use any
equipment that you might need. Formaldehyde contaminated equipment must be
cleaned before reuse.
If a spill of appreciable quantity occurs,
leave the area quickly unless you have specific emergency duties. Do not touch spilled
material. Designated persons may stop the
leak and shut off ignition sources if these
procedures can be done without risk. Designated persons should isolate the hazard
area and deny entry except for necessary
people protected by suitable protective
368
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00378
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
clothing and respirators adequate for the exposure. Use water spray to reduce vapors. Do
not smoke, and prohibit all flames or flares
in the hazard area.
Special Firefighting Procedures: Learn procedures and responsibilities in the event of a
fire in your workplace. Become familiar with
the appropriate equipment and supplies and
their location. In firefighting, withdraw immediately in case of rising sound from venting safety device or any discoloration of
storage tank due to fire.
Spill, Leak, and Disposal Procedures
Occupational Spill: For small containers,
place the leaking container in a well ventilated area. Take up small spills with absorbent material and place the waste into properly labeled containers for later disposal.
For larger spills, dike the spill to minimize
contamination and facilitate salvage or disposal. You may be able to neutralize the spill
with sodium hydroxide or sodium sulfite.
Your employer must comply with EPA rules
regarding the clean-up of toxic waste and notify state and local authorities, if required.
If the spill is greater than 1,000 lb/day, it is
reportable under EPA’s Superfund legislation.
Waste Disposal: Your employer must dispose of waste containing formaldehyde in accordance with applicable local, state, and
Federal law and in a manner that minimizes
exposure of employees at the site and of the
clean-up crew.
erowe on DSK5CLS3C1PROD with CFR
Monitoring and Measurement Procedures
Monitoring Requirements: If your exposure
to formaldehyde exceeds the 0.5 ppm action
level or the 2 ppm STEL, your employer
must monitor your exposure. Your employer
need not measure every exposure if a ‘‘high
exposure’’ employee can be identified. This
person usually spends the greatest amount of
time nearest the process equipment. If you
are a ‘‘representative employee’’, you will be
asked to wear a sampling device to collect
formaldehyde. This device may be a passive
badge, a sorbent tube attached to a pump, or
an impinger containing liquid. You should
perform your work as usual, but inform the
person who is conducting the monitoring of
any difficulties you are having wearing the
device.
Evaluation of 8-hour Exposure: Measurements taken for the purpose of determining
time-weighted average (TWA) exposures are
best taken with samples covering the full
shift. Samples collected must be taken from
the employee’s breathing zone air.
Short-term Exposure Evaluation: If there are
tasks that involve brief but intense exposure
to formaldehyde, employee exposure must be
measured to assure compliance with the
STEL. Sample collections are for brief peri-
§ 1910.1048
ods, only 15 minutes, but several samples
may be needed to identify the peak exposure.
Monitoring Techniques: OSHA’s only requirement for selecting a method for sampling and analysis is that the methods used
accurately evaluate the concentration of
formaldehyde in employees’ breathing zones.
Sampling and analysis may be performed by
collection of formaldehyde on liquid or solid
sorbents with subsequent chemical analysis.
Sampling and analysis may also be performed by passive diffusion monitors and
short-term exposure may be measured by instruments such as real-time continuous
monitoring systems and portable direct reading instruments.
Notification of Results: Your employer must
inform you of the results of exposure monitoring representative of your job. You may
be informed in writing, but posting the results where you have ready access to them
constitutes compliance with the standard.
Protective Equipment and Clothing
[Material impervious to formaldehyde is
needed if the employee handles formaldehyde
solutions of 1% or more. Other employees
may also require protective clothing or
equipment to prevent dermatitis.]
Respiratory Protection: Use NIOSH-approved
full facepiece negative pressure respirators
equipped with approved cartridges or canisters within the use limitations of these devices. (Present restrictions on cartridges and
canisters do not permit them to be used for
a full workshift.) In all other situations, use
positive pressure respirators such as the
positive-pressure air purifying respirator or
the self-contained breathing apparatus
(SCBA). If you use a negative pressure respirator, your employer must provide you
with fit testing of the respirator at least
once a year.
Protective Gloves: Wear protective (impervious) gloves provided by your employer, at
no cost, to prevent contact with formalin.
Your employer should select these gloves
based on the results of permeation testing
and in accordance with the ACGIH Guidelines for Selection of Chemical Protective
Clothing.
Eye Protection: If you might be splashed in
the eyes with formalin, it is essential that
you wear goggles or some other type of complete protection for the eye. You may also
need a face shield if your face is likely to be
splashed with formalin, but you must not
substitute face shields for eye protection.
(This section pertains to formaldehyde solutions of 1% or more.)
Other Protective Equipment: You must wear
protective (impervious) clothing and equipment provided by your employer at no cost
to prevent repeated or prolonged contact
with formaldehyde liquids. If you are required to change into whole-body chemical
369
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00379
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
protective clothing, your employer must provide a change room for your privacy and for
storage of your normal clothing.
If you are splashed with formaldehyde, use
the emergency showers and eyewash fountains provided by your employer immediately to prevent serious injury. Report the
incident to your supervisor and obtain necessary medical support.
ENTRY INTO AN IDLH ATMOSPHERE
Enter areas where the formaldehyde concentration might be 100 ppm or more only
with complete body protection including a
self-contained breathing apparatus with a
full facepiece operated in a positive pressure
mode or a supplied air respirator with full
facepiece and operated in a positive pressure
mode. This equipment is essential to protect
your life and health under such extreme conditions.
Engineering Controls
Ventilation is the most widely applied engineering control method for reducing the
concentration of airborne substances in the
breathing zones of workers. There are two
distinct types of ventilation.
Local Exhaust: Local exhaust ventilation is
designed to capture airborne contaminants
as near to the point of generation as possible. To protect you, the direction of contaminant flow must always be toward the
local exhaust system inlet and away from
you.
General (Mechanical): General dilution ventilation involves continuous introduction of
fresh air into the workroom to mix with the
contaminated air and lower your breathing
zone concentration of formaldehyde. Effectiveness depends on the number of air
changes per hour. Where devices emitting
formaldehyde are spread out over a large
area, general dilution ventilation may be the
only practical method of control.
Work Practices: Work practices and administrative procedures are an important part of
a control system. If you are asked to perform
a task in a certain manner to limit your exposure to formaldehyde, it is extremely important that you follow these procedures.
erowe on DSK5CLS3C1PROD with CFR
Medical Surveillance
Medical surveillance helps to protect employees’ health. You are encouraged strongly
to participate in the medical surveillance
program.
Your employer must make a medical surveillance program available at no expense to
you and at a reasonable time and place if
you are exposed to formaldehyde at concentrations above 0.5 ppm as an 8-hour average or 2 ppm over any 15-minute period. You
will be offered medical surveillance at the
time of your initial assignment and once a
year afterward as long as your exposure is at
least 0.5 ppm (TWA) or 2 ppm (STEL). Even
if your exposure is below these levels, you
should inform your employer if you have
signs and symptoms that you suspect,
through your training, are related to your
formaldehyde exposure because you may
need medical surveillance to determine if
your health is being impaired by your exposure.
The surveillance plan includes:
(a) A medical disease questionnaire.
(b) A physical examination if the physician
determines this is necessary.
If you are required to wear a respirator,
your employer must offer you a physical examination and a pulmonary function test
every year.
The physician must collect all information
needed to determine if you are at increased
risk from your exposure to formaldehyde. At
the physician’s discretion, the medical examination may include other tests, such as a
chest x-ray, to make this determination.
After a medical examination the physician
will provide your employer with a written
opinion which includes any special protective measures recommended and any restrictions on your exposure. The physician must
inform you of any medical conditions you
have which would be aggravated by exposure
to formaldehyde.
All records from your medical examinations, including disease surveys, must be retained at your employer’s expense.
EMERGENCIES
If you are exposed to formaldehyde in an
emergency and develop signs or symptoms
associated with acute toxicity from formaldehyde exposure, your employer must provide you with a medical examination as soon
as possible. This medical examination will
include all steps necessary to stabilize your
health. You may be kept in the hospital for
observation if your symptoms are severe to
ensure that any delayed effects are recognized and treated.
APPENDIX B TO § 1910.1048—SAMPLING STRATEGY AND ANALYTICAL METHODS FOR FORMALDEHYDE
To protect the health of employees, exposure measurements must be unbiased and
representative of employee exposure. The
proper measurement of employee exposure
requires more than a token commitment on
the part of the employer. OSHA’s mandatory
requirements establish a baseline; under the
best of circumstances all questions regarding
employee exposure will be answered. Many
employers, however, will wish to conduct
more extensive monitoring before undertaking expensive commitments, such as engineering controls, to assure that the modifications are truly necessary. The following
sampling strategy, which was developed at
370
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00380
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
NIOSH by Nelson A. Leidel, Kenneth A.
Busch, and Jeremiah R. Lynch and described
in NIOSH publication No. 77–173 (Occupational Exposure Sampling Strategy Manual)
will assist the employer in developing a
strategy for determining the exposure of his
or her employees.
There is no one correct way to determine
employee exposure. Obviously, measuring
the exposure of every employee exposed to
formaldehyde will provide the most information on any given day. Where few employees
are exposed, this may be a practical solution.
For most employers, however, use of the following strategy will give just as much information at less cost.
Exposure data collected on a single day
will not automatically guarantee the employer that his or her workplace is always in
compliance with the formaldehyde standard.
This does not imply, however, that it is impossible for an employer to be sure that his
or her worksite is in compliance with the
standard. Indeed, a properly designed sampling strategy showing that all employees
are exposed below the PELs, at least with a
95 percent certainty, is compelling evidence
that the exposure limits are being achieved
provided that measurements are conducted
using valid sampling strategy and approved
analytical methods.
There are two PELs, the TWA concentration and the STEL. Most employers will find
that one of these two limits is more critical
in the control of their operations, and OSHA
expects that the employer will concentrate
monitoring efforts on the critical component. If the more difficult exposure is controlled, this information, along with calculations to support the assumptions, should be
adequate to show that the other exposure
limit is also being achieved.
Sampling Strategy
erowe on DSK5CLS3C1PROD with CFR
Determination of the Need for Exposure
Measurements
The employer must determine whether employees may be exposed to concentrations in
excess of the action level. This determination becomes the first step in an employee
exposure monitoring program that minimizes employer sampling burdens while providing adequate employee protection. If employees may be exposed above the action
level, the employer must measure exposure.
Otherwise, an objective determination that
employee exposure is low provides adequate
evidence that exposure potential has been
examined.
The employer should examine all available
relevant information, eg. insurance company
and trade association data and information
from suppliers or exposure data collected
from similar operations. The employer may
also use previously-conducted sampling including area monitoring. The employer must
§ 1910.1048
make a determination relevant to each operation although this need not be on a separate
piece of paper. If the employer can demonstrate conclusively that no employee is
exposed above the action level or the STEL
through the use of objective data, the employer need proceed no further on employee
exposure monitoring until such time that
conditions have changed and the determination is no longer valid.
If the employer cannot determine that employee exposure is less than the action level
and the STEL, employee exposure monitoring will have to be conducted.
Workplace Material Survey
The primary purpose of a survey of raw
material is to determine if formaldehyde is
being used in the work environment and if
so, the conditions under which formaldehyde
is being used.
The first step is to tabulate all situations
where formaldehyde is used in a manner such
that it may be released into the workplace
atmosphere or contaminate the skin. This
information should be available through
analysis of company records and information
on the MSDSs available through provisions
of this standard and the Hazard Communication standard.
If there is an indication from materials
handling records and accompanying MSDSs
that formaldehyde is being used in the following types of processes or work operations,
there may be a potential for releasing formaldehyde into the workplace atmosphere:
(1) Any operation that involves grinding,
sanding, sawing, cutting, crushing, screening, sieving, or any other manipulation of
material that generates formaldehyde-bearing dust
(2) Any processes where there have been
employee complaints or symptoms indicative of exposure to formaldehyde
(3) Any liquid or spray process involving
formaldehyde
(4) Any process that uses formaldehyde in
preserved tissue
(5) Any process that involves the heating
of a formaldehyde-bearing resin.
Processes and work operations that use
formaldehyde in these manners will probably
require further investigation at the worksite
to determine the extent of employee monitoring that should be conducted.
Workplace Observations
To this point, the only intention has been
to provide an indication as to the existence
of potentially exposed employees. With this
information, a visit to the workplace is needed to observe work operations, to identify
potential health hazards, and to determine
whether any employees may be exposed to
hazardous concentrations of formaldehyde.
371
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00381
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
In many circumstances, sources of formaldehyde can be identified through the sense
of smell. However, this method of detection
should be used with caution because of olfactory fatigue.
Employee location in relation to source of
formaldehyde is important in determining if
an employee may be significantly exposed to
formaldehyde. In most instances, the closer
a worker is to the source, the higher the
probability that a significant exposure will
occur.
Other characteristics should be considered.
Certain high temperature operations give
rise to higher evaporation rates. Locations
of open doors and windows provide natural
ventilation that tend to dilute formaldehyde
emissions. General room ventilation also
provides a measure of control.
Calculation of Potential Exposure
Concentrations
By knowing the ventilation rate in a workplace and the quantity of formaldehyde generated, the employer may be able to determine by calculation if the PELs might be exceeded. To account for poor mixing of formaldehyde into the entire room, locations of
fans and proximity of employees to the work
operation, the employer must include a safety factor. If an employee is relatively close
to a source, particularly if he or she is located downwind, a safety factor of 100 may
be necessary. For other situations, a factor
of 10 may be acceptable. If the employer can
demonstrate through such calculations that
employee exposure does not exceed the action level or the STEL, the employer may
use this information as objective data to
demonstrate compliance with the standard.
erowe on DSK5CLS3C1PROD with CFR
Sampling Strategy
Once the employer determines that there
is a possibility of substantial employee exposure to formaldehyde, the employer is obligated to measure employee exposure.
The next step is selection of a maximum
risk employee. When there are different
processes where employees may be exposed
to formaldehyde, a maximum risk employee
should be selected for each work operation.
Selection of the maximum risk employee
requires professional judgment. The best procedure for selecting the maximum risk employee is to observe employees and select the
person closest to the source of formaldehyde.
Employee mobility may affect this selection;
eg. if the closest employee is mobile in his
tasks, he may not be the maximum risk employee. Air movement patterns and differences in work habits will also affect selection of the maximum risk employee.
When many employees perform essentially
the same task, a maximum risk employee
cannot be selected. In this circumstance, it
is necessary to resort to random sampling of
the group of workers. The objective is to select a subgroup of adequate size so that there
is a high probability that the random sample
will contain at least one worker with high
exposure if one exists. The number of persons
in the group influences the number that need
to be sampled to ensure that at least one individual from the highest 10 percent exposure group is contained in the sample. For
example, to have 90 percent confidence in the
results, if the group size is 10, nine should be
sampled; for 50, only 18 need to be sampled.
If measurement shows exposure to formaldehyde at or above the action level or the
STEL, the employer needs to identify all
other employees who may be exposed at or
above the action level or STEL and measure
or otherwise accurately characterize the exposure of these employees.
Whether representative monitoring or random sampling are conducted, the purpose remains the same—to determine if the exposure of any employee is above the action
level. If the exposure of the most exposed
employee is less than the action level and
the STEL, regardless of how the employee is
identified, then it is reasonable to assume
that measurements of exposure of the other
employees in that operation would be below
the action level and the STEL.
Exposure Measurements
There is no ‘‘best’’ measurement strategy
for all situations. Some elements to consider
in developing a strategy are:
(1) Availability and cost of sampling equipment
(2) Availability and cost of analytic facilities
(3) Availability and cost of personnel to
take samples
(4) Location of employees and work operations
(5) Intraday and interday variations in the
process
(6) Precision and accuracy of sampling and
analytic methods, and
(7) Number of samples needed.
Samples taken for determining compliance
with the STEL differ from those that measure the TWA concentration in important
ways. STEL samples are best taken in a nonrandom fashion using all available knowledge relating to the area, the individual, and
the process to obtain samples during periods
of maximum expected concentrations. At
least three measurements on a shift are generally needed to spot gross errors or mistakes; however, only the highest value represents the STEL.
If an operation remains constant throughout the workshift, a much greater number of
samples would need to be taken over the 32
discrete nonoverlapping periods in an 8-hour
workshift to verify compliance with a STEL.
If employee exposure is truly uniform
372
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00382
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
throughout the workshift, however, an employer in compliance with the l ppm TWA
would be in compliance with the 2 ppm
STEL, and this determination can probably
be made using objective data.
erowe on DSK5CLS3C1PROD with CFR
Need To Repeat the Monitoring Strategy
Interday and intraday fluctuations in employee exposure are mostly influenced by the
physical processes that generate formaldehyde and the work habits of the employee.
Hence, in-plant process variations influence
the employer’s determination of whether or
not additional controls need to be imposed.
Measurements that employee exposure is low
on a day that is not representative of worst
conditions may not provide sufficient information to determine whether or not additional engineering controls should be installed to achieve the PELs.
The person responsible for conducting sampling must be aware of systematic changes
which will negate the validity of the sampling results. Systematic changes in formaldehyde exposure concentration for an employee can occur due to:
(1) The employee changing patterns of
movement in the workplace
(2) Closing of plant doors and windows
(3) Changes in ventilation from season to
season
(4) Decreases in ventilation efficiency or
abrupt failure of engineering control equipment
(5) Changes in the production process or
work habits of the employee.
Any of these changes, if they may result in
additional exposure that reaches the next
level of action (i.e. 0.5 or 1.0 ppm as an 8-hr
average or 2 ppm over 15 minutes) require
the employer to perform additional monitoring to reassess employee exposure.
A number of methods are suitable for
measuring employee exposure to formaldehyde or for characterizing emissions within
the worksite. The preamble to this standard
describes some methods that have been widely used or subjected to validation testing. A
detailed analytical procedure derived from
the OSHA Method 52 for acrolein and formaldehyde is presented below for informational purposes.
Inclusion of OSHA’s method in this appendix in no way implies that it is the only acceptable way to measure employee exposure
to formaldehyde. Other methods that are
free from significant interferences and that
can determine formaldehyde at the permissible exposure limits within ±25 percent of
the ‘‘true’’ value at the 95 percent confidence
level are also acceptable. Where applicable,
the method shou1d a1so be capab1e of measuring formaldehyde at the action level to ±35
percent of the ‘‘true’’ value with a 95 percent
confidence
level.
OSHA
encourages
emp1oyers to choose methods that will be
§ 1910.1048
best for their individual needs. The employer
must exercise caution, however, in choosing
an appropriate method since some techniques suffer from interferences that are
likely to be present in workplaces of certain
industry sectors where formaldehyde is used.
OSHA’s Analytical Laboratory Method
Method No: 52
Matrix: Air
Target Concentration: 1 ppm (1.2 mg/m3)
Procedures: Air samples are collected by
drawing known volumes of air through
sampling tubes containing XAD–2 adsorbent which have been coated with 2(hydroxymethyl) piperidine. The samples
are desorbed with toluene and then analyzed by gas chromatography using a nitrogen selective detector.
Recommended Sampling Rate and Air Volumes:
0.1 L/min and 24 L
Reliable Quantitation Limit:16 ppb (20 µg/m3)
Standard Error of Estimate at the Target Concentration: 7.3%
Status of the Method: A sampling and analytical method that has been subjected to the
established evaluation procedures of the
Organic Methods Evaluation Branch.
Date: March 1985
1. General Discussion
1.1 Background: The current OSHA method for collecting acrolein vapor recommends
the use of activated 13X molecular sieves.
The samples must be stored in an ice bath
during and after sampling and also they
must be analyzed within 48 hours of collection. The current OSHA method for collecting formaldehyde vapor recommends the
use of bubblers containing 10% methanol in
water as the trapping solution.
This work was undertaken to resolve the
sample stability problems associated with
acrolein and also to eliminate the need to
use bubb1ers to sample formaldehyde. A goal
of this work was to develop and/or to evaluate a common sampling and analytical procedure for acrolein and formaldehyde.
NIOSH has developed independent methodologies for acrolein and formaldehyde
which recommend the use of reagent-coated
adsorbent tubes to collect the aldehydes as
stable derivatives. The formaldehyde sampling tubes contain Chromosorb 102 adsorbent coated with N-benzylethanolamine (BEA)
which reacts with formaldehyde vapor to
form a stable oxazolidine compound. The
acrolein sampling tubes contain XAD–2 adsorbent
coated
with
2(hydroxymethyl)piperidine (2–HMP) which
reacts with acrolein vapor to form a different, stable oxazolidine derivative. Acrolein does not appear to react with BEA to
give a suitable reaction product. Therefore,
the formaldehyde procedure cannot provide a
373
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00383
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
common method for both aldehydes. However, formaldehyde does react with 2–HMP to
form a very suitable reaction product. It is
the quantitative reaction of acrolein and
formaldehyde with 2–HMP that provides the
basis for this evaluation.
This sampling and analytical procedure is
very similar to the method recommended by
NIOSH for acrolein. Some changes in the
NIOSH methodology were necessary to permit the simultaneous determination of both
aldehydes and also to accommodate OSHA
laboratory equipment and analytical techniques.
1.2 Limit-defining parameters: The analyte
air concentrations reported in this method
are based on the recommended air volume
for each analyte collected separately and a
desorption volume of 1 mL. The amounts are
presented as acrolein and/or formaldehyde,
even though the derivatives are the actual
species analyzed.
1.2.1 Detection limits of the analytical procedure: The detection limit of the analytical
procedure was 386 pg per injection for formaldehyde. This was the amount of analyte
which gave a peak whose height was about
five times the height of the peak given by
the residual formaldehyde derivative in a
typical blank front section of the recommended sampling tube.
1.2.2 Detection limits of the overall procedure: The detection limits of the overall procedure were 482 ng per sample (16 ppb or 20
µg/m3 for formaldehyde). This was the
amount of analyte spiked on the sampling
device which allowed recoveries approximately equal to the detection limit of the
analytical procedure.
1.2.3 Reliable quantitation limits: The reliable quantitation limit was 482 ng per sample (16 ppb or 20 µg/m3) for formaldehyde.
These were the smallest amounts of analyte
which could be quantitated within the limits
of a recovery of at least 75% and a precision
(±1.96 SD) of ±25% or better.
llllllllllllllllllllllll
The reliable quantitation limit and detection limits reported in the method are based
upon optimization of the instrument for the
smallest possible amount of analyte. When
the target concentration of an analyte is exceptionally higher than these limits, they
may not be attainable at the routine operating parameters.
llllllllllllllllllllllll
1.2.4 Sensitivity: The sensitivity of the analytical procedure over concentration ranges
representing 0.4 to 2 times the target concentration, based on the recommended air
volumes, was 7,589 area units per µg/mL for
formaldehyde. This value was determined
from the slope of the calibration curve. The
sensitivity may vary with the particular instrument used in the analysis.
1.2.5 Recovery: The recovery of formaldehyde from samples used in an 18-day storage
test remained above 92% when the samples
were stored at ambient temperature. These
values were determined from regression lines
which were calculated from the storage data.
The recovery of the analyte from the collection device must be at least 75% following
storage.
1.2.6 Precision (analytical method only): The
pooled coefficient of variation obtained from
replicate determinations of analytical standards over the range of 0.4 to 2 times the target concentration was 0.0052 for formaldehyde (Section 4.3).
1.2.7 Precision (overall procedure): The precision at the 95% confidence level for the ambient temperature storage tests was ±14.3%
for formaldehyde. These values each include
an additional ±5% for sampling error. The
overall procedure must provide results at the
target concentrations that are ±25% at the
95% confidence level.
1.2.8 Reproducibility: Samples collected
from controlled test atmospheres and a draft
copy of this procedure were given to a chemist unassociated with this evaluation. The
formaldehyde samples were analyzed following 15 days storage. The average recovery
was 96.3% and the standard deviation was
1.7%.
1.3 Advantages:
1.3.1 The sampling and analytical procedures permit the simultaneous determination of acrolein and formaldehyde.
1.3.2 Samples are stable following storage
at ambient temperature for at least 18 days.
1.4 Disadvantages: None.
2. Sampling Procedure
2.1 Apparatus:
2.1.1 Samples are collected by use of a
personal sampling pump that can be calibrated to within ±5% of the recommended 0.1
L/min sampling rate with the sampling tube
in line.
2.1.2 Samples are collected with laboratory prepared sampling tubes. The sampling
tube is constructed of silane treated glass
and is about 8-cm long. The ID is 4 mm and
the OD is 6 mm. One end of the tube is tapered so that a glass wool end plug will hold
the contents of the tube in place during sampling. The other end of the sampling tube is
open to its full 4-mm ID to facilitate packing
of the tube. Both ends of the tube are firepolished for safety. The tube is packed with
a 75-mg backup section, located nearest the
tapered end and a 150-mg sampling section of
pretreated XAD–2 adsorbent which has been
coated with 2–HMP. The two sections of
coated adsorbent are separated and retained
with small plugs of silanized glass wool. Following packing, the sampling tubes are
sealed with two 7⁄32 inch OD plastic end caps.
Instructions for the pretreatment and the
coating of XAD–2 adsorbent are presented in
Section 4 of this method.
374
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00384
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
Occupational Safety and Health Admin., Labor
2.1.3 Sampling tubes, similar to those recommended in this method, are marketed by
Supelco, Inc. These tubes were not available
when this work was initiated; therefore, they
were not evaluated.
2.2 Reagents: None required.
2.3 Technique:
2.3.1 Properly label the sampling tube before sampling and then remove the plastic
end caps.
2.3.2 Attach the sampling tube to the
pump using a section of flexible plastic tubing such that the large, front section of the
sampling tube is exposed directly to the atmosphere. Do not place any tubing ahead of
the sampling tube. The sampling tube should
be attached in the worker’s breathing zone
in a vertical manner such that it does not
impede work performance.
2.3.3 After sampling for the appropriate
time, remove the sampling tube from the
pump and then seal the tube with plastic end
caps.
2.3.4 Include at least one blank for each
sampling set. The blank should be handled in
the same manner as the samples with the exception that air is not drawn through it.
2.3.5 List any potential interferences on
the sample data sheet.
2.4 Breakthrough:
2.4.1 Breakthrough was defined as the relative amount of analyte found on a backup
sample in relation to the total amount of
analyte collected on the sampling train.
2.4.2 For formaldehyde collected from test
atmospheres containing 6 times the PEL, the
average 5% breakthrough air volume was 41
L. The sampling rate was 0.1 L/min and the
average mass of formaldehyde collected was
250 µg.
2.5 Desorption Efficiency: No desorption efficiency corrections are necessary to compute air sample results because analytical
standards are prepared using coated adsorbent. Desorption efficiencies were determined,
however, to investigate the recoveries of the
analytes from the sampling device. The average recovery over the range of 0.4 to 2 times
the target concentration, based on the recommended air volumes, was 96.2% for formaldehyde. Desorption efficiencies were essentially constant over the ranges studied.
2.6 Recommended Air Volume and Sampling
Rate:
2.6.1 The recommended air volume for
formaldehyde is 24 L.
2.6.2 The recommended sampling rate is
0.1 L/min.
2.7 Interferences:
2.7.1 Any collected substance that is capable of reacting 2-HMP and thereby depleting
the derivatizing agent is a potential interference. Chemicals which contain a carbonyl
group, such as acetone, may be capable or reacting with 2-HMP.
2.7.2 There are no other known interferences to the sampling method.
§ 1910.1048
2.8 Safety Precautions:
2.8.1 Attach the sampling equipment to
the worker in such a manner that it well not
interfere with work performance or safety.
2.8.2 Follow all safety practices that
apply to the work area being sampled.
3. Analytical Procedure
3.1 Apparatus:
3.1.1 A gas chromatograph (GC), equipped
with a nitrogen selective detector. A Hewlett-Packard Model 5840A GC fitted with a
nitrogen-phosphorus flame ionization detector (NPD) was used for this evaluation. Injections were performed using a HewlettPackard Model 7671A automatic sampler.
3.1.2 A GC column capable of resolving
the analytes from any interference. A 6 ft ×
1⁄4 in OD (2mm ID) glass GC column containing 10% UCON 50–HB–5100 + 2% KOH on
80/100 mesh Chromosorb W-AW was used for
the evaluation. Injections were performed
on-column.
3.1.3 Vials, glass 2-mL with Teflon-lined
caps.
3.1.4 Volumetric flasks, pipets, and syringes for preparing standards, making dilutions, and performing injections.
3.2 Reagents:
3.2.1 Toluene and dimethylformamide.
Burdick and Jackson solvents were used in
this evaluation.
3.2.2 Helium, hydrogen, and air, GC grade.
3.2.3 Formaldehyde, 37%, by weight, in
water. Aldrich Chemical, ACS Reagent Grade
formaldehyde was used in this evaluation.
3.2.4 Amberlite XAD–2 adsorbent coated
with 2-(hydroxymethyl—piperidine (2-HMP),
10% by weight (Section 4).
3.2.5 Desorbing solution with internal
standard. This solution was prepared by adding 20 µL of dimethylformamide to 100 mL of
toluene.
3.3 Standard preparation:
3.3.1 Formaldehyde: Prepare stock standards by diluting known volumes of 37% formaldehyde solution with methanol. A procedure to determine the formaldehyde content
of these standards is presented in Section 4.
A standard containing 7.7 mg/mL formaldehyde was prepared by diluting 1 mL of the
37% reagent to 50 mL with methanol.
3.3.2 It is recommended that analytical
standards be prepared about 16 hours before
the air samples are to be analyzed in order to
ensure the complete reaction of the analytes
with 2–HMP. However, rate studies have
shown the reaction to be greater than 95%
complete after 4 hours. Therefore, one or two
standards can be analyzed after this reduced
time if sample results are outside the concentration range of the prepared standards.
3.3.3 Place 150-mg portions of coated
XAD–2 adsorbent, from the same lot number
as used to collect the air samples, into each
of several glass 2-mL vials. Seal each vial
with a Teflon-lined cap.
375
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00385
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
3.3.4 Prepare fresh analytical standards
each day by injecting appropriate amounts
of the diluted analyte directly onto 150-mg
portions of coated adsorbent. It is permissible to inject both acrolein and formaldehyde on the same adsorbent portion. Allow
the standards to stand at room temperature.
A standard, approximately the target levels,
was prepared by injecting 11 µL of the acrolein and 12 µL of the formaldehyde stock
standards onto a single coated XAD–2 adsorbent portion.
3.3.5 Prepare a sufficient number of standards to generate the calibration curves. Analytical standard concentrations should
bracket sample concentrations. Thus, if samples are not in the concentration range of
the prepared standards, additional standards
must be prepared to determine detector response.
3.3.7 Desorb the standards in the same
manner as the samples following the 16-hour
reaction time.
3.4 Sample preparation:
3.4.1 Transfer the 150-mg section of the
sampling tube to a 2-mL vial. Place the 75mg section in a separate vial. If the glass
wool plugs contain a significant number of
adsorbent beads, place them with the appropriate sampling tube section. Discard the
glass wool plugs if they do not contain a significant number of adsorbent beads.
3.4.2 Add 1 mL of desorbing solution to
each vial.
3.4.3 Seal the vials with Teflon-lined caps
and then allow them to desorb for one hour.
Shake the vials by hand with vigorous force
several times during the desorption time.
3.4.4 Save the used sampling tubes to be
cleaned and recycled.
3.5 Analysis:
3.5.1 GC Conditions
Column Temperature:
Bi-level temperature program—First level:
100 to 140 °C at 4 °C/min following completion of the first level.
Second level: 140 to 180 °C at 20 °C/min following completion of the first level.
Isothermal period: Hold column at 180 °C
until the recorder pen returns to baseline
(usually about 25 min after injection).
Injector temperature: 180 °C
Helium flow rate: 30 mL/min (detector response will be reduced if nitrogen is substituted for helium carrier gas).
Injection volume: 0.8 µL
GC column: Six-ft × 1⁄4-in OD (2 mm ID) glass
GC column containing 10% UCON 50–HB–
5100+2% KOH on 80/100 Chromosorb W-AW.
NPD conditions:
Hydrogen flow rate: 3 mL/min
Air flow rate: 50 mL/min
Detector temperature: 275 °C
3.5.2 Chromatogram: For an example of a
typical chromatogram, see Figure 4.11 in
OSHA Method 52.
3.5.3 Use a suitable method, such as electronic integration, to measure detector response.
3.5.4 Use an internal standard method to
prepare the calibration curve with several
standard solutions of different concentrations. Prepare the calibration curve daily.
Program the integrator to report results in
µg/mL.
3.5.5 Bracket sample concentrations with
standards.
3.6 Interferences (Analytical)
3.6.1 Any compound with the same general retention time as the analytes and
which also gives a detector response is a potential interference. Possible interferences
should be reported to the laboratory with
submitted samples by the industrial hygienist.
3.6.2 GC parameters (temperature, column, etc.) may be changed to circumvent
interferences.
3.6.3 A useful means of structure designation is GC/MS. It is recommended this procedure be used to confirm samples whenever
possible.
3.6.4 The coated adsorbent usually contains a very small amount of residual formaldehyde derivative (Section 4.8).
3.7 Calculations:
3.7.1 Results are obtained by use of calibration curves. Calibration curves are prepared by plotting detector response against
concentration for each standard. The best
line through the data points is determined
by curve fitting.
3.7.2 The concentration, in µg/mL, for a
particular sample is determined by comparing its detector response to the calibration curve. If either of the analytes is found
on the backup section, it is added to the
amount found on the front section. Blank
corrections should be performed before adding the results together.
3.7.3 The acrolein and/or formaldehyde air
concentration can be expressed using the following equation:
mg/m3=(A)(B)/C
where A=µg/mL from 3.7.2, B=desorption volume, and C=L of air sampled.
No desorption efficiency corrections are required.
3.7.4 The following equation can be used
to convert results in mg/m3 to ppm.
ppm=(mg/m3)(24.45)/MW
where mg/m3=result from 3.7.3, 24.45=molar
volume of an ideal gas at 760 mm Hg and 25
°C, MW=molecular weight (30.0).
4. Backup Data
4.1 Backup data on detection limits, reliable quantitation limits, sensitivity and precision of the analytical method, breakthrough, desorption efficiency, storage, reproducibility,
and
generation
of
test
376
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00386
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
atmospheres are available in OSHA Method
52, developed by the Organics Methods Evaluation Branch, OSHA Analytical Laboratory, Salt Lake City, Utah.
4.2 Procedure to Coat XAD–2 Adsorbent with
2–HMP:
4.2.1 Apparatus: Soxhlet extraction apparatus, rotary evaporation apparatus, vacuum
dessicator, 1–L vacuum flask, 1–L round-bottomed evaporative flask, 1–L Erlenmeyer
flask, 250-mL Buchner funnel with a coarse
fritted disc, etc.
4.2.2 Reagents:
4.2.2.1 Methanol, isooctane, and toluene.
4.2.2.2 2-(Hydroxymethyl)piperidine.
4.2.2.3 Amberlite XAD–2 non-ionic polymeric adsorbent, 20 to 60 mesh, Aldrich
Chemical XAD–2 was used in this evaluation.
4.2.3 Procedure: Weigh 125 g of crude XAD–
2 adsorbent into a 1–L Erlenmeyer flask. Add
about 200 mL of water to the flask and then
swirl the mixture to wash the adsorbent.
Discard any adsorbent that floats to the top
of the water and then filter the mixture
using a fritted Buchner funnel. Air dry the
adsorbent for 2 minutes. Transfer the adsorbent back to the Erlenmeyer flask and then
add about 200 mL of methanol to the flask.
Swirl and then filter the mixture as before.
Transfer the washed adsorbent back to the
Erlenmeyer flask and then add about 200 mL
of methanol to the flask. Swirl and then filter the mixture as before. Transfer the
washed adsorbent to a 1–L round-bottomed
evaporative flask, add 13 g of 2–HMP and
then 200 mL of methanol, swirl the mixture
and then allow it to stand for one hour. Remove the methanol at about 40 °C and reduced pressure using a rotary evaporation
apparatus. Transfer the coated adsorbent to
a suitable container and store it in a vacuum
desiccator at room temperature overnight.
Transfer the coated adsorbent to a Soxhlet
extractor and then extract the material with
toluene for about 24 hours. Discard the contaminated toluene, add methanol in its place
and then continue the Soxhlet extraction for
an additional 4 hours. Transfer the adsorbent
to a weighted 1–L round-bottom evaporative
flask and remove the methanol using the ro-
tary evaporation apparatus. Determine the
weight of the adsorbent and then add an
amount of 2-HMP, which is 10% by weight of
the adsorbent. Add 200 mL of methanol and
then swirl the mixture. Allow the mixture to
stand for one hour. Remove the methanol by
rotary evaporation. Transfer the coated adsorbent to a suitable container and store it
in a vacuum desiccator until all traces of
solvents are gone. Typically, this will take
2–3 days. The coated adsorbent should be protected from contamination. XAD–2 adsorbent
treated in this manner will probably not contain residual acrolein derivative. However,
this adsorbent will often contain residual
formaldehyde derivative levels of about 0.1
µg per 150 mg of adsorbent. If the blank values for a batch of coated adsorbent are too
high, then the batch should be returned to
the Soxhlet extractor, extracted with toluene again and then recoated. This process
can be repeated until the desired blank levels are attained.
The coated adsorbent is now ready to be
packed into sampling tubes. The sampling
tubes should be stored in a sealed container
to prevent contamination. Sampling tubes
should be stored in the dark at room temperature. The sampling tubes should be segregated by coated adsorbent lot number. A
sufficient amount of each lot number of
coated adsorbent should be retained to prepare analytical standards for use with air
samples from that lot number.
4.3 A Procedure to Determine Formaldehyde
by Acid Titration: Standardize the 0.1 N HCl
solution using sodium carbonate and methyl
orange indicator.
Place 50 mL of 0.1 M sodium sulfite and
three drops of thymophthalein indicator into
a 250-mL Erlenmeyer flask. Titrate the contents of the flask to a colorless endpoint
with 0.1 N HCl (usually one or two drops is
sufficient). Transfer 10 mL of the formaldehyde/methanol solution (prepared in 3.3.1)
into the same flask and titrate the mixture
with 0.1 N HCl, again, to a colorless endpoint. The formaldehyde concentration of
the standard may be calculated by the following equation:
acid titer × acid normality × 30.0
mL of sample
This method is based on the quantitative
liberation of sodium hydroxide when formaldehyde reacts with sodium sulfite to form
the formaldehyde-bisulfite addition product.
The volume of sample may be varied depending on the formaldehyde content but the solution to be titrated must contain excess sodium sulfite. Formaldehyde solutions con-
taining substantial amounts of acid or base
must be neutralized before analysis.
377
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00387
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
EC15NO91.041</MATH>
erowe on DSK5CLS3C1PROD with CFR
Formaldehyde, mg/mL =
§ 1910.1048
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
APPENDIX C TO § 1910.1048—MEDICAL
SURVEILLANCE—FORMALDEHYDE
I. Health Hazards
The occupational health hazards of formaldehyde are primarily due to its toxic effects after inhalation, after direct contact
with the skin or eyes by formaldehyde in liquid or vapor form, and after ingestion.
II. Toxicology
erowe on DSK5CLS3C1PROD with CFR
A. Acute Effects of Exposure
1. Inhalation (breathing): Formaldehyde is
highly irritating to the upper airways. The
concentration of formaldehyde that is immediately dangerous to life and health is 100
ppm. Concentrations above 50 ppm can cause
severe pulmonary reactions within minutes.
These include pulmonary edema, pneumonia,
and bronchial irritation which can result in
death. Concentrations above 5 ppm readily
cause lower airway irritation characterized
by cough, chest tightness and wheezing.
There is some controversy regarding whether
formaldehyde gas is a pulmonary sensitizer
which can cause occupational asthma in a
previously normal individual. Formaldehyde
can produce symptoms of bronchial asthma
in humans. The mechanism may be either
sensitization of the individual by exposure to
formaldehyde or direct irritation by formaldehyde in persons with pre-existing asthma. Upper airway irritation is the most common respiratory effect reported by workers
and can occur over a wide range of concentrations, most frequently above 1 ppm.
However, airway irritation has occurred in
some workers with exposures to formaldehyde as low as 0.1 ppm. Symptoms of upper
airway irritation include dry or sore throat,
itching and burning sensations of the nose,
and nasal congestion. Tolerance to this level
of exposure may develop within 1–2 hours.
This tolerance can permit workers remaining in an environment of gradually increasing formaldehyde concentrations to be unaware of their increasingly hazardous exposure.
2. Eye contact: Concentrations of formaldehyde between 0.05 ppm and 0.5 ppm produce a
sensation of irritation in the eyes with burning, itching, redness, and tearing. Increased
rate of blinking and eye closure generally
protects the eye from damage at these low
levels, but these protective mechanisms may
interfere with some workers’ work abilities.
Tolerance can occur in workers continuously
exposed to concentrations of formaldehyde
in this range. Accidental splash injuries of
human eyes to aqueous solutions of formaldehyde (formalin) have resulted in a wide
range of ocular injuries including corneal
opacities and blindness. The severity of the
reactions have been directly dependent on
the concentration of formaldehyde in solu-
tion and the amount of time lapsed before
emergency and medical intervention.
3. Skin contact: Exposure to formaldehyde
solutions can cause irritation of the skin and
allergic contact dermatitis. These skin diseases and disorders can occur at levels well
below those encountered by many formaldehyde workers. Symptoms include erythema,
edema, and vesiculation or hives. Exposure
to liquid formalin or formaldehyde vapor can
provoke skin reactions in sensitized individuals even when airborne concentrations of
formaldehyde are well below 1 ppm.
4. Ingestion: Ingestion of as little as 30 ml
of a 37 percent solution of formaldehyde (formalin) can result in death. Gastrointestinal
toxicity after ingestion is most severe in the
stomach and results in symptoms which can
include nausea, vomiting, and servere abdominal pain. Diverse damage to other organ
systems including the liver, kidney, spleen,
pancreas, brain, and central nervous systems
can occur from the acute response to ingestion of formaldehyde.
B. Chronic Effects of Exposure
Long term exposure to formaldehyde has
been shown to be associated with an increased risk of cancer of the nose and accessory
sinuses,
nasopharyngeal
and
oropharyngeal cancer, and lung cancer in humans. Animal experiments provide conclusive evidence of a causal relationship between nasal cancer in rats and formaldehyde
exposure. Concordant evidence of carcinogenicity includes DNA binding, genotoxicity
in short-term tests, and cytotoxic changes in
the cells of the target organ suggesting both
preneoplastic changes and a dose-rate effect.
Formaldehyde is a complete carcinogen and
appears to exert an effect on at least two
stages of the carcinogenic process.
III. Surveillance considerations
A. History
1. Medical and occupational history: Along
with its acute irritative effects, formaldehyde can cause allergic sensitization and
cancer. One of the goals of the work history
should be to elicit information on any prior
or additional exposure to formaldehyde in either the occupational or the non-occupational setting.
2. Respiratory history: As noted above, formaldehyde has recognized properties as an airway irritant and has been reported by some
authors as a cause of occupational asthma.
In addition, formaldehyde has been associated with cancer of the entire respiratory
system of humans. For these reasons, it is
appropriate to include a comprehensive review of the respiratory system in the medical history. Components of this history
might include questions regarding dyspnea
378
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00388
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
on exertion, shortness of breath, chronic airway complaints, hyperreactive airway disease, rhinitis, bronchitis, bronchiolitis, asthma, emphysema, respiratory allergic reaction, or other preexisting pulmonary disease.
In addition, generalized airway hypersensitivity can result from exposures to a
single sensitizing agent. The examiner
should, therefore, elicit any prior history of
exposure to pulmonary irritants, and any
short- or long-term effects of that exposure.
Smoking is known to decrease mucociliary
clearance of materials deposited during respiration in the nose and upper airways. This
may increase a worker’s exposure to inhaled
materials such as formaldehyde vapor. In addition, smoking is a potential confounding
factor in the investigation of any chronic
respiratory disease, including cancer. For
these reasons, a complete smoking history
should be obtained.
3. Skin Disorders: Because of the dermal irritant and sensitizing effects of formaldehyde, a history of skin disorders should be
obtained. Such a history might include the
existence of skin irritation, previously documented skin sensitivity, and other dermatologic disorders. Previous exposure to formaldehyde and other dermal sensitizers should
be recorded.
4. History of atopic or allergic diseases: Since
formaldehyde can cause allergic sensitization of the skin and airways, it might be useful to identify individuals with prior allergen
sensitization. A history of atopic disease and
allergies to formaldehyde or any other substances should also be obtained. It is not
definitely known at this time whether atopic
diseases and allergies to formaldehyde or
any other substances should also be obtained. Also it is not definitely known at
this time whether atopic individuals have a
greater propensity to develop formaldehyde
sensitivity than the general population, but
identification of these individuals may be
useful for ongoing surveillance.
5. Use of disease questionnaires: Comparison
of the results from previous years with
present results provides the best method for
detecting a general deterioration in health
when toxic signs and symptoms are measured subjectively. In this way recall bias
does not affect the results of the analysis.
Consequently, OSHA has determined that
the findings of the medical and work histories should be kept in a standardized form
for comparison of the year-to-year results.
erowe on DSK5CLS3C1PROD with CFR
B. Physical Examination
1. Mucosa of eyes and airways: Because of
the irritant effects of formaldehyde, the examining physician should be alert to evidence of this irritation. A speculum examination of the nasal mucosa may be helpful
in assessing possible irritation and cytotoxic
changes, as may be indirect inspection of the
posterior pharynx by mirror.
§ 1910.1048
2. Pulmonary system: A conventional respiratory examination, including inspection
of the thorax and auscultation and percussion of the lung fields should be performed as
part of the periodic medical examination. Although routine pulmonary function testing
is only required by the standard once every
year for persons who are exposed over the
TWA concentration limit, these tests have
an obvious value in investigating possible
respiratory dysfunction and should be used
wherever deemed appropriate by the physician. In cases of alleged formaldehyde-induced airway disease, other possible causes
of pulmonary disfunction (including exposures to other substances) should be ruled
out. A chest radiograph may be useful in
these circumstances. In cases of suspected
airway hypersensitivity or allergy, it may be
appropriate to use bronchial challenge testing with formaldehyde or methacholine to
determine the nature of the disorder. Such
testing should be performed by or under the
supervision of a physician experienced in the
procedures involved.
3. Skin: The physician should be alert to
evidence of dermal irritation of sensitization, including reddening and inflammation,
urticaria, blistering, scaling, formation of
skin fissures, or other symptoms. Since the
integrity of the skin barrier is compromised
by other dermal diseases, the presence of
such disease should be noted. Skin sensitivity testing carries with it some risk of inducing sensitivity, and therefore, skin testing for formaldehyde sensitivity should not
be used as a routine screening test. Sensitivity testing may be indicated in the investigation of a suspected existing sensitivity.
Guidelines for such testing have been prepared by the North American Contact Dermatitis Group.
C. Additional Examinations or Tests
The physician may deem it necessary to
perform other medical examinations or tests
as indicated. The standard provides a mechanism whereby these additional investigations are covered under the standard for occupational exposure to formaldehyde.
D. Emergencies
The examination of workers exposed in an
emergency should be directed at the organ
systems most likely to be affected. Much of
the content of the examination will be similar to the periodic examination unless the
patient has received a severe acute exposure
requiring immediate attention to prevent serious consequences. If a severe overexposure
requiring medical intervention or hospitalization has occurred, the physician
must be alert to the possibility of delayed
symptoms. Followup nonroutine examinations may be necessary to assure the patient’s well-being.
379
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00389
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
E. Employer Obligations
The employer is required to provide the
physician with the following information: A
copy of this standard and appendices A, C, D,
and E; a description of the affected employee’s duties as they relate to his or her exposure concentration; an estimate of the employee’s exposure including duration (e.g. 15
hr/wk, three 8-hour shifts, full-time); a description of any personal protective equipment, including respirators, used by the employee; and the results of any previous medical determinations for the affected employee related to formaldehyde exposure to
the extent that this information is within
the employer’s control.
F. Physician’s Obligations
The standard requires the employer to obtain a written statement from the physician.
This statement must contain the physician’s
opinion as to whether the employee has any
medical condition which would place him or
her at increased risk of impaired health from
exposure to formaldehyde or use of respirators, as appropriate. The physician must
also state his opinion regarding any restrictions that should be placed on the employee’s exposure to formaldehyde or upon the
use of protective clothing or equipment such
as respirators. If the employee wears a respirator as a result of his or her exposure to
formaldehyde, the physician’s opinion must
also contain a statement regarding the suitability of the employee to wear the type of
respirator assigned. Finally, the physician
must inform the employer that the employee
has been told the results of the medical examination and of any medical conditions
which require further explanation or treatment. This written opinion is not to contain
any information on specific findings or diagnoses unrelated to occupational exposure to
formaldehyde.
The purpose in requiring the examining
physician to supply the employer with a
written opinion is to provide the employer
with a medical basis to assist the employer
in placing employees initially, in assuring
that their health is not being inpaired by
formaldehyde, and to assess the employee’s
ability to use any required protective equipment.
APPENDIX D TO § 1910.1048—NONMANDATORY
MEDICAL DISEASE QUESTIONNAIRE
erowe on DSK5CLS3C1PROD with CFR
A. Identification
Plant Name lllllllllllllllll
Date lllllllllllllllllllll
Employee Name lllllllllllllll
S.S. # llllllllllllllllllll
Job Title llllllllllllllllll
Birthdate: llllllllllllllllll
Age: lllllllllllllllllllll
Sex: lllllllllllllllllllll
Height: lllllllllllllllllll
Weight: lllllllllllllllllll
B. Medical History
1. Have you ever been in the hospital as a patient?
Yes b No b
If yes, what kind of problem were you having? llllllllllllllllllll
llllllllllllllllllllllll
2. Have you ever had any kind of operation?
Yes b No b
If yes, what kind? llllllllllllll
llllllllllllllllllllllll
3. Do you take any kind of medicine regularly?
Yes b No b
If yes, what kind? llllllllllllll
llllllllllllllllllllllll
4. Are you allergic to any drugs, foods, or
chemicals?
Yes b No b
If yes, what kind of allergy is it? llllll
llllllllllllllllllllllll
What causes the allergy? llllllllll
llllllllllllllllllllllll
5. Have you ever been told that you have
asthma, hayfever, or sinusitis?
Yes b No b
6. Have you ever been told that you have emphysema, bronchitis, or any other respiratory problems?
Yes b No b
7. Have you ever been told you had hepatitis?
Yes b No b
8. Have you ever been told that you had cirrhosis?
Yes b No b
9. Have you ever been told that you had cancer?
Yes b No b
10. Have you ever had arthritis or joint pain?
Yes b No b
11. Have you ever been told that you had
high blood pressure?
Yes b No b
12. Have you ever had a heart attack or heart
trouble?
Yes b No b
B–1. Medical History Update
1. Have you been in the hospital as a patient
any time within the past year?
Yes b No b
If so, for what condition? llllllllll
llllllllllllllllllllllll
2. Have you been under the care of a physician during the past year?
Yes b No b
If so, for what condition? llllllllll
llllllllllllllllllllllll
3. Is there any change in your breathing
since last year?
380
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00390
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
Occupational Safety and Health Admin., Labor
Yes b No b
Better? lllllllllllllllllll
Worse?
lllllllllllllllllll
No change? lllllllllllllllll
If change, do you know why? llllllll
llllllllllllllllllllllll
4. Is your general health different this year
from last year?
Yes b No b
If different, in what way? llllllllll
llllllllllllllllllllllll
5. Have you in the past year or are you now
taking any medication on a regular
basis?
Yes b No b
Name Rx
llllllllllllllllll
Condition being treated lllllllllll
erowe on DSK5CLS3C1PROD with CFR
C. Occupational History
1. How long have you worked for your
present employer?
llllllllllllllllllllllll
2. What jobs have you held with this employer? Include job title and length of
time in each job.
llllllllllllllllllllllll
llllllllllllllllllllllll
llllllllllllllllllllllll
llllllllllllllllllllllll
3. In each of these jobs, how many hours a
day were you exposed to chemicals?
llllllllllllllllllllllll
4. What chemicals have you worked with
most of the time?
llllllllllllllllllllllll
5. Have you ever noticed any type of skin
rash you feel was related to your work?
Yes b No b
6. Have you ever noticed that any kind of
chemical makes you cough?
Yes b No b
Wheeze?
Yes b No b
Become short of breath or cause your chest
to become tight?
Yes b No b
7. Are you exposed to any dust or chemicals
at home?
Yes b No b
If yes, explain:
lllllllllllllll
llllllllllllllllllllllll
8. In other jobs, have you ever had exposure
to:
Wood dust?
Yes b No b
Nickel or chromium?
Yes b No b
Silica (foundry, sand blasting)?
Yes b No b
Arsenic or asbestos?
Yes b No b
Organic solvents?
Yes b No b
Urethane foams?
Yes b No b
§ 1910.1048
C–1. Occupational History Update
1. Are you working on the same job this year
as you were last year?
Yes b No b
If not, how has your job changed?
lllll
llllllllllllllllllllllll
2. What chemicals are you exposed to on
your job?
llllllllllllllllllllllll
3. How many hours a day are you exposed to
chemicals?
llllllllllllllllllllllll
4. Have you noticed any skin rash within the
past year you feel was related to your
work?
Yes b No b
If so, explain circumstances: llllllll
llllllllllllllllllllllll
5. Have you noticed that any chemical
makes you cough, be short of breath, or
wheeze?
Yes b No b
If so, can you identify it? llllllllll
llllllllllllllllllllllll
D. Miscellaneous
1. Do you smoke?
Yes b No b
If so, how much and for how long? lllll
llllllllllllllllllllllll
Pipe lllllllllllllllllllll
Cigars llllllllllllllllllll
Cigarettes llllllllllllllllll
2. Do you drink alcohol in any form?
Yes b No b
If so, how much, how long, and how often?
llllllllllllllllllllllll
3. Do you wear glasses or contact lenses?
Yes b No b
4. Do you get any physical exercise other
than that required to do your job?
Yes b No b
If so, explain: llllllllllllllll
llllllllllllllllllllllll
5. Do you have any hobbies or ‘‘side jobs’’
that require you to use chemicals, such
as furniture stripping, sand blasting, insulation or manufacture of urethane
foam, furniture, etc?
Yes b No b
If so, please describe, giving type of business
or hobby, chemicals used and length of exposures.
llllllllllllllllllllllll
E. Symptoms Questionnaire
1. Do you ever have any shortness of breath?
Yes b No b
If yes, do you have to rest after climbing several flights of stairs?
Yes b No b
If yes, if you walk on the level with people
your own age, do you walk slower than
they do?
Yes b No b
381
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00391
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
erowe on DSK5CLS3C1PROD with CFR
§ 1910.1048
29 CFR Ch. XVII (7–1–09 Edition)
If yes, if you walk slower than a normal
pace, do you have to limit the distance
that you walk?
Yes b No b
If yes, do you have to stop and rest while
bathing or dressing?
Yes b No b
2. Do you cough as much as three months out
of the year?
Yes b No b
If yes, have you had this cough for more than
two years?
Yes b No b
If yes, do you ever cough anything up from
chest?
Yes b No b
3. Do you ever have a feeling of smothering,
unable to take a deep breath, or tightness in your chest?
Yes b No b
If yes, do you notice that this on any particular day of the week?
Yes b No b
If yes, what day or the week?
Yes b No b
If yes, do you notice that this occurs at any
particular place?
Yes b No b
If yes, do you notice that this is worse after
you have returned to work after being off
for several days?
Yes b No b
4. Have you ever noticed any wheezing in
your chest?
Yes b No b
If yes, is this only with colds or other infections?
Yes b No b
Is this caused by exposure to any kind of
dust or other material?
Yes b No b
If yes, what kind? llllllllllllll
5. Have you noticed any burning, tearing, or
redness of your eyes when you are at
work?
Yes b No b
If so, explain circumstances: llllllll
llllllllllllllllllllllll
6. Have you noticed any sore or burning
throat or itchy or burning nose when you
are at work?
Yes b No b
If so, explain circumstances: llllllll
llllllllllllllllllllllll
7. Have you noticed any stuffiness or dryness
of your nose?
Yes b No b
8. Do you ever have swelling of the eyelids or
face?
Yes b No b
9. Have you ever been jaundiced?
Yes b No b
If yes, was this accompanied by any pain?
Yes b No b
10. Have you ever had a tendency to bruise
easily or bleed excessively?
Yes b No b
11. Do you have frequent headaches that are
not relieved by aspirin or tylenol?
Yes b No b
If yes, do they occur at any particular time
of the day or week?
Yes b No b
If yes, when do they occur? lllllllll
llllllllllllllllllllllll
12. Do you have frequent episodes of nervousness or irritability?
Yes b No b
13. Do you tend to have trouble concentrating or remembering?
Yes b No b
14. Do you ever feel dizzy, light-headed, excessively drowsy or like you have been
drugged?
Yes b No b
15. Does your vision ever become blurred?
Yes b No b
16. Do you have numbness or tingling of the
hands or feet or other parts of your body?
Yes b No b
17. Have you ever had chronic weakness or
fatigue?
Yes b No b
18. Have you ever had any swelling of your
feet or ankles to the point where you
could not wear your shoes?
Yes b No b
19. Are you bothered by heartburn or indigestion?
Yes b No b
20. Do you ever have itching, dryness, or
peeling and scaling of the hands?
Yes b No b
21. Do you ever have a burning sensation in
the hands, or reddening of the skin?
Yes b No b
22. Do you ever have cracking or bleeding of
the skin on your hands?
Yes b No b
23. Are you under a physician’s care?
Yes b No b
If yes, for what are you being treated? lll
llllllllllllllllllllllll
24. Do you have any physical complaints
today?
Yes b No b
If yes, explain? lllllllllllllll
llllllllllllllllllllllll
25. Do you have other health conditions not
covered by these questions?
Yes b No b
If yes, explain:
lllllllllllllll
llllllllllllllllllllllll
[57 FR 22310, May 27, 1992; 57 FR 27161, June
18, 1992; 61 FR 5508, Feb. 13, 1996; 63 FR 1292,
Jan. 8, 1998; 63 FR 20099, Apr. 23, 1998; 70 FR
1143, Jan. 5, 2005; 71 FR 16672, 16673, Apr. 3,
2006; 71 FR 50190, Aug. 24, 2006; 73 FR 75586,
Dec. 12, 2008]
382
VerDate Nov<24>2008
09:15 Aug 28, 2009
Jkt 217114
PO 00000
Frm 00392
Fmt 8010
Sfmt 8010
Y:\SGML\217114.XXX
217114
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[&
General Information Appendix D:
General Industry Standard on Emergency Action Plans
$ WR = ,QGH[ _ (Q HVSDxRO _ &RQWDFW 8V _ )$4V _ $ERXW 26+$
26+$
1HZVOHWWHU
566 )HHGV
3ULQW 7KLV 3DJH
7H[W 6L]H
:DV WKLV SDJH KHOSIXO"
:KDW
V 1HZ _ 2IILFHV
+RPH
:RUNHUV
5HJXODWLRQV
(QIRUFHPHQW
'DWD 6WDWLVWLFV
7UDLQLQJ
3XEOLFDWLRQV
1HZVURRP
6PDOO %XVLQHVV
5HJXODWLRQV 6WDQGDUGV &)5 7DEOH RI &RQWHQWV
‡ 3DUW 1XPEHU
‡ 3DUW 7LWOH
‡ 6XESDUW
‡ 6XESDUW 7LWOH
‡ 6WDQGDUG 1XPEHU
‡ 7LWOH
2FFXSDWLRQDO 6DIHW\ DQG +HDOWK 6WDQGDUGV
(
0HDQV RI (JUHVV
(PHUJHQF\ DFWLRQ SODQV
D
$SSOLFDWLRQ $Q HPSOR\HU PXVW KDYH DQ HPHUJHQF\ DFWLRQ SODQ ZKHQHYHU DQ 26+$ VWDQGDUG LQ WKLV SDUW UHTXLUHV RQH 7KH UHTXLUHPHQWV LQ WKLV
VHFWLRQ DSSO\ WR HDFK VXFK HPHUJHQF\ DFWLRQ SODQ
E
:ULWWHQ DQG RUDO HPHUJHQF\ DFWLRQ SODQV $Q HPHUJHQF\ DFWLRQ SODQ PXVW EH LQ ZULWLQJ NHSW LQ WKH ZRUNSODFH DQG DYDLODEOH WR HPSOR\HHV IRU
UHYLHZ +RZHYHU DQ HPSOR\HU ZLWK RU IHZHU HPSOR\HHV PD\ FRPPXQLFDWH WKH SODQ RUDOO\ WR HPSOR\HHV
F
0LQLPXP HOHPHQWV RI DQ HPHUJHQF\ DFWLRQ SODQ $Q HPHUJHQF\ DFWLRQ SODQ PXVW LQFOXGH DW D PLQLPXP
F
3URFHGXUHV IRU UHSRUWLQJ D ILUH RU RWKHU HPHUJHQF\;
F
F
3URFHGXUHV IRU HPHUJHQF\ HYDFXDWLRQ LQFOXGLQJ W\SH RI HYDFXDWLRQ DQG H[LW URXWH DVVLJQPHQWV;
F
3URFHGXUHV WR EH IROORZHG E\ HPSOR\HHV ZKR UHPDLQ WR RSHUDWH FULWLFDO SODQW RSHUDWLRQV EHIRUH WKH\ HYDFXDWH;
F
3URFHGXUHV WR DFFRXQW IRU DOO HPSOR\HHV DIWHU HYDFXDWLRQ;
F
3URFHGXUHV WR EH IROORZHG E\ HPSOR\HHV SHUIRUPLQJ UHVFXH RU PHGLFDO GXWLHV; DQG
F
7KH QDPH RU MRE WLWOH RI HYHU\ HPSOR\HH ZKR PD\ EH FRQWDFWHG E\ HPSOR\HHV ZKR QHHG PRUH LQIRUPDWLRQ DERXW WKH SODQ RU DQ H[SODQDWLRQ RI WKHLU
GXWLHV XQGHU WKH SODQ
G
(PSOR\HH DODUP V\VWHP $Q HPSOR\HU PXVW KDYH DQG PDLQWDLQ DQ HPSOR\HH DODUP V\VWHP 7KH HPSOR\HH DODUP V\VWHP PXVW XVH D GLVWLQFWLYH
VLJQDO IRU HDFK SXUSRVH DQG FRPSO\ ZLWK WKH UHTXLUHPHQWV LQ † H
7UDLQLQJ $Q HPSOR\HU PXVW GHVLJQDWH DQG WUDLQ HPSOR\HHV WR DVVLVW LQ D VDIH DQG RUGHUO\ HYDFXDWLRQ RI RWKHU HPSOR\HHV
I
5HYLHZ RI HPHUJHQF\ DFWLRQ SODQ $Q HPSOR\HU PXVW UHYLHZ WKH HPHUJHQF\ DFWLRQ SODQ ZLWK HDFK HPSOR\HH FRYHUHG E\ WKH SODQ
I
:KHQ WKH SODQ LV GHYHORSHG RU WKH HPSOR\HH LV DVVLJQHG LQLWLDOO\ WR D MRE;
I
:KHQ WKH HPSOR\HH
V UHVSRQVLELOLWLHV XQGHU WKH SODQ FKDQJH; DQG
I
:KHQ WKH SODQ LV FKDQJHG
> )5 6HSW ; )5 1RY @
1H[W 6WDQGDUG 5HJXODWLRQV 6WDQGDUGV &)5 7DEOH RI &RQWHQWV
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL['
General Information Appendix E: OSHA Fact Sheet – Formaldehyde
FactSheet
Formaldehyde
Formaldehyde is a colorless, strong-smelling gas often found in aqueous (waterbased) solutions. Commonly used as a preservative in medical laboratories and
mortuaries, formaldehyde is also found in many products such as chemicals, particle
board, household products, glues, permanent press fabrics, paper product coatings,
fiberboard, and plywood. It is also widely used as an industrial fungicide, germicide
and disinfectant.
Although the term formaldehyde describes various mixtures of formaldehyde, water, and alcohol,
the term “formalin” is used to describe a saturated
solution of formaldehyde dissolved in water,
typically with another agent, most commonly
methanol, added to stabilize the solution. Formalin
is typically 37% formaldehyde by weight (40% by
volume) and 6-13% methanol by volume in water.
The formaldehyde component provides the disinfectant effects of formalin.
exposure is highly irritating to the eyes, nose, and
throat and can make anyone exposed cough and
wheeze. Subsequent exposure may cause severe
allergic reactions of the skin, eyes and respiratory
tract. Ingestion of formaldehyde can be fatal, and
long-term exposure to low levels in the air or on
the skin can cause asthma-like respiratory problems and skin irritation such as dermatitis and
itching. Concentrations of 100 ppm are immediately dangerous to life and health (IDLH).
What Employers Should Know
Note: The National Institute for Occupational
Safety and Health (NIOSH) considers 20 ppm of
formaldehyde to be IDLH.
The OSHA Formaldehyde standard (29 CFR
1910.1048) and equivalent regulations in states
with OSHA-approved state plans protects workers
exposed to formaldehyde and apply to all occupational exposures to formaldehyde from formaldehyde gas, its solutions, and materials that release
formaldehyde.
• The permissible exposure limit (PEL) for
formaldehyde in the workplace is 0.75 parts
formaldehyde per million parts of air (0.75 ppm)
measured as an 8-hour time-weighted average
(TWA).
• The standard includes a second PEL in the form
of a short-term exposure limit (STEL) of 2 ppm
which is the maximum exposure allowed during a 15-minute period.
• The action level – which is the standard’s trig-
ger for increased industrial hygiene monitoring
and initiation of worker medical surveillance –
is 0.5 ppm when calculated as an 8-hour TWA.
Harmful Effects on Workers
Formaldehyde is a sensitizing agent that can
cause an immune system response upon initial
exposure. It is also a cancer hazard. Acute
Routes of Exposure
Workers can inhale formaldehyde as a gas or
vapor or absorb it through the skin as a liquid.
They can be exposed during the treatment of textiles and the production of resins. In addition to
healthcare professionals and medical lab technicians, groups at potentially high risk include mortuary workers as well as teachers and students
who handle biological specimens preserved with
formaldehyde or formalin.
How Employers Can Protect Workers
Airborne concentrations of formaldehyde above
0.1 ppm can cause irritation of the respiratory
tract. The severity of irritation intensifies as concentrations increase.
Provisions of the OSHA standard require employers to do the following:
• Identify all workers who may be exposed to
formaldehyde at or above the action level or
STEL through initial monitoring and determine
their exposure.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[(
• Reassign workers who suffer significant
adverse effects from formaldehyde exposure to
jobs with significantly less or no exposure until
their condition improves. Reassignment may
continue for up to 6 months until the worker is
determined to be able to return to the original
job or to be unable to return to work – whichever comes first.
• Implement feasible engineering and work practice controls to reduce and maintain worker
exposure to formaldehyde at or below the 8hour TWA and the STEL. If these controls cannot reduce exposure to or below the PELs,
employers must provide workers with respirators.
• Label all mixtures or solutions composed of
greater than 0.1 percent formaldehyde and
materials capable of releasing formaldehyde
into the air at concentrations reaching or
exceeding 0.1 ppm. For all materials capable of
releasing formaldehyde at levels above 0.5 ppm
during normal use, the label must contain the
words “potential cancer hazard.”
• Train all workers exposed to formaldehyde concentrations of 0.1 ppm or greater at the time of
initial job assignment and whenever a new
exposure to formaldehyde is introduced into
the work area. Repeat training annually.
gloves, aprons, and chemical splash goggles to
prevent skin and eye contact with formaldehyde.
• Provide showers and eyewash stations if
splashing is likely.
• Provide medical surveillance for all workers
exposed to formaldehyde at concentrations at
or above the action level or exceeding the
STEL, for those who develop signs and symptoms of overexposure, and for all workers
exposed to formaldehyde in emergencies.
Recordkeeping Requirements
Employers are required to do the following
regarding worker exposure records:
• Retain exposure records for 30 years.
• Retain medical records for 30 years after
employment ends.
• Allow access to medical and exposure records
to current and former workers or their designated representatives upon request.
Additional Information
For more information on this, and other healthrelated issues affecting workers, visit OSHA’s web
site at www.osha.gov.
• Select, provide and maintain appropriate per-
sonal protective equipment (PPE). Ensure that
workers use PPE such as impervious clothing,
This is one in a series of informational fact sheets highlighting OSHA programs, policies or
standards. It does not impose any new compliance requirements. For a comprehensive list of
compliance requirements of OSHA standards or regulations, refer to Title 29 of the Code of Federal
Regulations. This information will be made available to sensory-impaired individuals upon request.
The voice phone is (202) 693-1999; the teletypewriter (TTY) number is (877) 889-5627.
For assistance, contact us. We can help. It’s confidential.
Occupational Safety
and Health Administration
www.osha.gov 1-800-321-6742
DSG 4/2011
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[(
General Information Appendix F: OSHA Plans per State
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
OSHA
A to Z Index | En Español | Contact Us | FAQs | About OSHA
Newsletter
RSS Feeds
Occupational Safety & Health Administration
We Can Help
Home
Training
Workers
Publications
Regulations
Newsroom
Enforcement
Small Business
Data & Statistics
Search
Search
Anti-Retaliation
Was this page helpful?
What's New | Offices
Back to Previous /Directory of States with Approved Occupational Safety and Health Plans
Directory of States with Approved Occupational Safety and Health Plans
(Text Version)
Alaska Department of Labor and Workforce Development
P.O. Box 111149
1111 W. 8th Street, Room 304
Juneau, Alaska 99811-1149
Dianne Blumer, Commissioner (907) 465-2700 Fax: (907) 465-2784
Grey Mitchell, Director (907) 465-4855 Fax: (907) 465-6012
Industrial Commission of Arizona
800 W. Washington
Phoenix, Arizona 85007-2922
Laura L. McGrory, Director, ICA (602) 542-4411 Fax: (602) 542-7889
Bill Warren, Program Director (602) 542-5795 Fax: (602) 542-1614
California Department of Industrial Relations
1515 Clay Street, 17th Floor
Oakland, California 94612
Christine Baker, Director (510) 622-3965 Fax: (510) 286-7037
Juliann Sum, Acting Chief, Cal/OSHA (510) 286-7000 Fax: (510) 286-7037
Cora Gherga, Acting Deputy Chief, Enforcement, Cal/OSHA (510) 286-7000 Fax: (510) 286-7037
Deborah Gold, Deputy Chief, Health and Engineering Services, Cal/OSHA (510) 286-7000 Fax: (510) 286-7037
Connecticut Department of Labor
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
200 Folly Brook Boulevard
Wethersfield, Connecticut 06109
Sharon Palmer, Commissioner (860) 263-6505 Fax: (860) 263-6529
CONN-OSHA
38 Wolcott Hill Road
Wethersfield, Connecticut 06109
Kenneth Tucker, Director (860) 263-6900 Fax: (860) 263-6940
Hawaii Department of Labor and Industrial Relations
830 Punchbowl Street
Honolulu, Hawaii 96813
Dwight Takamine, Director (808) 586-8844 Fax: (808) 586-9099
Diantha Goo, HIOSH Administrator (808) 586-9116 Fax: (808) 586-9104
Illinois Department of Labor
900 South Spring Street
Springfield, IL 62702
Joe Costigan, Director (217) 782-6206 Fax: (217) 782-0596
Cheryl Neff, Manager (217) 782-1442
Indiana Department of Labor
State Office Building
402 West Washington Street, Room W195
Indianapolis, Indiana 46204-2751
Rick J. Ruble, Commissioner of Labor (317) 232-2693 Fax: (317) 233-3790
Tim Maley, Deputy Commissioner, IOSHA (317) 233-3605 Fax: (317) 233-3790
Iowa Division of Labor Services
1000 E. Grand Avenue
Des Moines, Iowa 50319-0209
Michael A. Mauro, Labor Commissioner (515) 281-3447 Fax: (515) 281-5631
Stephen Slater, Deputy Labor Commissioner/IOSH Administrator (515) 281-3469 Fax: (515) 281-7995
Kentucky Labor Cabinet
1047 US HWY 127 South, Suite 4
Frankfort KY 40601
Larry L. Roberts, Secretary (502) 564-0684, FAX: 502-564-5387
Rocky Comito, Deputy Secretary (502) 564-0684, FAX: 502-564-5387
Anthony Russell, Commissioner, Department of Workplace Standards (502) 564-3070, FAX: (502) 564-5387
Chuck Stribling, CSP, OSH Federal-State Coordinator, Department of Workplace Standards (502) 564-3070
Maryland Division of Labor and Industry
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
Department of Labor, Licensing and Regulation
Division of Labor and Industry
1100 North Eutaw Street, Room 606
Baltimore, Maryland 21201-2206
Ron DeJuliis, Commissioner (410) 767-2241 Fax: (410) 767-2986
Craig Lowry, Deputy Commissioner (410) 767-2929 Fax: (410) 767-7909
Maryland Occupational Safety and Health (MOSH)
10946 Golden West Drive, Suite 160
Hunt Valley, MD 21031
Eric Uttenreither, Assistant Commissioner (410) 527-4499 Fax: (410) 527-4481
Michigan Department of Licensing and Regulatory Affairs
Mike Zimmer, Acting Director (517) 241-7124 Fax: (517) 373-2129
Michigan Occupational Safety and Health Administration
P.O. Box 30643
Lansing, MI 48909-8143
Martha Yoder, Director, MIOSHA, (517) 322-1817 Fax: (517) 322-1775
Minnesota Department of Labor and Industry
443 Lafayette Road
St. Paul, Minnesota 55155
Ken Peterson, Commissioner (651) 284-5010 Fax: (651) 284-5721
Cindy Valentine, Workplace Safety Manager (651) 284-5602 Fax: (651) 284-5724
James Krueger, Compliance Director, MNOSHA Compliance (651) 284-5110 Fax: (651) 284-5741
Nevada Division of Industrial Relations
Department of Business & Industry
400 West King Street, Suite 400
Carson City, Nevada 89703
Steve George, Administrator (775) 684-7262, Fax: (775)-684-7086
Occupational Safety and Health Administration
1301 N. Green Valley Parkway, Suite 200
Henderson, Nevada 89074
John Wanamaker, Chief Administrative Officer (702) 486-9020 Fax: (702) 990-0365
New Jersey Department of Labor and Workforce Development
Office of Public Employees' Occupational Safety & Health (PEOSH)
1 John Fitch Plaza
P.O. Box 386
Trenton, NJ 08625-0386
Harold J. Wirths, Commissioner (609) 292-2975 Fax: (609) 292-3749
John Monahan, Assistant Commissioner (609) 292-2313 Fax: (609) 695-1314
Howard Black, Director, PEOSH (609) 292-0501 Fax: (609) 292-4409
Joe Eldridge, Director, Consumer, Environmental and Occupational Health Service, NJ Dept. of Health and Senior Services
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
(609) 826-4920 Fax: (609) 984-2779
New Mexico Environment Department
525 Camino de los Marquez, Suite 3
P.O. Box 5469
Santa Fe, New Mexico 87502
Ryan Flynn, Secretary-Designate (505) 827-2855 Fax: (505) 827-2836
Robert Genoway, Bureau Chief (505) 476-8700 Fax: (505) 476-8734
New York Department of Labor
New York Public Employee Safety and Health Bureau (PESH)
State Office Campus Building 12, Room 158
Albany, New York 12240
Peter Rivera, Commissioner (518) 457-2746 Fax: (518) 457-5545
Eileen Franko, Acting Director, Division of Safety and Health (DOSH) (518) 457-3518 Fax: (518) 457-5545
Normand Labbe, Public Employee Safety and Health Program Manager (518) 457-1263 Fax: (518) 457-5545
North Carolina Department of Labor
1101 Mail Service Center
Raleigh, North Carolina 27699-1101
Cherie Berry, Commissioner (919) 733-0359 Fax: (919) 733-6197
Allen McNeely, Deputy Commissioner, OSH Director (919) 807-2861 Fax: (919) 807-2855
Kevin Beauregard, OSH Assistant Director (919) 807-2863 Fax: (919) 807-2856
Oregon Occupational Safety and Health Division
Department of Consumer and Business Services
350 Winter Street, NE, Room 430
P.O. Box 14480
Salem, Oregon 97309-0405
Michael Wood, Administrator (503) 378-3272 Fax: (503) 947-7461
Joan Fraser, Deputy Administrator (503) 378-3272 Fax: (503) 947-7461
Puerto Rico Department of Labor and Human Resources
Puerto Rico Department of Labor and Human Resources
Prudencio Rivera Martinez Building 21st Floor
505 Muñoz Rivera Avenue
Hato Rey, Puerto Rico 00918
Vance Thomas Rider, Secretary of Labor (787) 754-2119 Fax: (787) 753-9550
Jose Israel Droz Alvarado, Assistant Secretary of Labor (787) 754-2172 Fax: (787) 767-6051
South Carolina Department of Labor, Licensing, and Regulation
Synergy Business Park, Kingstree Building
110 Centerview Drive
P.O. Box 11329
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
Columbia, South Carolina 29211
Holly Pisarik, Director (803) 896-4300 Fax: (803) 896-4393
Dottie Ison, Administrator (803) 896-7686 Fax: (803) 896-7670
Office of Voluntary Programs (803) 896-7787 Fax: (803) 896-7750
Tennessee Department of Labor and Workforce Development
220 French Landing Drive
Nashville, Tennessee 37243
Burns Phillips, Commissioner (615) 741-2582 Fax: (615) 741-5078
Steve Hawkins, TOSHA Administrator (615) 741-2793 Fax: (615) 741-3325
Utah Labor Commission
160 East 300 South, 3rd Floor
P.O. Box 146600
Salt Lake City, Utah 84114-6600
Sherrie M. Hayashi, Commissioner (801) 530-6848 Fax: (801) 530-6390
Christopher Hill, Director, Utah Occupational Safety and Health (801) 530-6901 Fax: (801) 530-7606
Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Montpelier, Vermont 05601-0488
Annie Noonan, Commissioner (802) 828-4000 Fax: (802) 888-4022
Daniel Whipple, VOSHA Program Manager (802) 828-5084 Fax: (802) 828-0408
Virgin Islands Division of Occupational Safety and Health (VIDOSH)
4401 Sion Farm
Christiansted, St. Croix, VI 00820
Albert Bryan, Jr., Commissioner, Virgin Islands Department of Labor (VIDOL) (340) 773-1994 Fax: (340) 773-1858
Dean R. Andrews, Director (340) 773-1994 X-2161 Fax: (340) 773-0094
Virginia Department of Labor and Industry
Main Street Centre
600 East Main Street
Richmond, VA 23219
C. Ray Davenport, Commissioner (804) 786-2377 Fax: (804) 371-6524
William Burge, Assistant Commissioner (804) 371-2327 Fax: (804) 371-6524
Ronald L. Graham, VOSH Health Director (804) 786-0574 Fax: (804) 371-6524
Paul B. Schilinski, VOSH Safety Director (703) 392-0900 or (804) 786-7776 Fax: (703) 392-0308
Jay Withrow, Director, Division of Legal Support (804) 371-2327 Fax: (804) 371-6524
Washington Department of Labor and Industries
General Administration Building
PO Box 44001
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
State Occupational Safety and Health Plans | Directory of States with Approved Occupational Safety and Health Plans - Text Version
Olympia, Washington 98504-4001
7273 Linderson Way SW
Tumwater, WA 98501-5414
Judy Schurke, Director (360) 902-4200 Fax: (360) 902-4202
Division of Occupational Safety and Health
Anne Soiza, Assistant Director, DOSH, (360) 902-4805 Fax: (360) 902-5619
Dave Puente, Deputy Assistant Director, DOSH
Wyoming Department of Workforce Services
Workers' Safety and Compensation Division
1510 East Pershing Boulevard - West Wing
Cheyenne, Wyoming 82002
John Ysebaert, Administrator Standards & Compliance (307) 777-7672 Fax: (307) 777-5805
Mike Todd, OSHA Division Manager (307) 777-3581 Fax: (307) 777-3646
Freedom of Information Act |
Privacy & Security Statement | Disclaimers |
Contact Us
Important Web Site Notices |
International |
U.S. Department of Labor | Occupational Safety & Health Administration | 200 Constitution Ave., NW, Washington, DC 20210
Telephone: 800-321-OSHA (6742) | TTY
www.OSHA.gov
https://www.osha.gov/dcsp/osp/states_text.html[11/20/2014 2:27:59 PM]
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[)
______________________________________________________________________________________
General Information Appendix G: Glossary
Glossary of terms and abbreviations used in
the Compliance Manual____________________________
ACGIH- American Conference of Governmental Industrial Hygienists
ADA- American Dental Association
AIDS- Acquired Immune Deficiency Syndrome
Bloodborne pathogens- pathogenic microorganisms that are present in human
blood and can cause disease in humans. These include, but are not limited to,
HBV and HIV.
CDC- Centers for Disease Control and Prevention
Compliance Manager- the person designated as the coordinator of the program
who will bring the dental office into compliance with OSHA regulations.
Contaminated laundry- laundry that has been soiled with blood or other
potentially infectious materials or that may contain sharps.
Contaminated- the presence or the reasonably anticipated presence of blood or
other potentially infectious material on an item or surface.
CPR- cardiopulmonary resuscitation
Decontamination- the use of physical or chemical means to remove, inactivate
or destroy pathogens.
Disinfectant- an agent that eliminates virtually all recognized pathogenic
microorganisms but not necessarily all microbial forms (bacterial endospores) on
inanimate objects.
DOT- Department of Transportation
EPA- Environmental Protection Agency
Exposure incident- a specific eye, mouth, other mucous membrane, nonintact
skin, or parenteral contact with blood or other potentially infectious materials
that results from the performance of an employee’s duties.
FDA- Food and Drug Administration, an agency of the United States Public
Health Service.
Formal complaint- any complaint that is in writing, alleges that an imminent
danger or a violation threatening physical harm exists, sets forth with
reasonable particularity the grounds on which the complaint is based, and is
signed by at least one current employee or the employee’s authorized
representative (former employees can only submit nonformal complaints).
HBV- Hepatitis B virus
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[*
______________________________________________________________________________________
HCP- healthcare professional
HCV Hepatitis C virus
HIV Human immunodeficiency virus, the etiologic agent for AIDS.
HIV+ term used to describe someone who tests positive for HIV antibody.
HIV antibody positive- phrase used to describe someone who tests positive for
HIV antibody.
Infectious waste (OSHA definition)- see Regulated waste
Infectious waste (EPA definition)- contaminated sharps, teeth, pathologic
waste, and blood soaked items, when applied to dentistry.
MMWR-Morbidity and Mortality Weekly Report, a weekly publication of the CDC.
MWTA- Medical Waste Tracking Act, enacted by Congress in 1988.
NIOSH- National Institute for Occupational Safety and Health
Nonformal complaint- any complaint that does not meet the requirements of a
formal complaint, e.g., unsigned or oral complaints by current employees,
written and oral complaints by non-employees or former employees.
Occupational exposure- skin, eye, mucous membrane, or parenteral contact
with blood or other potentially infectious materials that results from the
performance of an employee’s duties.
OSHA- Occupational Safety and Health Administration, a part of the U.S.
Department of Labor.
Other potentially infectious materials (OPIM)- 1) body fluids including
semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures; and
any body fluid that is visibly contaminated by blood; and all body fluids in
situations where differentiating between body fluids is difficult or impossible; 2)
any unfixed tissue or organ from a human (living or dead); and 3) HIVcontaining cell or tissue cultures, organ cultures; HIV- or HBV-containing
culture medium or other solutions; and blood, organs, or other tissues from
experimental animals infected with HIV or HBV.
Parenteral- piercing mucous membranes or the skin barrier through
needlesticks, human bites, cuts and abrasions.
PEL- OSHA-permissible exposure limit
PEP- postexposure prophylaxis
Percutaneous- pierced through the skin
Personal protective equipment (PPE)- clothing or equipment worn for
protection against a hazard.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[*
______________________________________________________________________________________
Regulated Waste (OSHA definition)- liquid or semiliquid blood or other
potentially infectious materials, items that would release blood or other
potentially infectious materials if compressed, items that are caked with dried
blood and could release it during handling, contaminated sharps, extracted
teeth and pathological waste (tissue).
REL- recommended exposure limit
Safety Data Sheet (SDS)- a sheet of information that lists the chemical,
physical, and biological properties of a product and the precautions to be used
when handling the product.
Seropositive- term used to describe someone who tests positive for HIV
antibody.
Sharps- any object that can penetrate the skin, such as needles, scalpels,
broken glass and exposed ends of dental wires. Federal EPA and state waste
disposal regulations may also regulate unused or uncontaminated sharps.
Source individual- any individual whose blood or other potentially infectious
materials may be a source of occupational exposure to the dental team.
Standard- the term applied to a final regulation of OSHA, in this Manual, the
Standard on Bloodborne Pathogens and the Hazard Communication Standard.
Such standards have the force of law.
Standard precautions- an approach to infection control that integrates and
expands the elements of universal precautions, and in which human blood or
any other body fluid, excretion, or secretion (except sweat) is treated as if known
to be infectious for HIV, HBV, and other bloodborne pathogens.
Sterilize- the use of a physical or chemical procedure to destroy all microbial
life, including highly resistant endospores.
TLV- ACGIH threshold limit value
Universal precautions- an approach to infection control in which all human
blood and certain human body fluids are treated as if known to be infectious for
HIV, HBV, and other bloodborne pathogens.
USPHS- U.S. Public Health Service
ZDV- zidovudine
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[*
Does the plan identify how or where personal information on employees can be
obtained in an emergency?
…
Does the plan address the types of actions expected of different employees for
the various types of potential emergencies?
Does the plan designate who, if anyone, will stay to shut down critical
operations during an evacuation?
Does the plan outline specific evacuation routes and exits and are these posted
in the workplace where they are easily accessible to all employees?
Does the plan address procedures for assisting people during evacuations,
particularly those with disabilities or who do not speak English?
…
…
…
Does the plan identify the conditions under which an evacuation would be
necessary?
Does the plan identify a clear chain of command and designate a person
authorized to order an evacuation or shutdown of operations?
…
…
…
Evacuation Policy and Procedure
Does the plan address how medical assistance will be provided?
Does the plan consider all potential natural or man-made emergencies that
could disrupt your workplace?
Does the plan consider all potential internal sources of emergencies that could
disrupt your workplace?
Does the plan consider the impact of these internal and external emergencies
on the workplace’s operations and is the response tailored to the workplace?
Does the plan contain a list of key personnel with contact information as well
as contact information for local emergency responders, agencies and
contractors?
Does the plan contain the names, titles, departments, and telephone numbers of
individuals to contact for additional information or an explanation of duties
and responsibilities under the plan?
Does the plan address how rescue operations will be performed?
…
…
…
…
…
…
…
General Issues
The plan should identify the different types of situations that will require an evacuation of the workplace. This might
include a fire, earthquake, or chemical spill. The extent of evacuation may be different for different types of hazards.
It is common practice to select a responsible individual to lead and coordinate your emergency plan and evacuation. It is
critical that employees know who the coordinator is and understand that this person has the authority to make decisions
during emergencies. The coordinator should be responsible for assessing the situation to determine whether an
emergency exists requiring activation of the emergency procedures, overseeing emergency procedures, notifying and
coordinating with outside emergency services, and directing shutdown of utilities or plant operations if necessary.
The plan may specify different actions for employees depending on the emergency. For example, employers may want
to have employees assemble in one area of the workplace if it is threatened by a tornado or earthquake but evacuate to an
exterior location during a fire.
You may want to include in your plan locations where utilities (such as electrical and gas utilities) can be shut down for
all or part of the facility. All individuals remaining behind to shut down critical systems or utilities must be capable of
recognizing when to abandon the operation or task and evacuate themselves.
Most employers create maps from floor diagrams with arrows that designate the exit route assignments. These maps
should include locations of exits, assembly points and equipment (such as fire extinguishers, first aid kits, spill kits) that
may be needed in an emergency. Exit routes should be clearly marked and well lit, wide enough to accommodate the
number of evacuating personnel, unobstructed and clear of debris at all times, and unlikely to expose evacuating
personnel to additional hazards.
Many employers designate individuals as evacuation wardens to help move employees from danger to safe areas during
an emergency. Generally, one warden for every 20 employees should be adequate, and the appropriate number of
wardens should be available at all times during working hours. Wardens may be responsible for checking offices and
Unless you are a large employer handling hazardous materials and processes or have employees regularly working in
hazardous situations, you will probably choose to rely on local public resources, such as the fire department, who are
trained, equipped, and certified to conduct rescues. Make sure any external department or agency identified in your plan
is prepared to respond as outlined in your plan. Untrained individuals may endanger themselves and those they are trying
to rescue.
Most small employers do not have a formal internal medical program and make arrangements with medical clinics or
facilities close by to handle emergency cases and provide medical and first-aid services to their employees. If an
infirmary, clinic, or hospital is not close to your workplace, ensure that onsite person(s) have adequate training in first
aid. The American Red Cross, some insurance providers, local safety councils, fire departments, or other resources may
be able to provide this training. Treatment of a serious injury should begin within 3 to 4 minutes of the accident. Consult
with a physician to order appropriate first-aid supplies for emergencies. Establish a relationship with a local ambulance
service so transportation is readily available for emergencies.
In the event of an emergency, it could be important to have ready access to important personal information about your
employees. This includes their home telephone numbers, the names and telephone numbers of their next of kin, and
medical information.
Common sources of emergencies identified in emergency action plans include - fires, explosions, floods, hurricanes,
tornadoes, toxic material releases, radiological and biological accidents, civil disturbances and workplace violence.
Conduct a hazard assessment of the workplace to identify any physical or chemical hazards that may exist and could
cause an emergency.
Brainstorm worst case scenarios asking yourself what you would do and what would be the likely impact on your
operation and device appropriate responses.
Keep your list of key contacts current and make provisions for an emergency communications system such as a cellular
phone, a portable radio unit, or other means so that contact with local law enforcement, the fire department, and others
can be swift.
List names and contact information for individuals responsible for implementation of the plan.
Emergency Action Plan Checklist
General Information Appendix H: Emergency Action Plan Checklist
Available at: www.osha.gove/SLTC/etools/evaluation/implementation.html
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[+
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
*HQHUDO,QIRUPDWLRQ$SSHQGL[+
Does the plan address how visitors will be assisted in evacuation and
accounted for?
…
Does the plan describe the method to be used to alert employees, including
disabled workers, to evacuate or take other action?
Does the plan identify a preferred method for reporting fires and other
emergencies?
Training should be offered employees when you develop your initial plan and when new employees are hired.
Employees should be retrained when your plan changes due to a change in the layout or design of the facility, when new
equipment, hazardous materials, or processes are introduced that affect evacuation routes, or when new types of hazards
are introduced that require special actions. General training for your employees should address the following:
x
Individual roles and responsibilities;
x
Threats, hazards, and protective actions;
x
Notification, warning, and communications procedures;
x
Emergency response procedures;
x
Evacuation, shelter, and accountability procedures;
x
Location and use of common emergency equipment; and
x
Emergency shutdown procedures.
You may also need to provide additional training to your employees (i.e. first-aid procedures, portable fire extinguisher
use, etc.) depending on the responsibilities allocated employees in your plan.
If training is not reinforced it will be forgotten. Consider retaining employees annually.
Once you have reviewed your emergency action plan with your employees and everyone has had the proper training, it is
a good idea to hold practice drills as often as necessary to keep employees prepared. Include outside resources such as
fire and police departments when possible. After each drill, gather management and employees to evaluate the
effectiveness of the drill. Identify the strengths and weaknesses of your plan and work to improve it.
Does the plan identify how and when employees will be trained so that they
understand the types of emergencies that may occur, their responsibilities and
actions as outlined in the plan?
Does the plan address how and when retraining will be conducted?
Does the plan address if and how often drills will be conducted?
…
…
Dialing 911 is a common method for reporting emergencies if external responders are utilized. Internal numbers may be
used. Internal numbers are sometimes connected to intercom systems so that coded announcements may be made. In
some cases employees are requested to activate manual pull stations or other alarm systems.
Make sure alarms are distinctive and recognized by all employees as a signal to evacuate the work area or perform other
actions identified in your plan. Sequences of horn blows or different types of alarms (bells, horns, etc.) can be used to
signal different responses or actions from employees. Consider making available an emergency communications system,
such as a public address system, for broadcasting emergency information to employees. Ideally alarms will be able to be
heard, seen, or otherwise perceived by everyone in the workplace including those that may be blind or deaf. Otherwise
floor wardens or others must be tasked with ensuring all employees are notified. You might want to consider providing
an auxiliary power supply in the event of an electrical failure.
…
Employee Training and Drills
…
…
Reporting Emergencies and Alerting Employees in an Emergency
Does the plan identify one or more assembly areas (as necessary for different
types of emergencies) where employees will gather and a method for
accounting for all employees?
…
bathrooms before being the last person to exit an area as well as ensuring that fire doors are closed when exiting.
Employees designated to assist in emergency evacuation procedures should be trained in the complete workplace layout
and various alternative escape routes. Employees designated to assist in emergencies should be made aware of employees
with special needs (who may require extra assistance during an evacuation), how to use the buddy system, and any
hazardous areas to avoid during an emergency evacuation.
Accounting for all employees following an evacuation is critical. Confusion in the assembly areas can lead to delays in
rescuing anyone trapped in the building, or unnecessary and dangerous search-and-rescue operations. To ensure the
fastest, most accurate accounting of your employees, consider taking a head count after the evacuation. The names and
last known locations of anyone not accounted for should be passed on to the official in charge.
Some employers have all visitors and contractors sign in when entering the workplace. The hosts and/or area wardens, if
established, are often tasked with assisting these individuals evacuate safely.
General Information Appendix I:
Sample Emergency Action Plan
Adapted from the Centers for Disease Control and Prevention’s Emergency Action Plan (Template), which is
available at www.cdc.gov/niosh/docs/2004-101/emrgact/emrgact1.html.
01/2015
49
General Information Appendix I
EMERGENCY ACTION PLAN
For
Facility Name: ___________________________________________________________
Facility Address: _________________________________________________________
DATE PREPARED: _______/_______/_______
01/2015
50
General Information Appendix I
EMERGENCY PERSONNEL NAMES AND PHONE NUMBERS
DESIGNATED RESPONSIBLE OFFICIAL:
Name: _______________________________________ Phone: ( ________ ) ________________
EMERGENCY COORDINATOR:
Name: _______________________________________ Phone: ( ________ ) ________________
AREA/FLOOR MONITORS (If applicable):
Area/Floor: _____________________________________________________________________
Name: _______________________________________ Phone: ( ________ ) ________________
Area/Floor: _____________________________________________________________________
Name: _______________________________________ Phone: ( ________ ) ________________
ASSISTANTS TO PHYSICALLY CHALLENGED (If applicable):
Name: _______________________________________ Phone: ( ________ ) ________________
Name: _______________________________________ Phone: ( ________ ) ________________
Date: _______/_______/_______
01/2015
51
General Information Appendix I
EVACUATION ROUTES
Evacuation route maps have been posted in each work area.
The following information is marked on evacuation maps:
1. Emergency exits
2. Primary and secondary evacuation routes
3. Locations of fire extinguishers
4. Fire alarm pull stations’ location
5. Assembly points
Site personnel should know at least two evacuation routes.
01/2015
52
General Information Appendix I
EMERGENCY PHONE NUMBERS
FIRE DEPARTMENT: ____________________________________________________
PARAMEDICS: ___________________________________________________________
AMBULANCE: ___________________________________________________________
POLICE: ________________________________________________________________
FEDERAL PROTECTIVE SERVICE: ______________________________________
SECURITY (If applicable): ________________________________________________
BUILDING MANAGER (If applicable): _____________________________________
Date: _______/_______/_______
01/2015
53
General Information Appendix I
UTILITY COMPANY EMERGENCY CONTACTS
(Specify name of the company, phone number and point of contact)
ELECTRIC: ______________________________________________________________
__________________________________________________________________________
WATER: _________________________________________________________________
__________________________________________________________________________
GAS (if applicable): ______________________________________________________
__________________________________________________________________________
TELEPHONE COMPANY: ________________________________________________
__________________________________________________________________________
Date: _______/_______/_______
01/2015
54
General Information Appendix I
EMERGENCY REPORTING AND EVACUATION PROCEDURES
Types of emergencies to be reported by site personnel are:
• MEDICAL
• FIRE
• SEVERE WEATHER
• BOMB THREAT
• CHEMICAL SPILL
• STRUCTURE CLIMBING/DESCENDING
• EXTENDED POWER LOSS
• OTHER (specify): ______________________________________________________
(e.g., terrorist attack/hostage taking)
Date: _______/_______/_______
01/2015
55
General Information Appendix I
MEDICAL EMERGENCY
Call medical emergency phone number (check applicable):
Paramedics
Ambulance
Fire Department
Other
Provide the following information:
a. Nature of medical emergency
b. Location of the emergency (address, building, room number)
c. Your name and phone number from which you are calling
Do not move victim unless absolutely necessary.
Call the following personnel trained in CPR and First Aid to provide the required
assistance prior to the arrival of the professional medical help:
Name: _____________________________________ Phone: ( ________ ) ________________
Name: _____________________________________ Phone: ( ________ ) ________________
If personnel trained in First Aid are not available, as a minimum, attempt to provide
the following assistance:
1. Stop the bleeding with firm pressure on the wounds (note: avoid contact with
blood or other bodily fluids).
2. Clear the air passages using the Heimlich Maneuver in case of choking.
In case of rendering assistance to personnel exposed to hazardous materials,
consult the Safety Data Sheet (SDS) and wear the appropriate personal protective
equipment. Attempt first aid ONLY if trained and qualified.
Date: _______/_______/_______
01/2015
56
General Information Appendix I
FIRE EMERGENCY
When fire is discovered:
• Activate the nearest fire alarm (if installed)
• Notify the local Fire Department by calling
• If the fire alarm is not available, notify the site personnel about the fire emergency
by the following means (check applicable):
Voice Communication
Phone Paging
Radio
Other (specify)
Fight the fire ONLY if:
• The Fire Department has been notified
• The fire is small and is not spreading to other areas
• Escaping the area is possible by backing up to the nearest exit
• The fire extinguisher is in working condition and personnel are trained to use it
Upon being notified about the fire emergency, occupants must:
• Leave the building using the designated escape routes
• Assemble in the designated area (specify location):
• Remain outside until the competent authority (designated official or designee)
announces that it is safe to reenter.
Designated official, emergency coordinator or supervisors must (underline one):
• Disconnect utilities and equipment unless doing so jeopardizes his/her safety
• Coordinate an orderly evacuation of personnel
• Perform an accurate head count of personnel reported to the designated area
• Determine a rescue method to locate missing personnel
• Provide the Fire Department personnel with the necessary information about the
facility
• Perform assessment and coordinate weather forecast office emergency closing
procedures
Area/Floor Monitors must:
• Ensure that all employees have evacuated the area/floor
• Report any problems to the emergency coordinator at the assembly area
Assistants to physically challenged should:
• Assist all physically challenged employees in emergency evacuation.
Date: _______/_______/_______
01/2015
57
General Information Appendix I
EXTENDED POWER LOSS
In the event of extended power loss to a facility certain precautionary measures
should be taken depending on the geographical location and environment of the
facility:
• Unnecessary electrical equipment and appliances should be turned off in the
event that power restoration would surge causing damage to electronics and
affecting sensitive equipment
• Facilities with freezing temperatures should turn off and drain the following lines
in the event of a long term power loss
o Fire sprinkler system
o Standpipes
o Potable water lines
o Toilets
• Add propylene-glycol to drains to prevent traps from freezing
• Equipment that contain fluids that may freeze due to long term exposure to
freezing temperatures should be moved to heated areas, drained of liquids,
or provided with auxiliary heat sources
Upon restoration of heat and power:
• Electronic equipment should be brought up to ambient temperatures before
energizing to prevent condensate from forming on circuitry
• Fire and potable water piping should be checked for leaks from freeze damage
after the heat has been restored to the facility and water turned back on
Date: _______/_______/_______
01/2015
58
General Information Appendix I
CHEMICAL SPILL
The following are the locations of:
Spill Containment and Security Equipment: ________________________________
Personal Protective Equipment (PPE): _____________________________________
Safety Data Sheets (SDS): ________________________________________________
When a large chemical spill has occurred:
• Immediately notify the designated official and emergency coordinator
• Contain the spill with available equipment (e.g., pads, booms, absorbent powder,
etc.)
• Secure the area and alert other site personnel
• Do not attempt to clean the spill unless trained to do so
• Attend to injured personnel and call the medical emergency number, if required
• Call a local spill cleanup company or the Fire Department (if arrangement has
been made) to perform a large chemical (e.g., mercury) spill cleanup
Name of Spill Cleanup Company: _______________________________________
Phone Number: ________________________________________________________
• Evacuate building as necessary
When a small chemical spill has occurred:
• Notify the emergency coordinator and/or supervisor (select one)
• If toxic fumes are present, secure the area (with caution tapes or cones) to
prevent other personnel from entering
• Deal with the spill in accordance with the instructions described in the SDS
• Small spills must be handled in a safe manner, while wearing the proper PPE
• Review the general spill cleanup procedures
Date: _______/_______/_______
01/2015
59
General Information Appendix I
STRUCTURE CLIMBING/DESCENDING EMERGENCIES
List structures maintained by site personnel (tower, river gauge, etc.):
No.
Structure Type Location (address, if
applicable)
Emergency Response
Organization* (if available
within 30-minute
response time)
Name: ________________________________ Phone: ( ________ ) ________________
Name: ________________________________ Phone: ( ________ ) ________________
(Attach Emergency Response Agreement if available)
* N/A. If no Emergency Response Organization available within 30-minute
response time, additional personnel trained in rescue operations and equipped
with rescue kit must accompany the climber(s).
01/2015
60
General Information Appendix I
TELEPHONE BOMB THREAT CHECKLIST
INSTRUCTIONS: BE CALM, BE COURTEOUS. LISTEN. DO NOT INTERRUPT
THE CALLER.
YOUR NAME: _________________________________________________________________
TIME: _________________________________ DATE:_________________________________
CALLER’S IDENTITY SEX: Male ____ Female____ Adult ___ Juvenile ___ APPROX. AGE: ___
ORIGIN OF CALL:
Local ____ Long Distance ____ Telephone Booth ____
VOICE CHARACTERISTICS
/RXG
+LJK3LWFK
5DVS\
,QWR[LFDWHG
6RIW
'HHS
3OHDVDQW
2WKHU
5DFH
1RW/RFDO
5HJLRQ
MANNER
&DOP
5DWLRQDO
&RKHUHQW
'HOLEHUDWH
5LJKWHRXV
$QJU\
,UUDWLRQDO
,QFRKHUHQW
(PRWLRQDO
/DXJKLQJ
SPEECH
)DVW
'LVWLQFW
6WXWWHU
6OXUUHG
6ORZ
'LVWRUWHG
1DVDO
2WKHU
BACKGROUND NOISES
)DFWRU\
0DFKLQHV
0XVLF
2IILFH
0DFKLQHV
6WUHHW
7UDIILF
7UDLQV
LANGUAGE
([FHOOHQW
)DLU
)RXO
*RRG
3RRU
2WKHU
ACCENT
/RFDO
)RUHLJQ
01/2015
61
$QLPDOV
4XLHW
9RLFHV
$LUSODQHV
3DUW\
$WPRVSKHUH
General Information Appendix I
BOMB FACTS
• Pretend to have difficulty hearing.
• Keep the caller talking.
• If the caller seems agreeable to further conversation, ask questions like:
o
When will it go off? Certain Hour ______ Time Remaining_______________________
o
Where is it located? Building _______________________________________________
Area _________________________________________________________________
o
What kind of bomb? _______________________________________________________
o
What kind of package? ____________________________________________________
o
How do you know so much about the bomb? _________________________________
o
What is your name and address? ___________________________________________
• If building is occupied, inform caller that detonation could cause injury or death.
• Call Security at _____________________________ and relay information about call.
• Did the caller appear familiar with plant or building (by his/her description of the bomb
location)?
• Write out the message in its entirety and any other comments on a separate sheet
of paper and attach to this checklist.
• Notify your supervisor immediately.
01/2015
62
General Information Appendix I
SEVERE WEATHER AND NATURAL DISASTERS
Tornado
• When a warning is issued by sirens or other means, seek inside shelter.
Consider the following:
o Small interior rooms on the lowest floor and without windows
o Hallways on the lowest floor away from doors and windows
o Rooms constructed with reinforced concrete, brick, or block with no windows
• Stay away from outside walls and windows
• Use arms to protect head and neck
• Remain sheltered until the tornado threat is announced to be over
Earthquake
• Stay calm and await instructions from the emergency coordinator or the designated
official
• Keep away from overhead fixtures, windows, filing cabinets, and electrical power.
• Assist people with disabilities in finding a safe place.
• Evacuate as instructed by the emergency coordinator and/or the designated official.
Flood
If indoors:
• Be ready to evacuate as directed by the emergency coordinator and/or the designated
official.
• Follow the recommended primary or secondary evacuation routes.
If outdoors:
• Climb to high ground and stay there.
• Avoid walking or driving through flood water.
• If car stalls, abandon it immediately and climb to a higher ground.
Hurricane
• The nature of a hurricane provides for more warning than other natural and weather
disasters. A hurricane watch issued when a hurricane becomes a threat to a coastal
area. A hurricane warning is issued when hurricane winds of 74 mph or higher, or a
combination of dangerously high water and rough seas, are expected in the area within
24 hours.
Once a hurricane watch has been issued:
•
•
•
•
Stay calm and await instructions from the emergency coordinator or the designated official.
Moor any boats securely, or move to a safe place if time allows.
Continue to monitor local TV and radio stations for instructions.
Move early out of low-lying areas or from the coast, at the request of officials.
01/2015
63
General Information Appendix I
• If you are on high ground, away from the coast and plan to stay, secure the building,
moving all loose items indoors and boarding up windows and openings.
• Collect drinking water in appropriate containers.
Once a hurricane warning has been issued:
• Be ready to evacuate as directed by the emergency coordinator and/or the designated
official.
• Leave areas that might be affected by storm tide or stream flooding.
During a hurricane:
• Remain indoors and consider the following:
o Small interior rooms on the lowest floor and without windows,
o Hallways on the lowest floor away from doors and windows, and
o Rooms constructed with reinforced concrete, brick, or block with no windows.
Blizzard
If indoors:
• Stay calm and await instructions from the emergency coordinator or the designated official.
• Stay indoors!
• If there is no heat:
o Close off unneeded rooms or areas.
o Stuff towels or rags in cracks under doors.
o Cover windows at night.
• Eat and drink. Food provides the body with energy and heat. Fluids prevent dehydration.
• Wear layers of loose-fitting, light-weight, warm clothing, if available.
If outdoors:
• Find a dry shelter. Cover all exposed parts of the body.
• If shelter is not available:
o Prepare a lean-to, wind break, or snow cave for protection from the wind.
o Build a fire for heat and to attract attention. Place rocks around the fire to absorb and
reflect heat.
o Do not eat snow. It will lower your body temperature. Melt it first.
If stranded in a car or truck:
• Stay in the vehicle!
• Run the motor about ten minutes each hour. Open the windows a little for fresh air to
avoid carbon monoxide poisoning. Make sure the exhaust pipe is not blocked.
• Make yourself visible to rescuers.
o Turn on the dome light at night when running the engine.
o Tie a colored cloth to your antenna or door.
o Raise the hood after the snow stops falling.
• Exercise to keep blood circulating and to keep warm.
01/2015
64
General Information Appendix I
CRITICAL OPERATIONS
During some emergency situations, it will be necessary for some specially assigned
personnel to remain at the work areas to perform critical operations.
Assignments:
Work Area
Name
Job Title
Description of
Assignment
• Personnel involved in critical operations may remain on the site upon the
permission of the site designated official or emergency coordinator.
• In case emergency situation will not permit any of the personnel to remain at
the facility, the designated official or other assigned personnel shall notify the
appropriate _____________________ offices to initiate backups. This information
can be obtained from the Emergency Evacuation Procedures included in the
______________________________ Manual.
The following offices should be contacted:
Name/Location: _____________________________________________________________
Telephone Number: _________________________________________________________
Name/Location: _____________________________________________________________
Telephone Number: _________________________________________________________
Name/Location: _____________________________________________________________
Telephone Number: _________________________________________________________
01/2015
65
General Information Appendix I
TRAINING
The following personnel have been trained to ensure a safe and orderly emergency
evacuation of other employees:
Facility:
Name
01/2015
Title
Responsibility
66
Date
General Information Appendix I
General Policy
Austin Community College, Department of Dental Hygiene (known as ACC-DH) is committed to
providing a safe and healthful workplace for all employees through compliance with applicable
OSHA standards.
This written exposure control plan has been developed to comply with OSHA’s Bloodborne
Pathogens Standard. The standard is designed to protect employees from occupational
exposure to HIV, HBV and other bloodborne pathogens.
The exposure control plan is accessible to all employees and will be reviewed at least annually
and updated as often as changes in positions, tasks or procedures require.
The exposure control plan is filed under the tab marked “Exposure control plan” in the
Bloodborne Pathogens section of the ACC-DH Regulatory Compliance Manual. The manual
is kept: in the computer study area of the Dental Hygiene Clinic, Room #8142, Eastview
Campus.
Kate Goin, RDH, Clinic Manager has been designated the OSHA compliance manager for this
office and is responsible for implementing the exposure control plan. The compliance manager
will provide employees with a copy of the plan upon request.
Exposure Determination
The Bloodborne Pathogens Standard describes how to determine which employees have
occupational exposure to bloodborne pathogens. The standard defines occupational
exposure as reasonably anticipated skin, eye, mucous membrane, or parenteral contact
with blood or other potentially infectious materials that may result from the performance of an
employee’s duties. Other potentially infectious materials defined in the standard include
saliva in dental procedures and unfixed tissue. Occupational exposure must be determined
without regard to the use of personal protective equipment.
The standard requires each employer who has one or more employees with occupational
exposure to prepare an exposure determination that includes the following:
• A list of job classifications in which all employees in the job classification have occupational
exposure.
“Dentist,” “dental hygienist,” and “dental assistant” are examples of job classifications that would
typically be on this list. All employees with these jobs probably have occupational exposure.
It is not necessary to list the specific tasks and procedures that give rise to the exposure.
• A list of job classifications in which some employees in the job classification have occupational
exposure. For each job classification on this list the employer must list the tasks and
procedures that give rise to the occupational exposure.
01/2008
1
Bloodborne Pathogens
An example of a job classification on this list might be “receptionist.” Receptionists in some
offices have chairside or cleanup duties involving occupational exposure to blood or other
potentially infectious materials. If some receptionists in your office have occupational exposure,
(e.g., have chairside duties) the job classification belongs on the second list with a list of tasks
and procedures that give rise to the exposure, e.g., “dental assisting procedures.”
If all receptionists in your office have occupational exposure, the job classification belongs
on the first list. If no receptionist in your office has occupational exposure, the job
classification does not need to be listed.
You do not need to list the names of the individuals in these job classifications, but if you
choose to do so, remember to update the exposure determination whenever the names
change. Treat the dentist as an employee of an incorporated practice.
The following exposure determination has been prepared for this office:
All employees in the following job classifications have occupational exposure (write
“none,” if none):
Job Classification
Name (optional)
Dentists
Faculty
Dental Hygienists
Faculty
Dental Hygiene Students
Students
Dental Assisting Students
Students
Advanced Degree/Independent Study Students
Students
Some employees in the following job classifications have occupational exposure, and
the tasks/procedures that give rise to the exposure are listed (write “none,” if none):
Job Classification
Name (optional)
Task or Procedure
none
01/2008
2
Bloodborne Pathogens
Schedule and Methods of Implementation
The exposure control plan must include the schedule and methods for implementing each
section of the standard. The information that follows complies with this requirement.
DATES
This office implemented all sections of the Bloodborne Pathogens Standard by the dates
shown below:
Provision
Implemented by
Standard precautions
09/01/03
Exposure control plan
09/01/03
Information and training
09/01/03
Recordkeeping
09/01/03
Engineering/work practice controls
09/01/03
Personal protective equipment
09/01/03
Housekeeping
09/01/03
HBV vaccination/post-exposure evaluation and
follow-up procedures
09/01/03
Labels and signs
09/01/03
Standard Precautions
The OSHA Bloodborne Pathogens Standard adopted an approach to infection control called
universal precautions that treats all human blood and other potentially infectious materials as if
they were infectious for HIV and HBV or other bloodborne pathogens. The CDC1 recommends
implementation of standard precautions, which expands coverage to include all body
fluids and substances (except sweat). No operational difference exists in clinical dental
practice when implementing universal or standard precautions, because saliva has always
been considered a potentially infectious material in dental infection control.
Engineering controls isolate or remove a hazard from the workplace. Examples of
engineering controls that might be used in a dental office are sharps containers, rubber dams,
needleless or shielded needle devices, and high volume evacuators.
1
Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings –
2003 MMWR 2003;52(No.RR-17).
01/2008
3
Bloodborne Pathogens
NEW ENGINEERING CONTROLS EVALUATION RECORD
In this office, the following engineering controls have been evaluated and/or implemented for
appropriate usage in a dental setting:
Engineering Control
Sharps containers
Date Evaluated
Person Evaluated
05/20/2015
Results of
Evaluation (i.e.
implemented or not
appropriate)
K. Goin
Implemented
High volume evacuation 01/05/2015
K. Goin/R. Cornett
Implemented
Rubber dams
S. Pearce
Implemented
K. Goin
Implemented
09/01/2011
Dedicated housekeeping
01/05/2015
procedures
Input has been solicited from non-managerial employees responsible for direct patient care in
the identification, evaluation and selection of effective engineering and work practice controls,
using the following processes:
Weekly faculty meetings; clinical testing
The following non-managerial employees were involved in this process, by name and/or
position:
Departmental faculty
The following process was used to consider safer needle devices and, where necessary, to
implement them:
Changes in instrument cassettes to design with syringe cap holders
Input for the above process was sought from the following non-managerial employees:
Departmental faculty
Engineering controls must be examined routinely and maintained or replaced as needed to
ensure their effectiveness (e.g., inspecting sharps containers daily to make sure they are not
overfilled.)
01/2008
4
Bloodborne Pathogens
CURRENT ENGINEERING CONTROLS MAINTENANCE SCHEDULE
In this office, engineering controls are inspected and maintained or replaced as follows:
Engineering Control
Inspection/Maintenance
Schedule
Who is responsible
Sharps containers
Daily
Clinic Manager
Housekeeping
Daily
Clinic Manager
High volume suction
Annually
Clinic Manager
HANDWASHING
Handwashing facilities are readily accessible to employees in the following locations:
operatories, darkroom, sterilization room, dental laboratory, and restrooms.
• Employees and students must wash their hands immediately or as soon as feasible after
removing gloves or other personal protective equipment.
• Employees and students must wash their hands and any other skin with soap and water, and
flush mucous membranes (eyes, nose, mouth) with water immediately or as soon as
possible after contact with blood or other potentially infectious materials.
• Employees and students will be provided with antiseptic hand cleaner and towels if
handwashing facilities are not feasible.
HANDLING CONTAMINATED NEEDLES AND OTHER SHARPS
The standard defines contaminated sharps to mean any contaminated object that can
penetrate the skin including, but not limited to needles, scalpels, broken glass, broken capillary
tubes, and exposed ends of dental wires.
Contaminated sharps are handled as follows to minimize employee exposure:
• In general, contaminated sharps must not be bent, recapped or removed.
• Recapping/removal is permitted for the procedures listed below because there is no
feasible alternative or recapping/removal is required by the specific dental procedure
(e.g., administering multiple doses of an anesthetic to the same patient).
• In cases where recapping/removal of contaminated sharps is permitted, employees
must use a mechanical device or one-handed technique.
01/2008
5
Bloodborne Pathogens
In this office, recapping/removal of contaminated sharps is only permitted for the following
procedures using the mechanical device or one-handed technique indicated:
Procedure
Device or technique
Administering multiple doses of anesthetic to the
One-handed technique
same patient
• Recapping is also permitted in the following circumstances because it is not feasible to
immediately discard the used needles into a sharps container. (NOTE: used sharps must
always be discarded in an appropriate sharps container if it is feasible to do so).
Circumstances: N/A
• Shearing or breaking of contaminated sharps is never permitted.
Immediately or as soon as possible after use, contaminated reusable sharps (such as scaler
or explorer) must be placed in appropriate containers until they are processed. Containers
provided for this purpose are puncture resistant, marked with the biohazard label or colorcoded red, leakproof on the sides and bottom and handled in a manner that does not require
employees to reach by hand into the containers.
Below is a brief description of the procedures used in this office to ensure that employees do
not reach by hand into containers of contaminated, reusable sharps: The instruments are
placed in cassettes or strainer-type baskets for soaking. The cassettes are then transferred
into the Miele disinfector for decontamination. Contents in strainer-type baskets are removed
with forceps and/or the container is turned on its side and the contents are carefully emptied
onto a towel on the countertop.
EATING AND DRINKING
• Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses is
prohibited in the following work areas where there is a reasonable likelihood of occupational
exposure:
Dental operatories, sterilization room, and darkroom
• Food and drink may not be stored in refrigerators, freezers, shelves, cabinets or on
countertops or benchtops where blood or other potentially infectious materials are present.
In this office, food and drink may be stored in the following locations:
Dental hygiene conference room #8145.1
01/2008
7
Bloodborne Pathogens
TECHNIQUES TO MINIMIZE SPLASHING AND SPRAYING
• Procedures involving blood or other potentially infectious materials are performed in a
manner to minimize splashing, spraying, spattering and generating droplets of these
substances. Methods that may be used to accomplish this goal include:
high volume evacuation, use of the dental dam
SPECIMENS
Check the one that applies:
No specimens of blood or other potentially infectious materials are handled in this office.
Specimens of blood or other potentially infectious materials are handled in this office as
follows:
• Specimens are placed in a container that prevents leakage during collection, handling,
processing, storing, transporting, or shipping.
• Containers provided for this purpose are marked with the biohazard label or colorcoded
red and are closed before they are stored, transported, or shipped.
• If outside contamination of the primary container occurs, it must be placed inside a
secondary container that prevents leakage. Any specimen that could puncture the
primary container must be placed in a secondary container that is puncture resistant.
The secondary container must also be marked with the biohazard label or be colorcoded red.
CONTAMINATED EQUIPMENT
• Equipment that becomes contaminated with blood or other potentially infectious materials
must be examined before servicing or shipping and decontaminated as necessary, unless
decontamination is not feasible.
• Equipment that cannot be completely decontaminated before servicing or shipping must be
marked with a biohazard label that states which parts are still contaminated. This information
must be conveyed to employees, service people, and others who handle the contaminated
equipment.
01/2008
7
Bloodborne Pathogens
Personal Protective Equipment (PPE)
The standard defines personal protective equipment (PPE) as specialized clothing or
equipment worn by an employee to protect against a hazard. General work clothes that are not
intended to function as protection against a hazard are not regarded as PPE.
• Employees and students are provided with appropriate PPE at no cost to them. Examples of
PPE that might be used in a dental office are gloves; gowns; laboratory coats or clinical
jackets; face shields or masks and eye protection; and resuscitation bags and mouthpieces.
• The specific PPE used will depend on the task and degree of exposure anticipated. In general,
PPE is appropriate if it prevents blood or other potentially infectious materials from passing
through or reaching employees’ undergarments, clothing, skin, eyes, mouth, or other mucous
membranes under normal conditions of use.
USE OF PPE
• Employees and students must use appropriate PPE whenever there is occupational
exposure. This is an OSHA requirement.
• The only exception is in rare and extraordinary circumstances where, in the employee’s or
student’s judgment, using the PPE would: 1) expose the employee or student to greater
hazard or 2) prevent the employee or student from delivering patient care.
• Generally, this exception would only apply in cases of extreme emergency. When an
employee or student makes this judgment, the circumstances will be investigated and
documented to determine whether changes can be made to prevent such occurrences in
the future.
GLOVES
• Gloves must be worn whenever hand contact with blood or other potentially infectious
materials, mucous membranes, or nonintact skin can reasonably be anticipated. Gloves
must also be worn when touching contaminated items or surfaces.
• Disposable (single-use) gloves, such as surgical or examination gloves, must be replaced
as soon as practical when they become contaminated (e.g., between patients) or as soon as
feasible if they are torn or punctured or their ability to function as a barrier is compromised.
• Disposable (single-use) gloves should never be reused.
• Utility gloves may be decontaminated for reuse as long as the integrity of the gloves is not
compromised. However, they must be discarded if they become cracked or torn or show any
other sign that their ability to function as a barrier is compromised.
MASKS, PROTECTIVE EYEWEAR AND FACE SHIELDS
• A surgical mask that covers the nose and mouth in combination with protective eyewear
(such as goggles or glasses with solid side shields) must be worn whenever splashes, spray,
spatter, or droplets of blood or other potentially infectious materials may be generated and
eye, nose, or mouth contamination can reasonably be anticipated. When using a face shield,
a mask should also be worn.
01/2008
8
Bloodborne Pathogens
GOWNS AND OTHER PROTECTIVE CLOTHING
• Gowns, lab coats, clinic jackets, or some other form of protective clothing must be worn
whenever the employee’s or student’s skin, street clothing or underwear is subject to
occupational exposure. The fabric and style selected depend on the task and degree of
exposure anticipated. OSHA considers the standard cotton, cotton/poly clinic jacket, or
lab coat to be appropriate for most routine dental procedures. An ordinary shirt or blouse
may also be appropriate, depending on the task and degree of exposure anticipated.
Additional personal protective clothing, such as surgical caps or boots, may be required
when gross contamination can reasonably be anticipated.
In this office, employees and students must use the PPE indicated when performing the
following tasks and procedures:
Task/Procedure
Type of PPE Required
Decontaminating equipment/surfaces
Overgown, gloves, mask, protective eyewear
Providing routine patient care
Overgown, gloves, mask, protective eyewear
Providing advanced patient care (i.e., ultrasonic Overgown, gloves, mask, protective eyewear,
scaling, air abrasive polishing)
bonnet
Transporting contaminated items
Gloves
Processing contaminated items
Overgown, gloves, mask, protective eyewear
Employees should contact: Clinic Manager or Department Chair
if additional PPE is required by unusual circumstances involving large quantities of blood or
other potentially infectious materials.
ACCESSIBILITY
• PPE in appropriate sizes is made readily available in the following locations:
Type of PPE
Location
Gloves
Operatories, darkroom, sterilization room,
laboratory
Overgowns
Operatories, sterilization room
Masks
Operatories, sterilization room
Protective eyewear
Operatories, sterilization room, laboratory
Bonnets
Operatories
• Glove liners, powderless gloves, or other similar alternatives will be made readily available to
employees who are allergic to the gloves normally provided.
01/2008
9
Bloodborne Pathogens
CLEANING, DISPOSAL, REPAIR AND REPLACEMENT
• PPE will be cleaned, laundered, repaired, replaced and disposed of at no cost to employees or
students.
• PPE must be removed immediately or as soon as feasible after blood or other potentially
infectious materials penetrate it.
• All PPE must be removed before employees or students leave the work area.
• After PPE is removed, it must be placed in the designated area or container for storage,
washing, decontamination, or disposal. The following areas/containers have been designated
in this office for PPE after it is removed:
Type of PPE
Area/Container
Overgowns
Operatories, sterilization room trash receptacles
Masks
Operatories, sterilization room trash receptacles
Gloves
Operatories, sterilization room trash receptacles
Bonnets
Operatories, sterilization room trash receptacles
Protective eyewear
After decontamination, in operatory cabinet
Face shield
After decontamination, in computer study area
LAUNDRY
The standard defines contaminated laundry as laundry that has become soiled with blood or
other potentially infectious materials or may contain sharps. OSHA interprets the standard as
prohibiting employees or students from taking contaminated laundry home to clean. However,
employees and students are permitted to take uniforms or clothing they wear under PPE
home to clean, as long as clothing has not become contaminated.
The following work rules apply in this office to contaminated laundry:
• Handle as little as possible
• Remove where used and place in the bag or container provided
• Store or transport in bags/containers that are marked with the biohazard label or color-coded red
• Never sort or rinse laundry where it is used
• Handle laundry with gloves, overgown, mask, and protective eyewear
In this office, contaminated laundry is cleaned in the following manner:
Washer and dryer on-site, according to manufacturer’s recommendations for the garment
01/2008
11
Bloodborne Pathogens
Housekeeping
The following work rules apply in this office to housekeeping tasks:
• All equipment and environmental and work surfaces must be cleaned and decontaminated
after contact with blood or other potentially infectious materials.
• Contaminated work surfaces must be decontaminated with an appropriate disinfectant after
completion of procedures, immediately or as soon as feasible when surfaces are overtly
contaminated or after any spill of blood or other potentially infectious materials, and at the
end of the workday if the surface may have become contaminated since the last cleaning.
• Contaminated work surfaces should be cleaned with appropriate disinfectants. Appropriate
disinfectants include a diluted bleach solution and EPA-registered tuberculocides, sterilants
or products registered against HIV/HBV. Lists of these EPA-registered products are available
from the EPA website at www.epa.gov/opppmsd1/PPISdata/index.html
• If they are used, protective coverings such as plastic wrap, aluminum foil, or imperviously
backed absorbent paper must be removed and replaced whenever they become overtly
contaminated and at the end of the workday.
• All bins, pails, cans and similar receptacles intended for reuse that have a reasonable
likelihood for becoming contaminated with blood or other potentially infectious materials
must be inspected and decontaminated on a regular basis and cleaned and decontaminated
immediately or as soon as feasible upon visible contamination.
• Spills of blood or other potentially infectious materials must be wiped up immediately
or as soon as feasible, and the area decontaminated using an appropriate disinfectant.
See Appendix C for specific sterilization/disinfection information.
• Employees and students must wear utility gloves when cleaning contaminated equipment and
surfaces.
• Employees and students must use mechanical means (e.g., brush and dustpan or
forceps) to pick up broken glassware that may be contaminated. Broken contaminated
glassware may never be picked up by hand, even if gloves are used.
The dental setting is cleaned and decontaminated according to the following schedule:
Area or Receptacle
Schedule (e.g., between
patients, daily)
Method and Cleaning
Solution/Disinfectant Used
Operatories
Between patients
Wipe-discard-wipe with Birex
Sterilization Room
Daily
Wipe-discard-wipe with Birex
Darkroom and Laboratory
As needed
Wipe-discard-wipe with Birex
Operatory and Sterilization
trash receptacles
Twice daily
Biohazard trash
As needed
Emptied by janitorial staff and
disinfected as required with Birex
Disposed of in biohazard room in
building 8000
Use of disinfectant and dedicated
cleaning equipment
Floors – Clinic and Sterilization Daily
01/2008
11
Bloodborne Pathogens
Regulated Waste
The Standard defines regulated waste as:
• Liquid or semi-liquid blood or other potentially infectious materials
• Contaminated items that would release blood or other potentially infectious materials in a
liquid or semi-liquid state if compressed
• Items that are caked with dried blood or other potentially infectious materials and are capable
of releasing these materials during handling
• Contaminated sharps (including dental wires)
• Pathological and microbiological wastes containing blood or other potentially infectious
materials (including extracted teeth)
CONTAMINATED DISPOSABLE SHARPS
Immediately, or as soon as feasible after use, contaminated sharps must be disposed of in
sharps containers. Containers provided for this purpose are closable, puncture resistant,
leakproof on the sides and bottom and marked with the biohazard label or color-coded red.
Sharps containers are located as close as feasible to the immediate area of use, which in the
office is: in each operatory and the sterilization room.
Containers for contaminated sharps must be kept upright while in use. They must be replaced
routinely to prevent overfilling. If the sharps container has an unwinder to separate needles
from reusable syringes, the device must be used in a safe, one-handed manner.
Containers of contaminated sharps must be closed before they are moved to prevent spills.
If leakage is possible, the first container must be placed in a second container with the same
characteristics as the first. Reusable sharps containers may not be opened, emptied, or cleaned
manually or in any other manner that would expose employees to the risk of percutaneous injury.
OTHER REGULATED WASTE
Other regulated waste must be placed in containers that are:
• Closable
• Constructed to contain all contents and prevent leakage of fluids during handling, storage,
transport, or shipping
• Marked with the biohazard label or color-coded red
• Closed before removal to prevent the contents from spilling or protruding from the container
during handling, storage, transport, or shipping. If outside contamination of the regulated
waste container occurs, the container must be placed in a second container with the same
characteristics as the first.
01/2008
12
Bloodborne Pathogens
Containers for other regulated waste in this office are located:
in the sterilization room.
All regulated waste is disposed of according to applicable local, state and federal laws. OSHA
does not require waste to be labeled after it is decontaminated. However, state and local waste
laws may have different requirements.
NOTE: This standard does not prohibit giving an extracted tooth to the patient, but the tooth
should be handled with precautions.
Hepatitis B Vaccination
Hepatitis B vaccination will be provided free of charge to all employees identified as having
occupational exposure, unless:
• The employee previously received and responded to the complete vaccination series
• Testing reveals the employee is already immune
• The vaccine is contraindicated for medical reasons
• The employee chose not to be vaccinated
No employee will be required to participate in a prescreening program as a condition of
receiving hepatitis B vaccination.
An employee is entitled to refuse vaccination, but the employee must sign a form
declining vaccination using the exact language in OSHA’s Appendix A of the Bloodborne
Pathogens Standard. This is an OSHA requirement. A blank declination form is found under
“Recordkeeping” in the Bloodborne Pathogens section of the manual. An employee who initially
declines to be vaccinated may elect to be vaccinated later at no cost to the employee.
The first dose of vaccine will be administered within 10 working days of the employee’s
assignment to a job involving occupational exposure. Before the vaccine is made available, the
employee will receive training about the efficacy, safety, method of administration and benefits
of vaccination. The employee will also be told that vaccination is provided free of charge.
The licensed healthcare professional selected to administer the vaccine will be provided
with a copy of the Bloodborne Pathogens Standard. The employer will obtain from the
healthcare professional within 15 days after the evaluation is completed a written opinion
stating: 1) whether Hepatitis B vaccination was indicated for the employee and 2) whether
the vaccine was administered. The employee will be given a copy of the opinion and the
original will be kept in the employee’s confidential medical record. 3) Post vaccination
testing for antibody to HBV surface antigen response is indicated. Knowledge of antibody
response aids in determining appropriate exposure prophylaxis.
Employers are not currently required to make available routine booster doses of hepatitis B
vaccine. If in the future the U.S. Public Health Service recommends this service, the employer
will provide it at no cost to employees.
Students enroll in the program meeting vaccination requirements.
01/2008
13
Bloodborne Pathogens
Postexposure Evaluation and Follow-Up
The standard defines an exposure incident as a specific eye, mouth, or other mucous
membrane, non-intact skin or parenteral contact with blood or other potentially infectious
materials that results from performance of an employee’s duties.
Any employee or student who suffers an exposure incident must immediately report the
incident to: the Clinic Coordinator on duty and/or the Department Chair.
Employees or students who experience an exposure incident will be offered postexposure
evaluation and follow-up at no cost to the employee or student, as follows:
• A report of the incident will be made documenting the route of exposure and circumstances
in which the exposure occurred. The report should be sufficiently detailed to permit review
of the exposure incident, including information about the engineering controls in use at the
time, work practice controls followed, a description of any devices involved in the exposure
e.g., syringe), PPE in use at the time, where the exposure occurred, the procedure being
performed and any relevant information about the exposed employee’s or student’s training.
The source patient will be identified, if possible. The report will note if the source patient is
unknown or if it would be a violation of state or local law to disclose the source patient’s
identity.
• The employer will attempt to have source patient’s blood tested as soon as feasible to
determine HBV, HCV, and HIV infectivity. The employer will determine if the source patient’s
consent to testing is required by law. If consent is required and cannot be obtained, the
employer will document that fact in the incident report. If consent is not required and the
source patient’s blood is available, it will be tested. Testing is not required if the source
patient is known to be infected.
• Results of the source patient’s blood tests will be made available to the exposed employee
or student, if the patient consents to disclosure or if the law permits disclosure without the
patient’s consent. The exposed employee or student will be notified of any applicable law
governing further disclosure of the test results.
• The employee’s or student’s blood will be collected, with the employee’s or student’s consent, for
baseline testing for HBV, HCV and HIV. If the employee or student consents to have blood
collected but not tested, the blood will be kept for 90 days after the exposure incident to allow the
employee or student to change his or her mind.
• The exposed employee or student will be offered any medically indicated prophylaxis
recommended by the U.S. Public Health Service. Counseling and evaluation of any reported
illness will also be provided. See the “HBV vaccination/post-exposure procedures” in this
section and Appendix D for further information.
• The licensed healthcare professional who provides post-exposure evaluation and follow-up
services will be given a copy of the Bloodborne Pathogens Standard, a description of the exposed
employee’s or student’s relevant job duties, a copy of the incident report, results of the
source patient’s blood testing (if available) and any relevant medical records in the
employer’s possession.
01/2008
14
Bloodborne Pathogens
• The employer will obtain from the healthcare professional within 15 days after the evaluation
is completed a written opinion stating that the employee or student has been informed of the
results of the evaluation and any medical conditions that may require further evaluation and
treatment. The employee or student will be given a copy of the opinion, and the original will
be kept in the employee’s or student’s confidential medical record.
• The circumstances of the exposure incident will be reviewed to determine if procedures,
protocols, and/or training need to be revised to prevent the incident from happening again.
Labels
In this office, potentially biohazardous materials are color-coded red or identified with the
following biohazard symbol and the word “biohazard” in contrasting color on a fluorescent
orange or orange-red label:
BIOHAZARD SYMBOL
Medical Records
A confidential medical record is maintained for each employee or student with occupational
exposure. The medical record includes:
• The employee’s or student’s name and social security number
• A copy of the employee’s or student’s hepatitis B immunization status and any of the
following that apply:
o Exposure incident report
o Written opinion of health care professional
o Form refusing hepatitis B vaccination
o Form refusing postexposure evaluation and follow-up (not required by OSHA, but highly
recommended)
Employee and student medical records for this office are maintained: in the Department
Chair’s office, Room 8155 and in the office of the Executive Dean of Health Sciences in
building 8000, Eastview Campus, Austin Community College
01/2008
15
Bloodborne Pathogens
Employee and student medical records are kept confidential and will not be disclosed without
the employee’s or student’s consent or as required by law.
Employee and student medical records are retained for the length of employment plus 30
years. Medical records of employees or students who have worked for less than one year
need not be retained beyond the term of employment or student’s enrollment in the program if
the records are provided to the employee or student upon termination of employment or
withdrawal from the dental hygiene program. Employees or students should contact: the
Dental Hygiene Department Chair to inspect their medical records or to obtain a copy.
OSHA standard 1910.1020 gives employees the right of access to their own medical and
exposure records. For further information, see the copy of standard 1910.1020 located under
the “Appendices” tab in the section of the manual entitled “General Information for the DentistEmployer.” To ensure that you are reviewing the most current version of the standard, check
OSHA’s website, www.osha.gov.
Training
All employees and students will be provided with initial training before they begin work involving
occupational exposure. Thereafter, refresher training will be provided at least annually and
whenever changes in tasks or procedures require. Someone who is familiar with the standard
will provide training during work hours at no cost to the employee or student as it relates to the
dental office. Employees and students will have the opportunity for interactive questions and
answers with the person conducting the training. Initial training will cover:
• An explanation of the Bloodborne Pathogens Standard and where a copy of the standard is
filed (e.g., in the Bloodborne Pathogens section of the Manual)
• General information about the epidemiology and symptoms of bloodborne diseases
• Modes of transmission of bloodborne pathogens
• An explanation of this office’s exposure control plan and how to obtain a copy
• How to recognize tasks involving occupational exposure
• The use and limits of engineering controls, work practice controls and personal protective
equipment
• Where PPE is located and how to use, remove, handle, decontaminate, and dispose of it
• How to select appropriate PPE
• The effectiveness, safety, benefits, and method of administering hepatitis B vaccine and that
vaccination will be provided free of charge
• What to do if there is an emergency spill of blood or other potentially infectious material
• What to do if an exposure incident occurs
01/2008
16
Bloodborne Pathogens
• Postexposure evaluation and follow-up that will be made available to employees or
students in case of an exposure incident
• The system of labels and color-coding used in this office to warn employees of biohazards
• An opportunity for interactive questions and answers
Refresher training will cover the same subjects, to the extent needed, and will emphasize
new information and procedures, including but not limited to training in the effective use of
engineering controls in this office.
A model initial training program for employees and students is provided under “Training” in the
Bloodborne Pathogens section of the Manual.
The employer will maintain a record of all training sessions. The training record will include:
• Date of training
• Contents of training (a summary or list of subjects is sufficient)
• Name and qualification of trainer
• Name and job title of each person attending
Training records for this office are kept: in the office of the OSHA compliance manager.
Training records are retained for 3 years following the training session. Employees may inspect
training records or obtain a copy by contacting: the OSHA compliance manager.
If this dental hygiene program is transferred, employee and student records will be
transferred to the new institution. If the practice is closed, employee and student records
will be offered to the National Institute for Occupational Safety and Health (NIOSH).
Any employee or student who has a question about this exposure control plan or how it is
implemented in this office is encouraged to contact: Kate Goin, the OSHA compliance manager
for more information.
01/2008
17
Bloodborne Pathogens
Hepatitis B Vaccination/Postexposure Procedures
Introduction
The OSHA Standard on Bloodborne Pathogens defines the responsibilities of the employer
for providing hepatitis B vaccination to employees who have occupational exposure to
bloodborne pathogens and postexposure evaluation and follow-up to employees who have
had an exposure incident. (See Glossary in General Information for definition of terms.)
OSHA considers part-time, temporary, and probationary workers as employees. Newly
hired employees are permitted to participate in patient care during the two- to six-month
period it takes to complete the series of vaccine injections, but the vaccination series
must be made available to them within 10 days of their initial assignment to a job with
occupational exposure.
NOTE: All ACC-DH procedures are also performed in accordance with the procedures set
forth by the ACC Office of Environmental Health and Safety.
Hepatitis B Vaccination
• Hepatitis B vaccination must be made available at no cost to all employees who have
occupational exposure.
• Vaccination shall be made available after the employee has received the training described
under the heading “Training” and within 10 working days of initial assignment.
• This requirement is waived if the employee has previously received the complete HBV
vaccination series (three vaccines, or in the case of a nonresponder, six) if antibody testing
reveals that the employee is immune, or if the vaccine is contraindicated for medical reasons.
• The employer may not require pre-screening for antibody to HBV prior to vaccination.
• If the employee initially declines to be vaccinated but at a later date, while still covered under
the Standard, decides to accept vaccination, the employer must make it available at no cost.
• Employees who refuse to be vaccinated must sign the Hepatitis B Vaccine Declination form,
included in this section of the manual.
• Employees not responding or completing the primary vaccination series should be
revaccinated with a second three-dose vaccine. Revaccinated persons should be tested for
anti-HBV antibodies on completion of second vaccine series.
• While current U.S. Public Health Service guidelines do not recommend booster doses, if they
should in the future, the employer must provide these at no cost.
• The employer must provide a copy of the Standard to the healthcare professional who will
evaluate the employee and/or administer the vaccine, if the healthcare professional does not
have one already.
• If the employee wishes to be evaluated before vaccination, the employer must obtain the
healthcare professional’s written opinion (see Healthcare Professional’s Written Opinion form
on page 28) and give it to the employee within 15 days of its completion. The report should
state whether HBV Vaccination is indicated and if vaccination has been received.
01/2008
18
Bloodborne Pathogens
• This report should be filed in the employee’s Medical Record; findings and diagnoses not
pertaining to HBV must remain confidential and cannot be included in the written report.
• Post-vaccination testing for antibody to HBV surface antigen is indicated. Knowledge of
antibody response aids in determining appropriate postexposure prophylaxis.
• Although OSHA does not require it, you may wish to request new employees who have
already been vaccinated to provide proof of their vaccination (e.g., a written statement from
their physician to place in your files.)
Postexposure evaluation and follow-up (Management of occupational exposures to bloodborne
pathogens) – Immediately following an exposure incident (see Glossary in General Information),
the employer must make available to the employee a confidential medical evaluation and
follow-up. OSHA’s requirements are based on recommendations of the United States Public
Health Service, Centers for Disease Control and Prevention (CDC) and may change from time
to time with changes in the CDC’s recommendations.
In June of 2001, the CDC published new recommendations for the management of
occupational exposures to bloodborne pathogens and recommendations for postexposure
prophylaxis (MMWR 2001:50, 1-52; available online at http://www.cdc.gov/mmwr/PDF/rr/rr5011.
pdf.) It updates and consolidates all previous CDC recommendations for the management of
health-care personnel (HCP) who have occupational exposure to blood and other bodily fluids
that might contain hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency
virus (HIV). (See Table 1, “Recommended postexposure prophylaxis for exposure to hepatitis B
virus.”)
The portion of these 2001 Guidelines pertaining to HIV Recommendations has been
superseded by the Updated U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HIV and Recommendations for Post- Exposure Prophylaxis - 2005
(see Appendix F). A poster summarizing postexposure procedures for both HBV and HIV is
available on the CDC’s web site at www.cdc.gov and is included here in Appendix I.
One of the most important things a dentist can do to prepare is to select the health care
professional before an exposure incident occurs. This person should be familiar with the CDCrecommended evaluation and treatment protocols. They should be readily available in the event
of an exposure incident during work hours and have access to postexposure prophylaxis as
necessary. Postexposure prophylaxis, if indicated, is most likely to be effective if administered
as soon after the exposure as possible.
According to OSHA (and based on the CDC’s latest recommendations) if an exposure occurs,
the following must be done:
• Provide immediate care to the exposure site (e.g., wash wounds and skin with soap and
water, flush mucous membranes with water).
• Document the route(s) of exposure and how it occurred, including determining the risk
associated with exposure by type of fluid (e.g., blood, visibly bloody fluid, other potentially
infectious fluid or tissue) and type of exposure (i.e., percutaneous injury, mucous membrane
or nonintact skin exposure, and bites resulting in blood exposure).
01/2008
19
Bloodborne Pathogens
• Identify and document the source individual, unless prohibited by state or local law or not
feasible.
• Obtain consent of the source individual and make arrangements to have him/her tested
for HBV, HCV and/or HIV as soon as possible. Document that the source individual’s test
results were conveyed to the employee’s HCP. If the source individual is already known to be
positive for any of the viruses, then no additional testing for that specific virus is necessary.
• Ensure that the exposed employee is provided with the source individual’s test results.
• Ensure that the exposed employee is informed about laws protecting confidentiality, such as
applicable disclosure laws and regulations concerning the identity and infectious status of
the source individual.
• Evaluate the exposed employee by assessing immune status for HBV infection.
• Test exposed employee’s blood for HBV, and obtain history of hepatitis B vaccination
and vaccine response (see table 1), and HIV serological status as soon as feasible after
exposure incident. Obtain consent prior to collecting blood.
• If the employee does not consent to HIV testing at baseline, preserve the baseline blood
sample for at least 90 days. If at any time the exposed employee then elects to have the
baseline blood sample tested, do so as soon as it is feasible.
Exposures through a percutaneous injury (i.e., needlestick or other penetrating sharpsrelated event) or through contact with a mucous membrane are situations that pose a risk for
bloodborne virus transmission and require further evaluation.
For skin exposure, follow-up is indicated only if it involves exposure to a type of body fluid
that poses a risk and evidence exists of compromised skin integrity (e.g., dermatitis, abrasion,
or open wound). If a bite results in bloody exposure to either person involved, postexposure
follow-up should be provided.
Occupational Exposure Report (information required by evaluating healthcare professional
[HCP]) – The HCP should be provided with an occupational exposure report that includes the
items listed in Box 1. It should also include the following:
• A copy of the Bloodborne Pathogens Standard, if the HCP does not have one already.
• A description of the exposed employee’s responsibilities as they relate to the exposure
incident.
• All medical records relevant to the treatment of the employee, which are the employee’s
responsibility to maintain.
01/2008
20
Bloodborne Pathogens
Recommendations for the Contents of the Occupational
Exposure Report
• Date and time of the exposure;
• Details of the procedure being performed, includes where and how the exposure
occurred; if related to a sharp device, the type and brand of device and how and when
in the course of handling the device the exposure occurred;
• Details of the exposure, including the type and amount of fluid or material and the
severity of the exposure (e.g., for a percutaneous exposure, depth of injury and whether
fluid was injected; for a skin and mucous membrane exposure, the estimated volume of
material and condition of the skin [e.g., chapped, abraded, intact]);
• Details about the exposure source (e.g.. whether the source material contained HBV,
HCV, or HIV; if the source is HIV infected, the stage of disease, history of antiretroviral
therapy, viral load, and antiretroviral resistance information, if known);
• Details about the exposed person (e.g. hepatitis B vaccination and vaccine-response
status); and Details about counseling, postexposure management, and follow-up.
Healthcare Professional’s Written Opinion
The written opinion of the evaluating HCP should be made available to the employee within
15 days of completion of the evaluation. All findings and diagnoses unrelated to the exposure
incident are to remain confidential and are not to be included in the written report. It must be
limited to the following:
That the employee has been informed about any medical conditions resulting from the
exposure to blood or other potentially infectious materials, that require further evaluation
or treatment.
That the employee has been informed of the results of the evaluation.
Postexposure Recommendations
The OSHA standard does not provide specific recommendations on PEP. Instead, the
recommendation of the evaluating HCP regarding the use of PEP is to be based on current
CDC recommendations. These are summarized in table form below for HBV and appear in
Appendix F for HIV.
01/2008
21
Bloodborne Pathogens
Table 1. Recommended Postexposure Prophylaxis for Exposure
to Hepatitis B Virus
Treatment
Vaccination and
antibody response
status of exposed
workers*
Source
Source
HBsAg• positive
HBsAg• negative
Source unknown or not
available for testing
HBIG x 1 and initiate
HB vaccine series
Initiate HB vaccine
series
Initiate HB vaccine
series
Known responder**
No treatment
No treatment
No treatment
Known
HBIG x 1 and initiate
revaccination or HBIG
x2
No treatment
If known high risk
source, treat as if
source were HBsAg
positive
Test exposed person for
anti-HBs
No treatment
Test exposed person for
anti-HBs
Unvaccinated
Previously vaccinated
nonresponder ••
Antibody response
Unknown
1. If adequate,**
no treatment is
necessary
1. If adequate,
no treatment is
necessary
2. If inadequate,••
administer HBIG x 1
and vaccine booster
2. If inadequate,
administer vaccine
booster and recheck
titer in 1-2 months
* Persons who have previously been infected with HBV are immune to reinfection and do not
require postexposure prophylaxis.
• Hepatitis B surface antigen.
Hepatitis B immune globulin; dose is 0.06 mL/kg intramuscularly.
Hepatitis B vaccine.
** A responder is a person with adequate levels of serum antibody to HBsAg
(i.e., serum anti- HBs<10 mIU/mL).
•• A nonresponder is a person with inadequate response to vaccination
(i.e. anti- HBs<10 mIU/mL.)
The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for
nonresponders who have not completed a second 3-dose vaccine series. For persons who
previously completed a second vaccine series but failed to respond, two doses of HBIG are
preferred.
Antibody to HBsAg.
01/2008
22
Bloodborne Pathogens
Confidential
Note to employer: This form should be signed by the healthcare professional twice: after
the first vaccination and again when the series is completed. If vaccination is not indicated,
only one signature is necessary. Maintain this record for the duration of employment plus 30
years. Provide a copy to the employee within 15 days of the initial evaluation.
Hepatitis B Vaccination
Healthcare Professional’s Written Opinion
for
(Name of employee)
To the healthcare professional:
OSHA requires the healthcare professional who evaluates an employee for hepatitis B
vaccination to provide a written opinion in the form provided below. Please complete this
form and return it to the employee at the time services are rendered. Thank you for your
cooperation.
----------------------------------------------------------------------------------------------------------------I hereby certify that on (date):
I evaluated the employee whose
name appears above and determined that hepatitis B vaccination:
Is indicated for this employee
In addition, the employee:
Did
Is not indicated for this
employee.
Did not receive the first hepatitis B vaccination.
Signed:
Date:
(Healthcare professional)
The employee:
Did
Did not receive the entire series of 3 hepatitis B
vaccinations.
Signed:
Date:
(Healthcare professional)
01/2008
23
Bloodborne Pathogens
Confidential
Note to employer: Maintain this record for duration of employment plus 30 years.
Provide a copy to the employee within 15 days after the evaluation is completed.
Postexposure Evaluation and Follow-Up
Healthcare Professional’s Written Opinion
for
(Name of employee)
To the healthcare professional:
OSHA requires the healthcare professional who provides postexposure evaluation and
follow-up services to an employee to provide a written opinion in the form provided below.
Please complete this form and return it to the employee at the time services are rendered.
Thank you for your cooperation.
----------------------------------------------------------------------------------------------------------------I hereby certify that on (date):
I evaluated the employee whose
name appears above and informed the employee of:
The results of the evaluation; and any medical conditions resulting from exposure to blood or
other potentially infectious materials which require further evaluation or treatment.
NOTE: ALL OTHER FINDINGS OR DIAGNOSES ARE CONFIDENTIAL AND SHOULD NOT
BE INCLUDED IN THIS WRITTEN REPORT.
Signed:
Date:
(Healthcare professional)
01/2008
24
Bloodborne Pathogens
Labeling
Introduction
The OSHA standard has a section entitled “Communication of hazards to employees,”
which includes requirements for labels and information and training of those employees with
occupational exposure.
Labels
• The required label is the biohazard symbol and the legend “Biohazard” (shown below) which
should be fluorescent orange or orange-red with lettering or symbols in a contrasting color.
• Labels are affixed or attached as closely as possible to the container, so that there is no
possibility of loss. Alternatively, labels can be imprinted on the container or bag.
• Red bags or red containers may be substituted for labels.
• Regulated waste that has been decontaminated need not be labeled or placed in red bags.
For example, autoclaved waste would not be labeled.
• Biohazard labels are placed on containers of regulated waste, e.g., sharps containers.
Laundry contaminated with blood or other potentially infectious materials is also labeled or
color-coded.
BIOHAZARD SYMBOL
01/2008
25
Bloodborne Pathogens
Training
Introduction
The OSHA Standard includes requirements for providing information and training of those
employees with occupational exposure.
Manner of Presentation
Information and training will be provided:
• At the time of initial assignments to duties that may result in occupational exposure.
• At least annually or as soon as possible when there are changes in procedures or
in job assignments.
• In a manner and language that can be understood by all employees and students.
• In an interactive style that encourages questions and answers.
• By a person knowledgeable in the subject matter specified by the Standard.
• During working hours.
• Office specific.
Contents of the Training Program
The training program contains the following elements.
OSHA STANDARD
An accessible copy of this standard (under “Appendices” tab in this section) and an explanation
of its contents is part of the training program.
EPIDEMIOLOGY, MODES OF TRANSMISSION, AND SYMPTOMS OF BLOODBORNE DISEASES
• Hepatitis B
Epidemiology. Numerous studies document that workers occupationally exposed to blood
have a prevalence of serum HBV markers, which indicates previous infection, several
times that of the general population or workers not exposed to blood. Prevalence of serum
HBV markers is related to the number of exposures to blood and/or needles but not patient
contacts per se. High-risk groups for hepatitis B include, among others, operating room staff,
phlebotomists, surgeons, dental professionals, and blood bank technicians.
Modes of Transmission. Blood and body fluids contaminated with blood contain the highest
quantities of virus and are the most likely vectors of HBV transmission. Certain other body
fluids such as saliva and semen contain infectious virus but at one-thousandth of the
concentration found in blood. Other body fluids such as urine and feces contain only small
quantities of virus unless they are visibly contaminated with blood. Lesions on the hands
from injuries incurred at the workplace or at home or from dermatitis may provide a route
of entry for the virus. In addition, transfer of contaminated blood via inanimate objects or
environmental surfaces has been shown to cause infection in healthcare workers.
01/2008
26
Bloodborne Pathogens
Symptoms. About one third of infected individuals have no symptoms when infected with
the virus, one third have a relatively mild clinical course of a flu-like illness that is usually not
diagnosed as hepatitis, and the remaining third have a much more severe clinical course of
jaundice, dark urine, extreme fatigue, anorexia, nausea, abdominal pain, and sometimes
joint pain, rash and fever.
The annual number of occupational infections has decreased 95% since the hepatitis B
vaccine became available in 1982, from over 10,000 in 1983 to less than 400 in 2001 (CDC,
unpublished data).
• Human immunodeficiency virus infection
Epidemiology. As of December 2001, CDC reported 57 documented cases and 138 possible
cases of occupationally acquired HIV infection among healthcare personnel in the United
States since reporting began in 1985. The average risk of infection resulting from exposure
to HIV-infected blood through a needlestick or cut is 0.3%, the eye, nose or mouth is 0.1%,
and non-intact skin is less than 0.1%. There are no documented cases of HIV transmission
due to an exposure involving a small amount of blood on intact skin (a few drops of blood
on skin for a short period of time) (Centers for Disease Control and Prevention National
Center for Infectious Diseases Division of Healthcare Quality Promotion and Division of Viral
Hepatitis. Exposure to Blood: What Healthcare Personnel Need to Know. July 2003).
Modes of transmission. HIV has been isolated from human blood, semen, breast milk,
vaginal secretions, saliva, tears, urine, cerebrospinal fluid, and amniotic fluid. However,
epidemiologic evidence implicates only blood, semen, vaginal secretions, and possibly
breast milk in the transmission of the virus. Documented modes of HIV transmission include:
engaging in sexual intercourse with an HIV-infected person; using needles contaminated
with the virus; having parenteral, mucous membrane, or nonintact skin contact with HIVinfected blood, blood components, or blood products; receiving transplants of HIV-infected
organs and tissues, including bone; receiving transfusions of HIV-infected blood; and
perinatal transmission (from mother to child around the time of birth).
The actual amount of virus may be very important in the likelihood of transmission since
it appears that there is a greater probability of infection from HIVcontaminated blood
transfusions (890 infections per 1,000 persons receiving such transfusions) than from
accidental needlesticks with needles that have been contaminated with HIV (approximately
three infections per 1,000 persons injured with contaminated needles.)
Symptoms. Within a month after exposure, an individual may experience acute retroviral
syndrome, the first clinical evidence of HIV infection. This is a flu-like illness with signs and
symptoms that can include fever, lymphadenopathy, myalgias, arthralgias, diarrhea, fatigue
and rash. This syndrome is usually self-limiting and is followed or accompanied by the
development of antibodies. Following this acute illness, HIV infection leads to a continuum
of events in which the patient is initially asymptomatic and apparently healthy and then, after
an indeterminate time, sometimes longer than 10 years, may develop symptoms uniquely
associated with a later stage of HIV infection that is classified as acquired immune deficiency
syndrome, or AIDS. Some of the signs and symptoms of HIV infection are persistent
generalized lymphadenopathy, fever for more than one month, significant weight loss,
persistent diarrhea, or a combination of these. An individual with HIV infection is considered
to have AIDS when one or more so-called “indicator” diseases has been diagnosed. The
most common of these indicator diseases are pneumocystis carninii pneumonia, esophogeal
01/2008
27
Bloodborne Pathogens
candidiasis, neurological disorders or dementia, and cancers such as Kaposi’s sarcoma and
non-Hodgkin’s lymphoma. An HIV infected person is also considered to have AIDS if he or
she has less than 200 CD4+ lymphocytes/mm³ of blood. The CD4+, or T-helper lymphocyte,
is the primary target cell for HIV infection and a decrease in number of these cells correlates
with the risk and severity of HIVrelated illness.
• Hepatitis C
Epidemiology. HCV, like all bloodborne pathogens, can be transmitted through occupational
exposure to infectious body fluids. The number of healthcare personnel occupationally
infected with HCV is unknown. Studies indicate, however, that about 1% of hospital
healthcare personnel have evidence of HCV infection, while about 3% of the U.S. population
has evidence of infection. The average risk of HCV infection after a needlestick or cut
exposure to HCV-infected blood is approximately 1.8%. HCV infection resulting from an
infected blood splash to the eye has been reported, as well as a possible infection from
exposure to nonintact skin (Centers for Disease Control and Prevention National Center
for Infectious Diseases Division of Healthcare Quality Promotion and Division of Viral
Hepatitis. Exposure to Blood: What Healthcare Personnel Need to Know. July 2003).
Modes of Transmission. HCV has been isolated from human blood and bodily fluids and is
transmitted primarily through large or repeated direct percutaneous exposures to blood,
e.g., intravenous drug use and blood transfusions. In other countries, different kinds of
percutaneous injuries such as tattooing and body piercing have been associated with HCV
infection; however, case studies in the U.S. have not shown this association. Although
inconsistencies exist among studies, data indicate overall that sexual transmission of
HCV does occur, but at a relatively low rate.
Symptoms. Only approximately 30% of individuals with newly acquired HCV infections
develop clinical symptoms such as jaundice, fatigue, abdominal pain, and loss of appetite.
The average time period from exposure to symptom onset is 6-7 weeks while the average
time period for seroconversion is 8-9 weeks. HCV does have a high rate of chronic infection
due to its genetic diversity that enables the virus to elude the host’s immune system.
EXPOSURE CONTROL PLAN
The written exposure control plan, which is included in this manual under the “Exposure
Control” tab, will be explained to all employees and students by either the DHDC or
compliance manager. A copy of the plan is available upon request. The plan will be updated
annually or when alterations in procedures create new occupational exposure.
RECOGNITION OF TASKS AND ACTIVITIES THAT MAY INVOLVE EXPOSURE
Tasks that involve contacts with blood or other potentially infectious materials and mucous
membranes may result in exposure to bloodborne pathogens. Items contaminated with blood
or other potentially infectious materials, such as soiled instruments, laundry, and equipment
can also result in occupational exposure.
METHODS TO REDUCE EXPOSURE
The use and limitations of methods that will prevent or reduce exposure, including appropriate
engineering controls, work practices, and personal protective equipment (see “Methods of
Compliance”), will be explained.
01/2008
28
Bloodborne Pathogens
TYPES, PROPER USE, LOCATION, REMOVAL, HANDLING, DECONTAMINATION,
AND/OR DISPOSAL OF PPE
Various kinds of gloves can be used in the dental office: vinyl, latex, rubber or nitrile, and
plastic film. Latex, nitrile or vinyl gloves are used for most treatment procedures. When surgical
procedures are performed, sterile surgical latex or vinyl gloves are required. Nonsterile latex or
vinyl treatment gloves are adequate for most procedures.
Rubber utility or nitrile puncture-resistant gloves are used for housekeeping procedures such
as cleaning instruments prior to sterilization or surface disinfection. Plastic film gloves may be
used temporarily over a latex treatment glove when it is necessary to prevent contamination of
an object such as a drawer handle or chart.
Gloves must be changed between patients, whether they are worn for treatment or examination.
They should not be washed for reuse. Disinfecting agents may cause deterioration of glove
material, and minute tears or punctures in gloves may occur during treatment, resulting in
contamination of hands. If tears or punctures do appear, gloves must be removed and replaced.
Hands should then be washed before regloving. Utility gloves can be washed and reused. They
should be replaced when they become cracked or worn. According to the CDC, using gloves in
health care settings reduces hand contamination by 70 to 80%, prevents cross- contamination
and protects patients and health care personnel from infection; but does not eliminate the need
for hand hygiene (Centers for Disease Control and Prevention. Guideline for Hand Hygiene in
Health-Care Settings. MMWR 2002;51(No.RR-17):1-44).
A mask is used to protect mucous membranes of the mouth and nose from exposure to blood
and saliva. The mask should be adjusted so that it fits snugly against the face so as not to allow
spatter to enter around its edges. Beards and mustaches should be groomed so that the mask
fits well. The mask should be changed between patients or if it gets wet. It should be removed
as soon as treatment is over. It should not be dangled around the neck or left in place after
leaving the operatory. When removing the mask, handle it only by the elastic or cloth tie string.
The mask itself should not be touched.
OSHA does not consider masks and gloves to be regulated waste. However, you must dispose
of masks and gloves according to state or local regulations, if they exist.
Protective eyewear must be worn when projectiles and splashes, spray, or spatter of
blood or other potentially infectious materials may be generated and eye, nose, or mouth
contamination can be reasonably anticipated. Protective eyewear may include
conventional glasses with solid side shields, safety glasses, or goggles. As an
alternative, a face shield with a mask may be worn.
Gowns, lab coats, clinic jackets, or similar outer garments must be worn when there is a
likelihood of occupational exposure to blood or other potentially infectious material. The type
and characteristics of protective clothing depends upon the task and degree of exposure
anticipated. The garment must be removed immediately or as soon as possible when
penetrated by blood or other potentially infectious materials and before leaving the work area.
Place contaminated gowns in designated, labeled laundry bags.
01/2008
29
Bloodborne Pathogens
The location of PPE in our office is as follows:
Personal
Protective
Gloves, nonsterile
Gloves, sterile
Location
Disposal
Operatories, Darkroom,
Operatory/Sterilization Room
Sterilization Room, Laboratory trash receptacles
Operatory/Sterilization Room
Sterilization Room
trash receptacles
Gloves, utility
Operatories, Sterilization Room Washed and autoclaved
Masks, face shields
Operatories, Sterilization Room
Protective eyewear
Operatories, Sterilization Room Disinfect with Birex
Protective clothing
(lab coats,
overgowns)
Operatories, Sterilization Room
Operatory/Sterilization Room
trash receptacles
Resuscitation
equipment pocket
masks
Emergency cart in computer
study area
Operatory/Sterilization Room
trash receptacles
Operatory/Sterilization Room
trash receptacles
Contact: Kate Goin, compliance manager if you need additional information on the location
and use of these items.
SELECTION OF PPE
Selection of PPE will depend on the degree of anticipated exposure and the procedure to be
performed. For example, an oral examination may simply require gloves, whereas procedures
in which exposure to blood or other potentially infectious materials may be reasonably anticipated
will require gloves, mask, protective eyewear, and a lab coat, clinic jacket, or gown.
HEPATITIS B VACCINES
Currently there are two licensed hepatitis B vaccines. Recombivax HB and Engerix-B
prepared from recombinant yeast cultures. These two vaccines are given in three intramuscular
injections (deltoid muscle of the arm) over a six-month period, at zero, one and six months.
Engerix-B, however, can also be administered at an accelerated schedule of zero, one, two, and
12 months for more rapid induction of immunity or for postexposure prophylaxis. Recombivax HB
and Engerix-B should not be given to individuals known to be hypersensitive to yeast or yeast
products. An earlier plasmaderived vaccine, Heptavax-B, is limitedly available for these specific
individuals. In 2001, a combined Hepatitis A (Havrix) and B (Engerix-B) vaccine became
available called Twinrix. Hepatitis B vaccines induce protective antibody levels in most healthy
adults, depending on age. Protection against infection and development of the carrier state both
last at least five to seven years after immunization. Even when the antibody titers have dropped
below detectable levels, vaccinated individuals develop a rapid immunologic memory response
and do not become clinically ill or infected with HBV. Booster inoculation is not officially
01/2008
30
Bloodborne Pathogens
recommended by the Centers for Disease Control and Prevention at this time. For individuals
who did not develop hepatitis antibodies following the primary series, revaccination results in
15-25% developing antibodies after one injection and up to 50% developing antibodies after a
complete second-series administration of the vaccine.
ACTIONS TO TAKE AND PERSONS TO CONTACT IN AN EMERGENCY
In cases of an emergency that may pose the potential for exposure to blood or other potentially
infectious materials, be certain to use appropriate PPE. For example, if a blood spill occurs,
don utility gloves, mask, lab coat, clinical jacket or gown, and protective eyewear before
proceeding with cleanup. Continue to wear protective equipment when decontaminating the
area with an appropriate disinfectant. If you are unsure of the appropriate action to take in an
emergency, contact the compliance manager or the DHDC.
Compliance manager
DHDC
Name: Kate Goin, BA, RDH
Name: Renee Cornett, RDH, MBA
Telephone number: 512-223-5708
Telephone number: 512-223-5711
Occasionally, emergency situations may arise in which the use of PPE may not be possible.
OSHA defines these emergency situations as extraordinary, unexpected events that threaten
the life or safety of a patient or fellow worker. It may be judged that the time required to don
personal protective equipment is critical to saving the person’s life. However, the use of the
exemption is meant to be limited in extent and time. Those practices associated with standard
precautions that can be used without jeopardizing the victim’s life are to be implemented
whenever possible. Moreover, as soon as the situation changes as, for example, the patient’s
condition stabilizes, the employee is expected to implement use of full standard precautions.
The decision not to utilize personal protective equipment in such situations rests with the
employee, not the employer. Employees must exercise their professional judgment in making
such a decision, but they should be aware that they may be asked to explain the reasons for
their course of action.
Although saliva has not been implicated in HIV transmission, OSHA considers it to be a
potentially infectious material in the dental setting. To minimize the need for emergency, mouthto-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices must be
kept in the office.
In case of an emergency, each employee must be aware of his or her responsibility. One of the
responsibilities is to contact the local hospital or rescue squad. The telephone number in case
of an emergency is:
Campus Emergencies, 222 (from campus phone) or 512-223-7999 (off campus phone)
01/2008
31
Bloodborne Pathogens
POSTEXPOSURE PROCEDURES
The procedure to follow if an exposure incident occurs, including the method of reporting the
incident and the medical evaluation and follow-up that will be made available (see information
under “HBV vaccination/postexposure procedures”) will be explained.
LABELING AND COLOR CODING
The signs and labels and/or color coding required by the OSHA Standard (see information
under “Labeling”) will be explained.
TRAINING SESSIONS
The DHDC or the compliance manager will conduct training sessions that are interactive and
allow the opportunity for questions and answers.
01/2008
32
Bloodborne Pathogens
Recordkeeping
This section of the manual contains record forms either mandated by the OSHA Standard or
that are recommended by the ADA.
Employee Medical Record
• This record is required by OSHA for each employee with occupational exposure.
• It must be confidential, separate from other personnel records, and may be maintained on
site or by the healthcare professional who provides services to dental healthcare employees.
The medical record must be retained for the duration of the employee’s employment plus 30
years. Medical records of employees who have worked for less than one year need not be
retained beyond the term of employment if the records are provided to the employee upon
the termination of employment.
• It must include the name and social security number of the employee.
• It must include the employee’s Hepatitis B vaccination status, including dates received,
and any medical records relative to the employee’s ability to receive the vaccination.
• If an occupational exposure incident occurs, copies of all results of examinations, medical
testing, and follow-up procedures, as well as the written opinion of the health care
professional, must be attached to the medical record.
• It must include copies of the information provided to the healthcare professional regarding
hepatitis B vaccination and/or exposure incidents, as appropriate.
Employee Training Record
Training records document each training session and must be retained by the employer
for three years. They should be made available upon request to employees or OSHA
representatives. Training records must include:
• Dates of training
• Summary of the contents of training
• Names and qualifications of the person(s) conducting the training
• Names and job titles of all persons attending the training
Hepatitis B Vaccine Declination Statement
The OSHA Standard requires that an employee who declines to accept hepatitis B vaccination
offered by the employer sign the Hepatitis B Vaccine Declination provided with the record
forms. This form must be retained for the duration of employment plus 30 years, except for
employees who have worked less than one year (see above).
01/2008
33
Bloodborne Pathogens
Informed Refusal by Employee of Postexposure Medical Evaluation
and Follow-up
There is no requirement that an employee who refuses postexposure medical evaluation and
follow-up sign a statement to that effect. However, it is suggested that employers may want to
use the form in this section to document such employee refusal.
01/2008
34
Bloodborne Pathogens
EMPLOYEE MEDICAL RECORD
CONFIDENTIAL
Employee Medical Record
Employee
name:
Employee address:
Employee social
security
Employee starting
number:
date:
Employee termination date (if any):
History of HBV vaccination (date received, or, if not received, a brief explanation of why not):
History of exposure incident(s) (dates, brief explanation, attachments):
Results of medical exams and follow-up procedures regarding exposure incident or hepatitis
B immunity, including written opinion of healthcare professional (dates, brief explanation,
attachments):
Information provided to the healthcare professional regarding hepatitis B vaccination and/or
exposure incident(s) (dates, brief explanation, attachments):
Note: Maintain this record for duration of employment plus 30 years. Medical records
of employees who have worked for less than one year need not be retained beyond the
term of employment if the records are provided to the employee upon termination of their
employment.
01/2008
35
Bloodborne Pathogens
HEPATITIS B VACCINE DECLINATION
CONFIDENTIAL
Hepatitis B Vaccine Declination
I understand that due to my occupational exposure to blood or other potentially infectious
materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given
the opportunity to be vaccinated with the hepatitis B vaccine, at no charge to myself.
However, I decline hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future
I continue to have occupational exposure to blood or other potentially infectious materials
and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination
series at no charge to me.
Witness
Signature
Name
Address
City, State, Zip Code
Date
Note: Maintain this record for duration of employment plus 30 years. Medical records of
employees who have worked for less than one year need not be retained beyond the term
of employment if the records are provided to the employee upon the termination of their
employment.
01/2008
36
Bloodborne Pathogens
INFORMED REFUSAL OF POSTEXPOSURE MEDICAL EVALUATION
CONFIDENTIAL
Informed Refusal of Postexposure Medical Evaluation
I,
, am employed by
as a dentist/dental assistant/hygienist/lab technician. My employer has provided training to me
regarding exposure control for bloodborne pathogens and the risk of disease transmission in
the dental office.
On
, 20
, I was involved in an exposure incident when I
(describe details of needlestick, etc.).
My employer has offered to provide post exposure medical evaluation and follow-up for me in
order to assure that I have full knowledge of whether I have been exposed to or contracted an
infectious disease from this incident.
However, I, of my own free will and volition, and despite my employer’s offer, have elected not
to have a medical evaluation. I have personal reasons for making this decision.
Witness
Signature
Name
Address
City, State, Zip Code
Date
Note: Maintain this record for duration of employment plus 30 years. Medical records of
employees who have worked for less than one year need not be retained beyond the term
of employment if the records are provided to the employee upon the termination of their
employment.
01/2008
37
Bloodborne Pathogens
This Page Intentionally Left Blank
01/2008
38
Bloodborne Pathogens
EMPLOYEE T R AI NING REC ORD
Employee Training Record
Name of office Austin Community College – Department of Dental Hygiene
Address of office 3401 Webberville Rd, Austin, TX 78702
Date of training session 09/01/2016
Name(s) and qualifications of person conducting training session
Kate Goin, BA, RDH, OSHA Compliance Manager and ADA OSHA Training for Dental Professionals Video
Contents/Summary of training session
General Safety Standards and OSHA overview; Bloodborne Pathogens Standard; Hazard Communications
Standard
Names and job titles of all persons attending training session:
Name
Job Title
Renee Cornett, RDH
Full Time Faculty, Department Chair
Michelle Landrum, RDH
Full Time Faculty, Clinic Coordinator
Tina Stein, RDH
Full Time Faculty, Clinic Coordinator
Joe Wright, DDS
Full Time Faculty
Kellie Hicks, RDH
Adjunct Faculty
Sima Sohrabi, RDH
Adjunct Faculty
Kimberly McDougall, RDH
Adjunct Faculty
David Reeves, DMD
Adjunct Faculty
Note: Maintain this record for duration of employment plus 30 years. Medical records of
employees who have worked for less than one year need not be retained beyond the term of
employment if the records are provided to the employee upon the termination of their employment.
01/2008
39
Bloodborne Pathogens
Name
Job Title
Debra Segen, RDH
Adjunct Faculty
Rita Snodell, RDH
Adjunct Faculty
Prema Strecker, RDH
Adjunct Faculty
Veronica Ledesma, RDH
Adjunct Faculty
Teri Frank, CDA
Administrative Assistant
01/2008
40
Bloodborne Pathogens
EMPLOYEE T R AI NING REC ORD
Employee Training Record
Name of office Austin Community College – Department of Dental Hygiene
Address of office 3401 Webberville Rd, Austin, TX 78702
Date of training session 09/12/2016
Name(s) and qualifications of person conducting training session
Kate Goin, BA, RDH, OSHA Compliance Manager and ADA OSHA Training for Dental Professionals Video
Contents/Summary of training session
General Safety Standards and OSHA overview; Bloodborne Pathogens Standard; Hazard Communications
Standard
Names and job titles of all persons attending training session:
Name
Job Title
Monique Alarcon
Dental Hygiene Student
Rachel Dickens
Dental Hygiene Student
Sunena Gagneja
Dental Hygiene Student
Lacie Herrin
Dental Hygiene Student
Dylon Hopper
Dental Hygiene Student
Cydnie Johnson
Dental Hygiene Student
Julia Levitt
Dental Hygiene Student
Stephanie Liu
Dental Hygiene Student
Note: Maintain this record for duration of employment plus 30 years. Medical records of
employees who have worked for less than one year need not be retained beyond the term of
employment if the records are provided to the employee upon the termination of their employment.
01/2008
41
Bloodborne Pathogens
Name
Job Title
Kristi Madrid
Dental Hygiene Student
Katie Natale
Dental Hygiene Student
Aneesa Patel
Dental Hygiene Student
Lee Pepe
Dental Hygiene Student
Jennifer Rice
Dental Hygiene Student
Shaunda Talamantez
Dental Hygiene Student
Yula Voznesenskaya
Dental Hygiene Student
Jeremiah Wallace
Dental Hygiene Student
Allyson Walter
Dental Hygiene Student
01/2008
42
Bloodborne Pathogens
EMPLOYEE T R AI NING REC ORD
Employee Training Record
Name of office Austin Community College – Department of Dental Hygiene
Address of office 3401 Webberville Rd, Austin, TX 78702
Date of training session 08/30/2016
Name(s) and qualifications of person conducting training session
Kate Goin, BA, RDH, OSHA Compliance Manager and ADA OSHA Training for Dental Professionals Video
Contents/Summary of training session
General Safety Standards and OSHA overview; Bloodborne Pathogens Standard; Hazard Communications
Standard
Names and job titles of all persons attending training session:
Name
Job Title
Jason Blunck
Dental Hygiene Student
Wendy Bushman
Dental Hygiene Student
Josette Chen
Dental Hygiene Student
Amy Deng
Dental Hygiene Student
Becca Eiserer
Dental Hygiene Student
Zainab Jabr
Dental Hygiene Student
Laura Jaimes
Dental Hygiene Student
Whitney Jones
Dental Hygiene Student
Note: Maintain this record for duration of employment plus 30 years. Medical records of
employees who have worked for less than one year need not be retained beyond the term of
employment if the records are provided to the employee upon the termination of their employment.
01/2008
43
Bloodborne Pathogens
Name
Job Title
Molly Keith
Dental Hygiene Student
Shari Langerhans
Dental Hygiene Student
Jessica Lee
Dental Hygiene Student
Jess Ross
Dental Hygiene Student
Azadeh Samani
Dental Hygiene Student
Elya Singler
Dental Hygiene Student
01/2008
44
Bloodborne Pathogens
Bloodborne Pathogens Appendix A
U.S. Department of Labor
Occupational Safety & Health Administration
www.osha.gov
[skip navigational links]
Search
Advanced Search | A-Z Ind
Regulations (Standards - 29 CFR)
Bloodborne pathogens. - 1910.1030
Regulations (Standards - 29 CFR) - Table of Contents
•
•
•
•
•
•
•
Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:
Appendix:
1910
Occupational Safety and Health Standards
Z
Toxic and Hazardous Substances
1910.1030
Bloodborne pathogens.
A
1910.1030(a)
Scope and Application. This section applies to all occupational exposure to
blood or other potentially infectious materials as defined by paragraph (b) of
this section.
1910.1030(b)
Definitions. For purposes of this section, the following shall apply:
Assistant Secretary means the Assistant Secretary of Labor for Occupational
Safety and Health, or designated representative.
Blood means human blood, human blood components, and products made from
human blood.
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, hepatitis B virus (HBV) and human immunodeficiency virus
(HIV).
Clinical Laboratory means a workplace where diagnostic or other screening
procedures are performed on blood or other potentially infectious materials.
Contaminated means the presence or the reasonably anticipated presence of
blood or other potentially infectious materials on an item or surface.
Contaminated Laundry means laundry which has been soiled with blood or
other potentially infectious materials or may contain sharps.
Contaminated Sharps means any contaminated object that can penetrate the
skin including, but not limited to, needles, scalpels, broken glass, broken
capillary tubes, and exposed ends of dental wires.
Decontamination means the use of physical or chemical means to remove,
inactivate, or destroy bloodborne pathogens on a surface or item to the point
where they are no longer capable of transmitting infectious particles and the
surface or item is rendered safe for handling, use, or disposal.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Director means the Director of the National Institute for Occupational Safety
and Health, U.S. Department of Health and Human Services, or designated
representative.
Engineering Controls means controls (e.g., sharps disposal containers, selfsheathing needles, safer medical devices, such as sharps with engineered
sharps injury protections and needleless systems) that isolate or remove the
bloodborne pathogens hazard from the workplace.
Exposure Incident means 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.
Handwashing Facilities means a facility providing an adequate supply of
running potable water, soap and single use towels or hot air drying machines.
Licensed Healthcare Professional is a person whose legally permitted scope
of practice allows him or her to independently perform the activities required by
paragraph (f) Hepatitis B Vaccination and Post-exposure Evaluation and Followup.
HBV means hepatitis B virus.
HIV means human immunodeficiency virus.
Needleless systems means a device that does not use needles for:
(1) The collection of bodily fluids or withdrawal of body fluids after initial venous
or arterial access is established; (2) The administration of medication or fluids;
or (3) Any other procedure involving the potential for occupational exposure to
bloodborne pathogens due to percutaneous injuries from contaminated sharps.
Occupational Exposure means reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or other potentially infectious
materials that may result from the performance of an employee's duties.
Other Potentially Infectious Materials means (1) The following human body
fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any body fluid that is visibly contaminated with blood, and all body
fluids in situations where it is difficult or impossible to differentiate between
body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a
human (living or dead); and (3) HIV-containing cell or tissue cultures, organ
cultures, and HIV- or HBV-containing culture medium or other solutions; and
blood, organs, or other tissues from experimental animals infected with HIV or
HBV.
Parenteral means piercing mucous membranes or the skin barrier through
such events as needlesticks, human bites, cuts, and abrasions.
Personal Protective Equipment is specialized clothing or equipment worn by
an employee for protection against a hazard. General work clothes (e.g.,
uniforms, pants, shirts or blouses) not intended to function as protection
against a hazard are not considered to be personal protective equipment.
Production Facility means a facility engaged in industrial-scale, large-volume
or high concentration production of HIV or HBV.
Regulated Waste means liquid or semi-liquid blood or other potentially
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
infectious materials; contaminated items that would release blood or other
potentially infectious materials in a liquid or semi-liquid state if compressed;
items that are caked with dried blood or other potentially infectious materials
and are capable of releasing these materials during handling; contaminated
sharps; and pathological and microbiological wastes containing blood or other
potentially infectious materials.
Research Laboratory means a laboratory producing or using researchlaboratory-scale amounts of HIV or HBV. Research laboratories may produce
high concentrations of HIV or HBV but not in the volume found in production
facilities.
Sharps with engineered sharps injury protections means a nonneedle
sharp or a needle device used for withdrawing body fluids, accessing a vein or
artery, or administering medications or other fluids, with a built-in safety
feature or mechanism that effectively reduces the risk of an exposure incident.
Source Individual means any individual, living or dead, whose blood or other
potentially infectious materials may be a source of occupational exposure to the
employee. 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.
Sterilize means the use of a physical or chemical procedure to destroy all
microbial life including highly resistant bacterial endospores.
Universal Precautions is an approach to infection control. According to the
concept of Universal Precautions, all human blood and certain human body
fluids are treated as if known to be infectious for HIV, HBV, and other
bloodborne pathogens.
Work Practice Controls means controls that reduce the likelihood of exposure
by altering the manner in which a task is performed (e.g., prohibiting recapping
of needles by a two-handed technique).
1910.1030(c)
Exposure Control -1910.1030(c)(1)
Exposure Control Plan.
1910.1030(c)(1)(i)
Each employer having an employee(s) with occupational exposure as defined by
paragraph (b) of this section shall establish a written Exposure Control Plan
designed to eliminate or minimize employee exposure.
1910.1030(c)(1)(ii)
The Exposure Control Plan shall contain at least the following elements:
1910.1030(c)(1)(ii)(A)
The exposure determination required by paragraph (c)(2),
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(c)(1)(ii)(B)
The schedule and method of implementation for paragraphs (d) Methods of
Compliance, (e) HIV and HBV Research Laboratories and Production Facilities,
(f) Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up, (g)
Communication of Hazards to Employees, and (h) Recordkeeping, of this
standard, and
1910.1030(c)(1)(ii)(C)
The procedure for the evaluation of circumstances surrounding exposure
incidents as required by paragraph (f)(3)(i) of this standard.
1910.1030(c)(1)(iii)
Each employer shall ensure that a copy of the Exposure Control Plan is
accessible to employees in accordance with 29 CFR 1910.1020(e).
1910.1030(c)(1)(iv)
The Exposure Control Plan shall be reviewed and updated at least annually and
whenever necessary to reflect new or modified tasks and procedures which
affect occupational exposure and to reflect new or revised employee positions
with occupational exposure. The review and update of such plans shall also:
1910.1030(c)(1)(iv)(A)
Reflect changes in technology that eliminate or reduce exposure to bloodborne
pathogens; and
1910.1030(c)(1)(iv)(B)
Document annually consideration and implementation of appropriate
commercially available and effective safer medical devices designed to eliminate
or minimize occupational exposure.
1910.1030(c)(1)(v)
An employer, who is required to establish an Exposure Control Plan shall solicit
input from non-managerial employees responsible for direct patient care who
are potentially exposed to injuries from contaminated sharps in the
identification, evaluation, and selection of effective engineering and work
practice controls and shall document the solicitation in the Exposure Control
Plan.
1910.1030(c)(1)(vi)
The Exposure Control Plan shall be made available to the Assistant Secretary
and the Director upon request for examination and copying.
1910.1030(c)(2)
Exposure Determination.
1910.1030(c)(2)(i)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Each employer who has an employee(s) with occupational exposure as defined
by paragraph (b) of this section shall prepare an exposure determination. This
exposure determination shall contain the following:
1910.1030(c)(2)(i)(A)
A list of all job classifications in which all employees in those job classifications
have occupational exposure;
1910.1030(c)(2)(i)(B)
A list of job classifications in which some employees have occupational
exposure, and
1910.1030(c)(2)(i)(C)
A list of all tasks and procedures or groups of closely related task and
procedures in which occupational exposure occurs and that are performed by
employees in job classifications listed in accordance with the provisions of
paragraph (c)(2)(i)(B) of this standard.
1910.1030(c)(2)(ii)
This exposure determination shall be made without regard to the use of
personal protective equipment.
1910.1030(d)
Methods of Compliance -1910.1030(d)(1)
General. Universal precautions shall be observed to prevent contact with blood
or other potentially infectious materials. Under circumstances in which
differentiation between body fluid types is difficult or impossible, all body fluids
shall be considered potentially infectious materials.
1910.1030(d)(2)
Engineering and Work Practice Controls.
1910.1030(d)(2)(i)
Engineering and work practice controls shall be used to eliminate or minimize
employee exposure. Where occupational exposure remains after institution of
these controls, personal protective equipment shall also be used.
1910.1030(d)(2)(ii)
Engineering controls shall be examined and maintained or replaced on a regular
schedule to ensure their effectiveness.
1910.1030(d)(2)(iii)
Employers shall provide handwashing facilities which are readily accessible to
employees.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(d)(2)(iv)
When provision of handwashing facilities is not feasible, the employer shall
provide either an appropriate antiseptic hand cleanser in conjunction with clean
cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or
towelettes are used, hands shall be washed with soap and running water as
soon as feasible.
1910.1030(d)(2)(v)
Employers shall ensure that employees wash their hands immediately or as
soon as feasible after removal of gloves or other personal protective equipment.
1910.1030(d)(2)(vi)
Employers shall ensure that employees wash hands and any other skin with
soap and water, or flush mucous membranes with water immediately or as soon
as feasible following contact of such body areas with blood or other potentially
infectious materials.
1910.1030(d)(2)(vii)
Contaminated needles and other contaminated sharps shall not be bent,
recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)
(vii)(B) below. Shearing or breaking of contaminated needles is prohibited.
1910.1030(d)(2)(vii)(A)
Contaminated needles and other contaminated sharps shall not be bent,
recapped or removed unless the employer can demonstrate that no alternative
is feasible or that such action is required by a specific medical or dental
procedure.
1910.1030(d)(2)(vii)(B)
Such bending, recapping or needle removal must be accomplished through the
use of a mechanical device or a one-handed technique.
1910.1030(d)(2)(viii)
Immediately or as soon as possible after use, contaminated reusable sharps
shall be placed in appropriate containers until properly reprocessed. These
containers shall be:
1910.1030(d)(2)(viii)(A)
Puncture resistant;
1910.1030(d)(2)(viii)(B)
Labeled or color-coded in accordance with this standard;
1910.1030(d)(2)(viii)(C)
Leakproof on the sides and bottom; and
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(d)(2)(viii)(D)
In accordance with the requirements set forth in paragraph (d)(4)(ii)(E) for
reusable sharps.
1910.1030(d)(2)(ix)
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact
lenses are prohibited in work areas where there is a reasonable likelihood of
occupational exposure.
1910.1030(d)(2)(x)
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or
on countertops or benchtops where blood or other potentially infectious
materials are present.
1910.1030(d)(2)(xi)
All procedures involving blood or other potentially infectious materials shall be
performed in such a manner as to minimize splashing, spraying, spattering, and
generation of droplets of these substances.
1910.1030(d)(2)(xii)
Mouth pipetting/suctioning of blood or other potentially infectious materials is
prohibited.
1910.1030(d)(2)(xiii)
Specimens of blood or other potentially infectious materials shall be placed in a
container which prevents leakage during collection, handling, processing,
storage, transport, or shipping.
1910.1030(d)(2)(xiii)(A)
The container for storage, transport, or shipping shall be labeled or color-coded
according to paragraph (g)(1)(i) and closed prior to being stored, transported,
or shipped. When a facility utilizes Universal Precautions in the handling of all
specimens, the labeling/color-coding of specimens is not necessary provided
containers are recognizable as containing specimens. This exemption only
applies while such specimens/containers remain within the facility. Labeling or
color-coding in accordance with paragraph (g)(1)(i) is required when such
specimens/containers leave the facility.
1910.1030(d)(2)(xiii)(B)
If outside contamination of the primary container occurs, the primary container
shall be placed within a second container which prevents leakage during
handling, processing, storage, transport, or shipping and is labeled or colorcoded according to the requirements of this standard.
1910.1030(d)(2)(xiii)(C)
If the specimen could puncture the primary container, the primary container
shall be placed within a secondary container which is puncture-resistant in
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
addition to the above characteristics.
1910.1030(d)(2)(xiv)
Equipment which may become contaminated with blood or other potentially
infectious materials shall be examined prior to servicing or shipping and shall be
decontaminated as necessary, unless the employer can demonstrate that
decontamination of such equipment or portions of such equipment is not
feasible.
1910.1030(d)(2)(xiv)(A)
A readily observable label in accordance with paragraph (g)(1)(i)(H) shall be
attached to the equipment stating which portions remain contaminated.
1910.1030(d)(2)(xiv)(B)
The employer shall ensure that this information is conveyed to all affected
employees, the servicing representative, and/or the manufacturer, as
appropriate, prior to handling, servicing, or shipping so that appropriate
precautions will be taken.
1910.1030(d)(3)
Personal Protective Equipment -1910.1030(d)(3)(i)
Provision. When there is occupational exposure, the employer shall provide, at
no cost to the employee, appropriate personal protective equipment such as,
but not limited to, gloves, gowns, laboratory coats, face shields or masks and
eye protection, and mouthpieces, resuscitation bags, pocket masks, or other
ventilation devices. Personal protective equipment will be considered
"appropriate" only if it does not permit blood or other potentially infectious
materials to pass through to or reach the employee's work clothes, street
clothes, undergarments, skin, eyes, mouth, or other mucous membranes under
normal conditions of use and for the duration of time which the protective
equipment will be used.
1910.1030(d)(3)(ii)
Use. The employer shall ensure that the employee uses appropriate personal
protective equipment unless the employer shows that the employee temporarily
and briefly declined to use personal protective equipment when, under rare and
extraordinary circumstances, it was the employee's professional judgment that
in the specific instance its use would have prevented the delivery of health care
or public safety services or would have posed an increased hazard to the safety
of the worker or co-worker. When the employee makes this judgement, the
circumstances shall be investigated and documented in order to determine
whether changes can be instituted to prevent such occurrences in the future.
1910.1030(d)(3)(iii)
Accessibility. The employer shall ensure that appropriate personal protective
equipment in the appropriate sizes is readily accessible at the worksite or is
issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or
other similar alternatives shall be readily accessible to those employees who are
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
allergic to the gloves normally provided.
1910.1030(d)(3)(iv)
Cleaning, Laundering, and Disposal. The employer shall clean, launder, and
dispose of personal protective equipment required by paragraphs (d) and (e) of
this standard, at no cost to the employee.
1910.1030(d)(3)(v)
Repair and Replacement. The employer shall repair or replace personal
protective equipment as needed to maintain its effectiveness, at no cost to the
employee.
1910.1030(d)(3)(vi)
If a garment(s) is penetrated by blood or other potentially infectious materials,
the garment(s) shall be removed immediately or as soon as feasible.
1910.1030(d)(3)(vii)
All personal protective equipment shall be removed prior to leaving the work
area.
1910.1030(d)(3)(viii)
When personal protective equipment is removed it shall be placed in an
appropriately designated area or container for storage, washing,
decontamination or disposal.
1910.1030(d)(3)(ix)
Gloves. Gloves shall be worn when it can be reasonably anticipated that the
employee may have hand contact with blood, other potentially infectious
materials, mucous membranes, and non-intact skin; when performing vascular
access procedures except as specified in paragraph (d)(3)(ix)(D); and when
handling or touching contaminated items or surfaces.
1910.1030(d)(3)(ix)(A)
Disposable (single use) gloves such as surgical or examination gloves, shall be
replaced as soon as practical when contaminated or as soon as feasible if they
are torn, punctured, or when their ability to function as a barrier is
compromised.
1910.1030(d)(3)(ix)(B)
Disposable (single use) gloves shall not be washed or decontaminated for reuse.
1910.1030(d)(3)(ix)(C)
Utility gloves may be decontaminated for re-use if the integrity of the glove is
not compromised. However, they must be discarded if they are cracked,
peeling, torn, punctured, or exhibit other signs of deterioration or when their
ability to function as a barrier is compromised.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(d)(3)(ix)(D)
If an employer in a volunteer blood donation center judges that routine gloving
for all phlebotomies is not necessary then the employer shall:
1910.1030(d)(3)(ix)(D)(1)
Periodically reevaluate this policy;
1910.1030(d)(3)(ix)(D)(2)
Make gloves available to all employees who wish to use them for phlebotomy;
1910.1030(d)(3)(ix)(D)(3)
Not discourage the use of gloves for phlebotomy; and
1910.1030(d)(3)(ix)(D)(4)
Require that gloves be used for phlebotomy in the following circumstances:
1910.1030(d)(3)(ix)(D)(4)(i)
When the employee has cuts, scratches, or other breaks in his or her skin;
1910.1030(d)(3)(ix)(D)(4)(ii)
When the employee judges that hand contamination with blood may occur, for
example, when performing phlebotomy on an uncooperative source individual;
and
1910.1030(d)(3)(ix)(D)(4)(iii)
When the employee is receiving training in phlebotomy.
1910.1030(d)(3)(x)
Masks, Eye Protection, and Face Shields. Masks in combination with eye
protection devices, such as goggles or glasses with solid side shields, or chinlength face shields, shall be worn whenever splashes, spray, spatter, or droplets
of blood or other potentially infectious materials may be generated and eye,
nose, or mouth contamination can be reasonably anticipated.
1910.1030(d)(3)(xi)
Gowns, Aprons, and Other Protective Body Clothing. Appropriate
protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic
jackets, or similar outer garments shall be worn in occupational exposure
situations. The type and characteristics will depend upon the task and degree of
exposure anticipated.
1910.1030(d)(3)(xii)
Surgical caps or hoods and/or shoe covers or boots shall be worn in instances
when gross contamination can reasonably be anticipated (e.g., autopsies,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
orthopaedic surgery).
1910.1030(d)(4)
Housekeeping -1910.1030(d)(4)(i)
General. Employers shall ensure that the worksite is maintained in a clean and
sanitary condition. The employer shall determine and implement an appropriate
written schedule for cleaning and method of decontamination based upon the
location within the facility, type of surface to be cleaned, type of soil present,
and tasks or procedures being performed in the area.
1910.1030(d)(4)(ii)
All equipment and environmental and working surfaces shall be cleaned and
decontaminated after contact with blood or other potentially infectious
materials.
1910.1030(d)(4)(ii)(A)
Contaminated work surfaces shall be decontaminated with an appropriate
disinfectant after completion of procedures; immediately or as soon as feasible
when surfaces are overtly contaminated or after any spill of blood or other
potentially infectious materials; and at the end of the work shift if the surface
may have become contaminated since the last cleaning.
1910.1030(d)(4)(ii)(B)
Protective coverings, such as plastic wrap, aluminum foil, or imperviouslybacked absorbent paper used to cover equipment and environmental surfaces,
shall be removed and replaced as soon as feasible when they become overtly
contaminated or at the end of the workshift if they may have become
contaminated during the shift.
1910.1030(d)(4)(ii)(C)
All bins, pails, cans, and similar receptacles intended for reuse which have a
reasonable likelihood for becoming contaminated with blood or other potentially
infectious materials shall be inspected and decontaminated on a regularly
scheduled basis and cleaned and decontaminated immediately or as soon as
feasible upon visible contamination.
1910.1030(d)(4)(ii)(D)
Broken glassware which may be contaminated shall not be picked up directly
with the hands. It shall be cleaned up using mechanical means, such as a brush
and dust pan, tongs, or forceps.
1910.1030(d)(4)(ii)(E)
Reusable sharps that are contaminated with blood or other potentially infectious
materials shall not be stored or processed in a manner that requires employees
to reach by hand into the containers where these sharps have been placed.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(d)(4)(iii)
Regulated Waste -1910.1030(d)(4)(iii)(A)
Contaminated Sharps Discarding and Containment.
1910.1030(d)(4)(iii)(A)
(1)
Contaminated sharps shall be discarded immediately or as soon as feasible in
containers that are:
1910.1030(d)(4)(iii)(A)(1)(i)
Closable;
1910.1030(d)(4)(iii)(A)(1)(ii)
Puncture resistant;
1910.1030(d)(4)(iii)(A)(1)(iii)
Leakproof on sides and bottom; and
1910.1030(d)(4)(iii)(A)(1)(iv)
Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard.
1910.1030(d)(4)(iii)(A)(2)
During use, containers for contaminated sharps shall be:
1910.1030(d)(4)(iii)(A)
(2)(i)
Easily accessible to personnel and located as close as is feasible to the
immediate area where sharps are used or can be reasonably anticipated to be
found (e.g., laundries);
1910.1030(d)(4)(iii)(A)(2)(ii)
Maintained upright throughout use; and
1910.1030(d)(4)(iii)(A)(2)(iii)
Replaced routinely and not be allowed to overfill.
1910.1030(d)(4)(iii)(A)(3)
When moving containers of contaminated sharps from the area of use, the
containers shall be:
1910.1030(d)(4)(iii)(A)
(3)(i)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Closed immediately prior to removal or replacement to prevent spillage or
protrusion of contents during handling, storage, transport, or shipping;
1910.1030(d)(4)(iii)(A)(3)(ii)
Placed in a secondary container if leakage is possible. The second container
shall be:
1910.1030(d)(4)(iii)(A)(3)(ii)(A)
Closable;
1910.1030(d)(4)(iii)(A)(3)(ii)(B)
Constructed to contain all contents and prevent leakage during handling,
storage, transport, or shipping; and
1910.1030(d)(4)(iii)(A)(3)(ii)(C)
Labeled or color-coded according to paragraph (g)(1)(i) of this standard.
1910.1030(d)(4)(iii)(A)(4)
Reusable containers shall not be opened, emptied, or cleaned manually or in
any other manner which would expose employees to the risk of percutaneous
injury.
1910.1030(d)(4)(iii)(B)
Other Regulated Waste Containment -1910.1030(d)(4)(iii)(B)(1)
Regulated waste shall be placed in containers which are:
1910.1030(d)(4)(iii)(B)(1)(i)
Closable;
1910.1030(d)(4)(iii)(B)(1)(ii)
Constructed to contain all contents and prevent leakage of fluids during
handling, storage, transport or shipping;
1910.1030(d)(4)(iii)(B)(1)(iii)
Labeled or color-coded in accordance with paragraph (g)(1)(i) this standard;
and
1910.1030(d)(4)(iii)(B)(1)(iv)
Closed prior to removal to prevent spillage or protrusion of contents during
handling, storage, transport, or shipping.
1910.1030(d)(4)(iii)(B)(2)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
If outside contamination of the regulated waste container occurs, it shall be
placed in a second container. The second container shall be:
1910.1030(d)(4)(iii)(B)(2)(i)
Closable;
1910.1030(d)(4)(iii)(B)(2)(ii)
Constructed to contain all contents and prevent leakage of fluids during
handling, storage, transport or shipping;
1910.1030(d)(4)(iii)(B)(2)(iii)
Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard;
and
1910.1030(d)(4)(iii)(B)(2)(iv)
Closed prior to removal to prevent spillage or protrusion of contents during
handling, storage, transport, or shipping.
1910.1030(d)(4)(iii)(C)
Disposal of all regulated waste shall be in accordance with applicable
regulations of the United States, States and Territories, and political
subdivisions of States and Territories.
1910.1030(d)(4)(iv)
Laundry.
1910.1030(d)(4)(iv)(A)
Contaminated laundry shall be handled as little as possible with a minimum of
agitation.
1910.1030(d)(4)(iv)(A)(1)
Contaminated laundry shall be bagged or containerized at the location where it
was used and shall not be sorted or rinsed in the location of use.
1910.1030(d)(4)(iv)(A)(2)
Contaminated laundry shall be placed and transported in bags or containers
labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard.
When a facility utilizes Universal Precautions in the handling of all soiled
laundry, alternative labeling or color-coding is sufficient if it permits all
employees to recognize the containers as requiring compliance with Universal
Precautions.
1910.1030(d)(4)(iv)(A)(3)
Whenever contaminated laundry is wet and presents a reasonable likelihood of
soak-through of or leakage from the bag or container, the laundry shall be
placed and transported in bags or containers which prevent soak-through
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
and/or leakage of fluids to the exterior.
1910.1030(d)(4)(iv)(B)
The employer shall ensure that employees who have contact with contaminated
laundry wear protective gloves and other appropriate personal protective
equipment.
1910.1030(d)(4)(iv)(C)
When a facility ships contaminated laundry off-site to a second facility which
does not utilize Universal Precautions in the handling of all laundry, the facility
generating the contaminated laundry must place such laundry in bags or
containers which are labeled or color-coded in accordance with paragraph (g)(1)
(i).
1910.1030(e)
HIV and HBV Research Laboratories and Production Facilities.
1910.1030(e)(1)
This paragraph applies to research laboratories and production facilities
engaged in the culture, production, concentration, experimentation, and
manipulation of HIV and HBV. It does not apply to clinical or diagnostic
laboratories engaged solely in the analysis of blood, tissues, or organs. These
requirements apply in addition to the other requirements of the standard.
1910.1030(e)(2)
Research laboratories and production facilities shall meet the following criteria:
1910.1030(e)(2)(i)
Standard Microbiological Practices. All regulated waste shall either be
incinerated or decontaminated by a method such as autoclaving known to
effectively destroy bloodborne pathogens.
1910.1030(e)(2)(ii)
Special Practices.
1910.1030(e)(2)(ii)(A)
Laboratory doors shall be kept closed when work involving HIV or HBV is in
progress.
1910.1030(e)(2)(ii)(B)
Contaminated materials that are to be decontaminated at a site away from the
work area shall be placed in a durable, leakproof, labeled or color-coded
container that is closed before being removed from the work area.
1910.1030(e)(2)(ii)(C)
Access to the work area shall be limited to authorized persons. Written policies
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
and procedures shall be established whereby only persons who have been
advised of the potential biohazard, who meet any specific entry requirements,
and who comply with all entry and exit procedures shall be allowed to enter the
work areas and animal rooms.
1910.1030(e)(2)(ii)(D)
When other potentially infectious materials or infected animals are present in
the work area or containment module, a hazard warning sign incorporating the
universal biohazard symbol shall be posted on all access doors. The hazard
warning sign shall comply with paragraph (g)(1)(ii) of this standard.
1910.1030(e)(2)(ii)(E)
All activities involving other potentially infectious materials shall be conducted
in biological safety cabinets or other physical-containment devices within the
containment module. No work with these other potentially infectious materials
shall be conducted on the open bench.
1910.1030(e)(2)(ii)(F)
Laboratory coats, gowns, smocks, uniforms, or other appropriate protective
clothing shall be used in the work area and animal rooms. Protective clothing
shall not be worn outside of the work area and shall be decontaminated before
being laundered.
1910.1030(e)(2)(ii)(G)
Special care shall be taken to avoid skin contact with other potentially infectious
materials. Gloves shall be worn when handling infected animals and when
making hand contact with other potentially infectious materials is unavoidable.
1910.1030(e)(2)(ii)(H)
Before disposal all waste from work areas and from animal rooms shall either
be incinerated or decontaminated by a method such as autoclaving known to
effectively destroy bloodborne pathogens.
1910.1030(e)(2)(ii)(I)
Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency
particulate air (HEPA) filters or filters of equivalent or superior efficiency and
which are checked routinely and maintained or replaced as necessary.
1910.1030(e)(2)(ii)(J)
Hypodermic needles and syringes shall be used only for parenteral injection and
aspiration of fluids from laboratory animals and diaphragm bottles. Only needlelocking syringes or disposable syringe-needle units (i.e., the needle is integral
to the syringe) shall be used for the injection or aspiration of other potentially
infectious materials. Extreme caution shall be used when handling needles and
syringes. A needle shall not be bent, sheared, replaced in the sheath or guard,
or removed from the syringe following use. The needle and syringe shall be
promptly placed in a puncture-resistant container and autoclaved or
decontaminated before reuse or disposal.
1910.1030(e)(2)(ii)(K)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
All spills shall be immediately contained and cleaned up by appropriate
professional staff or others properly trained and equipped to work with
potentially concentrated infectious materials.
1910.1030(e)(2)(ii)(L)
A spill or accident that results in an exposure incident shall be immediately
reported to the laboratory director or other responsible person.
1910.1030(e)(2)(ii)(M)
A biosafety manual shall be prepared or adopted and periodically reviewed and
updated at least annually or more often if necessary. Personnel shall be advised
of potential hazards, shall be required to read instructions on practices and
procedures, and shall be required to follow them.
1910.1030(e)(2)(iii)
Containment Equipment.
1910.1030(e)(2)(iii)(A)
Certified biological safety cabinets (Class I, II, or III) or other appropriate
combinations of personal protection or physical containment devices, such as
special protective clothing, respirators, centrifuge safety cups, sealed centrifuge
rotors, and containment caging for animals, shall be used for all activities with
other potentially infectious materials that pose a threat of exposure to droplets,
splashes, spills, or aerosols.
1910.1030(e)(2)(iii)(B)
Biological safety cabinets shall be certified when installed, whenever they are
moved and at least annually.
1910.1030(e)(3)
HIV and HBV research laboratories shall meet the following criteria:
1910.1030(e)(3)(i)
Each laboratory shall contain a facility for hand washing and an eye wash
facility which is readily available within the work area.
1910.1030(e)(3)(ii)
An autoclave for decontamination of regulated waste shall be available.
1910.1030(e)(4)
HIV and HBV production facilities shall meet the following criteria:
1910.1030(e)(4)(i)
The work areas shall be separated from areas that are open to unrestricted
traffic flow within the building. Passage through two sets of doors shall be the
basic requirement for entry into the work area from access corridors or other
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
contiguous areas. Physical separation of the high-containment work area from
access corridors or other areas or activities may also be provided by a doubledoored clothes-change room (showers may be included), airlock, or other
access facility that requires passing through two sets of doors before entering
the work area.
1910.1030(e)(4)(ii)
The surfaces of doors, walls, floors and ceilings in the work area shall be water
resistant so that they can be easily cleaned. Penetrations in these surfaces shall
be sealed or capable of being sealed to facilitate decontamination.
1910.1030(e)(4)(iii)
Each work area shall contain a sink for washing hands and a readily available
eye wash facility. The sink shall be foot, elbow, or automatically operated and
shall be located near the exit door of the work area.
1910.1030(e)(4)(iv)
Access doors to the work area or containment module shall be self-closing.
1910.1030(e)(4)(v)
An autoclave for decontamination of regulated waste shall be available within or
as near as possible to the work area.
1910.1030(e)(4)(vi)
A ducted exhaust-air ventilation system shall be provided. This system shall
create directional airflow that draws air into the work area through the entry
area. The exhaust air shall not be recirculated to any other area of the building,
shall be discharged to the outside, and shall be dispersed away from occupied
areas and air intakes. The proper direction of the airflow shall be verified (i.e.,
into the work area).
1910.1030(e)(5)
Training Requirements. Additional training requirements for employees in
HIV and HBV research laboratories and HIV and HBV production facilities are
specified in paragraph (g)(2)(ix).
1910.1030(f)
Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up -1910.1030(f)(1)
General.
1910.1030(f)(1)(i)
The employer shall make available the hepatitis B vaccine and vaccination
series to all employees who have occupational exposure, and post-exposure
evaluation and follow-up to all employees who have had an exposure incident.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(f)(1)(ii)
The employer shall ensure that all medical evaluations and procedures including
the hepatitis B vaccine and vaccination series and post-exposure evaluation and
follow-up, including prophylaxis, are:
1910.1030(f)(1)(ii)(A)
Made available at no cost to the employee;
1910.1030(f)(1)(ii)(B)
Made available to the employee at a reasonable time and place;
1910.1030(f)(1)(ii)(C)
Performed by or under the supervision of a licensed physician or by or under
the supervision of another licensed healthcare professional; and
1910.1030(f)(1)(ii)(D)
Provided according to recommendations of the U.S. Public Health Service
current at the time these evaluations and procedures take place, except as
specified by this paragraph (f).
1910.1030(f)(1)(iii)
The employer shall ensure that all laboratory tests are conducted by an
accredited laboratory at no cost to the employee.
1910.1030(f)(2)
Hepatitis B Vaccination.
1910.1030(f)(2)(i)
Hepatitis B vaccination shall be made available after the employee has received
the training required in paragraph (g)(2)(vii)(I) and within 10 working days of
initial assignment to all employees who have occupational exposure unless the
employee has previously received the complete hepatitis B vaccination series,
antibody testing has revealed that the employee is immune, or the vaccine is
contraindicated for medical reasons.
1910.1030(f)(2)(ii)
The employer shall not make participation in a prescreening program a
prerequisite for receiving hepatitis B vaccination.
1910.1030(f)(2)(iii)
If the employee initially declines hepatitis B vaccination but at a later date while
still covered under the standard decides to accept the vaccination, the employer
shall make available hepatitis B vaccination at that time.
1910.1030(f)(2)(iv)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
The employer shall assure that employees who decline to accept hepatitis B
vaccination offered by the employer sign the statement in Appendix A.
1910.1030(f)(2)(v)
If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S.
Public Health Service at a future date, such booster dose(s) shall be made
available in accordance with section (f)(1)(ii).
1910.1030(f)(3)
Post-exposure Evaluation and Follow-up. Following a report of an exposure
incident, the employer shall make immediately available to the exposed
employee a confidential medical evaluation and follow-up, including at least the
following elements:
1910.1030(f)(3)(i)
Documentation of the route(s) of exposure, and the circumstances under which
the exposure incident occurred;
1910.1030(f)(3)(ii)
Identification and documentation of the source individual, unless the employer
can establish that identification is infeasible or prohibited by state or local law;
1910.1030(f)(3)(ii)(A)
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. If consent is
not obtained, the employer shall establish that legally required consent cannot
be obtained. When the source individual's consent is not required by law, the
source individual's blood, if available, shall be tested and the results
documented.
1910.1030(f)(3)(ii)(B)
When the source individual is already known to be infected with HBV or HIV,
testing for the source individual's known HBV or HIV status need not be
repeated.
1910.1030(f)(3)(ii)(C)
Results of the source individual's testing shall be made available to the exposed
employee, and the employee shall be informed of applicable laws and
regulations concerning disclosure of the identity and infectious status of the
source individual.
1910.1030(f)(3)(iii)
Collection and testing of blood for HBV and HIV serological status;
1910.1030(f)(3)(iii)(A)
The exposed employee's blood shall be collected as soon as feasible and tested
after consent is obtained.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(f)(3)(iii)(B)
If the employee consents to baseline blood collection, but does not give consent
at that time for HIV serologic testing, the sample shall be preserved for at least
90 days. If, within 90 days of the exposure incident, the employee elects to
have the baseline sample tested, such testing shall be done as soon as feasible.
1910.1030(f)(3)(iv)
Post-exposure prophylaxis, when medically indicated, as recommended by the
U.S. Public Health Service;
1910.1030(f)(3)(v)
Counseling; and
1910.1030(f)(3)(vi)
Evaluation of reported illnesses.
1910.1030(f)(4)
Information Provided to the Healthcare Professional.
1910.1030(f)(4)(i)
The employer shall ensure that the healthcare professional responsible for the
employee's Hepatitis B vaccination is provided a copy of this regulation.
1910.1030(f)(4)(ii)
The employer shall ensure that the healthcare professional evaluating an
employee after an exposure incident is provided the following information:
1910.1030(f)(4)(ii)(A)
A copy of this regulation;
1910.1030(f)(4)(ii)(B)
A description of the exposed employee's duties as they relate to the exposure
incident;
1910.1030(f)(4)(ii)(C)
Documentation of the route(s) of exposure and circumstances under which
exposure occurred;
1910.1030(f)(4)(ii)(D)
Results of the source individual's blood testing, if available; and
1910.1030(f)(4)(ii)(E)
All medical records relevant to the appropriate treatment of the employee
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
including vaccination status which are the employer's responsibility to maintain.
1910.1030(f)(5)
Healthcare Professional's Written Opinion. The employer shall obtain and
provide the employee with a copy of the evaluating healthcare professional's
written opinion within 15 days of the completion of the evaluation.
1910.1030(f)(5)(i)
The healthcare professional's written opinion for Hepatitis B vaccination shall be
limited to whether Hepatitis B vaccination is indicated for an employee, and if
the employee has received such vaccination.
1910.1030(f)(5)(ii)
The healthcare professional's written opinion for post-exposure evaluation and
follow-up shall be limited to the following information:
1910.1030(f)(5)(ii)(A)
That the employee has been informed of the results of the evaluation; and
1910.1030(f)(5)(ii)(B)
That the employee has been told about any medical conditions resulting from
exposure to blood or other potentially infectious materials which require further
evaluation or treatment.
1910.1030(f)(5)(iii)
All other findings or diagnoses shall remain confidential and shall not be
included in the written report.
1910.1030(f)(6)
Medical Recordkeeping. Medical records required by this standard shall be
maintained in accordance with paragraph (h)(1) of this section.
1910.1030(g)
Communication of Hazards to Employees -1910.1030(g)(1)
Labels and Signs -1910.1030(g)(1)(i)
Labels.
1910.1030(g)(1)(i)(A)
Warning labels shall be affixed to containers of regulated waste, refrigerators
and freezers containing blood or other potentially infectious material; and other
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
containers used to store, transport or ship blood or other potentially infectious
materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).
1910.1030(g)(1)(i)(B)
Labels required by this section shall include the following legend:
1910.1030(g)(1)(i)(C)
These labels shall be fluorescent orange or orange-red or predominantly so,
with lettering and symbols in a contrasting color.
1910.1030(g)(1)(i)(D)
Labels shall be affixed as close as feasible to the container by string, wire,
adhesive, or other method that prevents their loss or unintentional removal.
1910.1030(g)(1)(i)(E)
Red bags or red containers may be substituted for labels.
1910.1030(g)(1)(i)(F)
Containers of blood, blood components, or blood products that are labeled as to
their contents and have been released for transfusion or other clinical use are
exempted from the labeling requirements of paragraph (g).
1910.1030(g)(1)(i)(G)
Individual containers of blood or other potentially infectious materials that are
placed in a labeled container during storage, transport, shipment or disposal are
exempted from the labeling requirement.
1910.1030(g)(1)(i)(H)
Labels required for contaminated equipment shall be in accordance with this
paragraph and shall also state which portions of the equipment remain
contaminated.
1910.1030(g)(1)(i)(I)
Regulated waste that has been decontaminated need not be labeled or colorcoded.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
1910.1030(g)(1)(ii)
Signs.
1910.1030(g)(1)(ii)(A)
The employer shall post signs at the entrance to work areas specified in
paragraph (e), HIV and HBV Research Laboratory and Production Facilities,
which shall bear the following legend:
(Name of the Infectious Agent)
(Special requirements for entering the area)
(Name, telephone number of the laboratory director or other responsible
person.)
1910.1030(g)(1)(ii)(B)
These signs shall be fluorescent orange-red or predominantly so, with lettering
and symbols in a contrasting color.
1910.1030(g)(2)
Information and Training.
1910.1030(g)(2)(i)
Employers shall ensure that all employees with occupational exposure
participate in a training program which must be provided at no cost to the
employee and during working hours.
1910.1030(g)(2)(ii)
Training shall be provided as follows:
1910.1030(g)(2)(ii)(A)
At the time of initial assignment to tasks where occupational exposure may take
place;
1910.1030(g)(2)(ii)(B)
At least annually thereafter.
1910.1030(g)(2)(iii)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
[Reserved]
1910.1030(g)(2)(iv)
Annual training for all employees shall be provided within one year of their
previous training.
1910.1030(g)(2)(v)
Employers shall provide additional training when changes such as modification
of tasks or procedures or institution of new tasks or procedures affect the
employee's occupational exposure. The additional training may be limited to
addressing the new exposures created.
1910.1030(g)(2)(vi)
Material appropriate in content and vocabulary to educational level, literacy,
and language of employees shall be used.
1910.1030(g)(2)(vii)
The training program shall contain at a minimum the following elements:
1910.1030(g)(2)(vii)(A)
An accessible copy of the regulatory text of this standard and an explanation of
its contents;
1910.1030(g)(2)(vii)(B)
A general explanation of the epidemiology and symptoms of bloodborne
diseases;
1910.1030(g)(2)(vii)(C)
An explanation of the modes of transmission of bloodborne pathogens;
1910.1030(g)(2)(vii)(D)
An explanation of the employer's exposure control plan and the means by which
the employee can obtain a copy of the written plan;
1910.1030(g)(2)(vii)(E)
An explanation of the appropriate methods for recognizing tasks and other
activities that may involve exposure to blood and other potentially infectious
materials;
1910.1030(g)(2)(vii)(F)
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;
1910.1030(g)(2)(vii)(G)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Information on the types, proper use, location, removal, handling,
decontamination and disposal of personal protective equipment;
1910.1030(g)(2)(vii)(H)
An explanation of the basis for selection of personal protective equipment;
1910.1030(g)(2)(vii)(I)
Information on the hepatitis B vaccine, including information on its efficacy,
safety, method of administration, the benefits of being vaccinated, and that the
vaccine and vaccination will be offered free of charge;
1910.1030(g)(2)(vii)(J)
Information on the appropriate actions to take and persons to contact in an
emergency involving blood or other potentially infectious materials;
1910.1030(g)(2)(vii)(K)
An explanation of 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;
1910.1030(g)(2)(vii)(L)
Information on the post-exposure evaluation and follow-up that the employer is
required to provide for the employee following an exposure incident;
1910.1030(g)(2)(vii)(M)
An explanation of the signs and labels and/or color coding required by
paragraph (g)(1); and
1910.1030(g)(2)(vii)(N)
An opportunity for interactive questions and answers with the person
conducting the training session.
1910.1030(g)(2)(viii)
The person conducting the training shall be knowledgeable in the subject matter
covered by the elements contained in the training program as it relates to the
workplace that the training will address.
1910.1030(g)(2)(ix)
Additional Initial Training for Employees in HIV and HBV Laboratories and
Production Facilities. Employees in HIV or HBV research laboratories and HIV or
HBV production facilities shall receive the following initial training in addition to
the above training requirements.
1910.1030(g)(2)(ix)(A)
The employer shall assure that employees demonstrate proficiency in standard
microbiological practices and techniques and in the practices and operations
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
specific to the facility before being allowed to work with HIV or HBV.
1910.1030(g)(2)(ix)(B)
The employer shall assure that employees have prior experience in the handling
of human pathogens or tissue cultures before working with HIV or HBV.
1910.1030(g)(2)(ix)(C)
The employer shall provide a training program to employees who have no prior
experience in handling human pathogens. Initial work activities shall not include
the handling of infectious agents. A progression of work activities shall be
assigned as techniques are learned and proficiency is developed. The employer
shall assure that employees participate in work activities involving infectious
agents only after proficiency has been demonstrated.
1910.1030(h)
Recordkeeping -1910.1030(h)(1)
Medical Records.
1910.1030(h)(1)(i)
The employer shall establish and maintain an accurate record for each
employee with occupational exposure, in accordance with 29 CFR 1910.1020.
1910.1030(h)(1)(ii)
This record shall include:
1910.1030(h)(1)(ii)(A)
The name and social security number of the employee;
1910.1030(h)(1)(ii)(B)
A copy of the employee's hepatitis B vaccination status including the dates of all
the hepatitis B vaccinations and any medical records relative to the employee's
ability to receive vaccination as required by paragraph (f)(2);
1910.1030(h)(1)(ii)(C)
A copy of all results of examinations, medical testing, and follow-up procedures
as required by paragraph (f)(3);
1910.1030(h)(1)(ii)(D)
The employer's copy of the healthcare professional's written opinion as required
by paragraph (f)(5); and
1910.1030(h)(1)(ii)(E)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
A copy of the information provided to the healthcare professional as required by
paragraphs (f)(4)(ii)(B)(C) and (D).
1910.1030(h)(1)(iii)
Confidentiality. The employer shall ensure that employee medical records
required by paragraph (h)(1) are:
1910.1030(h)(1)(iii)(A)
Kept confidential; and
1910.1030(h)(1)(iii)(B)
Not disclosed or reported without the employee's express written consent to
any person within or outside the workplace except as required by this section or
as may be required by law.
1910.1030(h)(1)(iv)
The employer shall maintain the records required by paragraph (h) for at least
the duration of employment plus 30 years in accordance with 29 CFR
1910.1020.
1910.1030(h)(2)
Training Records.
1910.1030(h)(2)(i)
Training records shall include the following information:
1910.1030(h)(2)(i)(A)
The dates of the training sessions;
1910.1030(h)(2)(i)(B)
The contents or a summary of the training sessions;
1910.1030(h)(2)(i)(C)
The names and qualifications of persons conducting the training; and
1910.1030(h)(2)(i)(D)
The names and job titles of all persons attending the training sessions.
1910.1030(h)(2)(ii)
Training records shall be maintained for 3 years from the date on which the
training occurred.
1910.1030(h)(3)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Availability.
1910.1030(h)(3)(i)
The employer shall ensure that all records required to be maintained by this
section shall be made available upon request to the Assistant Secretary and the
Director for examination and copying.
1910.1030(h)(3)(ii)
Employee training records required by this paragraph shall be provided upon
request for examination and copying to employees, to employee
representatives, to the Director, and to the Assistant Secretary.
1910.1030(h)(3)(iii)
Employee medical records required by this paragraph shall be provided upon
request for examination and copying to the subject employee, to anyone having
written consent of the subject employee, to the Director, and to the Assistant
Secretary in accordance with 29 CFR 1910.1020.
1910.1030(h)(4)
Transfer of Records.
1910.1030(h)(4)(i)
The employer shall comply with the requirements involving transfer of records
set forth in 29 CFR 1910.1020(h).
1910.1030(h)(4)(ii)
If the employer ceases to do business and there is no successor employer to
receive and retain the records for the prescribed period, the employer shall
notify the Director, at least three months prior to their disposal and transmit
them to the Director, if required by the Director to do so, within that three
month period.
1910.1030(h)(5)
Sharps injury log.
1910.1030(h)(5)(i)
The employer shall establish and maintain a sharps injury log for the recording
of percutaneous injuries from contaminated sharps. The information in the
sharps injury log shall be recorded and maintained in such manner as to protect
the confidentiality of the injured employee. The sharps injury log shall contain,
at a minimum:
1910.1030(h)(5)(i)(A)
The type and brand of device involved in the incident,
1910.1030(h)(5)(i)(B)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
The department or work area where the exposure incident occurred, and
1910.1030(h)(5)(i)(C)
An explanation of how the incident occurred.
1910.1030(h)(5)(ii)
The requirement to establish and maintain a sharps injury log shall apply to any
employer who is required to maintain a log of occupational injuries and illnesses
under 29 CFR 1904.
1910.1030(h)(5)(iii)
The sharps injury log shall be maintained for the period required by 29 CFR
1904.6.
1910.1030(i)
Dates -1910.1030(i)(1)
Effective Date. The standard shall become effective on March 6, 1992.
1910.1030(i)(2)
The Exposure Control Plan required by paragraph (c) of this section shall be
completed on or before May 5, 1992.
1910.1030(i)(3)
Paragraph (g)(2) Information and Training and (h) Recordkeeping shall take
effect on or before June 4, 1992.
1910.1030(i)(4)
Paragraphs (d)(2) Engineering and Work Practice Controls, (d)(3) Personal
Protective Equipment, (d)(4) Housekeeping, (e) HIV and HBV Research
Laboratories and Production Facilities, (f) Hepatitis B Vaccination and PostExposure Evaluation and Follow-up, and (g)(1) Labels and Signs, shall take
effect July 6, 1992.
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57
FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996; 66 FR 5325 Jan., 18,
2001; 71 FR 16672 and 16673, April 3, 2006]
Next Standard (1910.1030 App A)
Regulations (Standards - 29 CFR) - Table of Contents
Back to Top
www.osha.gov
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[$
Bloodborne Pathogens Appendix B
Summary of CDC’s Guidelines for Infection Control
in Dental Health-Care Settings - 2003
New CDC Guidelines for Infection Control in Dental Health-Care Settings - 2003 were released
on December 19, 2003. These recommendations incorporate into a single document advances
in infection control knowledge and technology acquired since 1993. Furthermore, pertinent
recommendations found in regulatory documents from other agencies are also included. The
CDC endeavored to base recommendations upon sound scientific data, theoretical rationale and
applicability to dentistry. Recommendations were categorized by the quality of the supporting
data. Guidance is provided for infection control issues when insufficient evidence is available
to make a recommendation. Several research studies conducted by the ADA contributed to the
formulation of these recommendations. The following summary focuses on recommendations
and guidances that are new or modified from 1993 infection control recommendations.
NEW: Issue not addressed in the 1993 recommendations or substantially modified since 1993.
UPDATED: Issue previously addressed but updated with new information.
Standard Precautions. UPDATED. Standard precautions now supercede the use of universal
precautions. In 1996, CDC replaced universal precautions with Standard Precautions. Standard
precautions integrate and expand the elements of universal precautions into a standard of
care designed to protect health care providers and patients from pathogens that may be
spread by blood or any other body fluid, excretion, or secretion. Standard precautions apply to
contact with 1) blood; 2) all body fluids, secretions, and excretions except sweat, regardless of
whether they contain blood; 3) nonintact skin; and 4) mucous membranes. Airborne pathogen
transmission cannot be adequately prevented by standard precautions.
Oral Surgical Procedures. NEW. The oral cavity is colonized with numerous microorganisms.
Oral surgical procedures present an opportunity for entry of microorganisms (i.e., exogenous
and endogenous) into the vascular system and other normally sterile areas of the oral cavity
(e.g., bone, subcutaneous tissue) and an increased potential for localized or systemic infection.
Oral surgical procedures involve the incision, excision, or reflection of tissue that exposes the
normally sterile areas of the oral cavity. Examples include biopsy, periodontal surgery, apical
surgery, implant surgery, and surgical extractions of teeth (e.g., removal of erupted or nonerupted tooth, requiring elevation of mucoperiosteal flap, removal of bone and/or section of
tooth, and suturing if needed).
Sterile gloves and sterile water are recommended for all oral surgical procedures. Furthermore,
either plain soap and water or an antimicrobial soap and water followed by an alcohol-based
hand rub with persistent activity should be used before any oral surgical procedure. Persistent
activity refers to prolonged or extended activity that prevents or inhibits the proliferation or
survival of microorganisms after application of the product. After application of an alcoholbased product, hands and forearms should dry thoroughly before immediately donning sterile
gloves and other personal protective equipment (e.g., surgical mask, protective eyewear,
protective clothing).
31
Bloodborne Pathogens Appendix B
Dental Unit Water Quality. NEW. Dentists need to assure that the quality of water emanating
from their dental units does not exceed 500 colony-forming units per milliliter (CFU/mL). This
means that dental units directly plumbed to municipal water sources likely need to be retrofitted
with a self-contained water supply as soon as possible. Furthermore, all closed-circuit water
supply systems in dental units would require implementation of a regular schedule of water line
cleaning or disinfection to control biofilm proliferation. This schedule includes periodic microbial
enumeration to assure effluent below 500 CFU/mL. 500 CFU/mL is a realistic, achievable
microbial level for dental unit water, and is the EPA standard level for potable drinking water.
The previous recommendation to flush waterlines at the beginning of each clinic day has
been eliminated. If dental unit water treatments are successful in meeting the requirement
for 500 CFU/mL, then there is no reason to continue initial flushing. The recommendation
remains for flushing the high-speed handpiece for 20-30 seconds between patients to expel
any patient material.
Environmental Surface Disinfection. UPDATED. A tuberculocidal claim is no longer required
for environmental surface disinfectants. Disinfectants carrying a virucidal claim for HBV and
HIV are now permitted; giving dentists a greater choice of available disinfectants, which may
be less corrosive to equipment, have a more pleasant odor or lower toxic potential than some
tuberculocidal products. Many surrogate tests for HBV or HCV virucidal activity have been
recently developed and have been accepted by the EPA as predictive of virucidal activity. As
a result many more disinfectants now carry a label claim of efficacy against HBV, HCV, HIV
as well as a host of pathogenic bacteria and fungi. This recommendation is consistent with the
OSHA bloodborne pathogens standard recommendations. Furthermore, disinfectants that carry
a TB kill claim can continue to be used as surface disinfectants, but do not use glutaraldehyde
based products for surface disinfection.
Immunization. UPDATED. Immunization of DHCP (dental health care providers) before they
are placed at risk remains the most efficient and effective use of vaccines in health-care
settings. Detailed recommendations and immunization schedule are provided for immunization
of dental health care providers against several pathogenic organisms for which vaccines are
available. Earliest possible hepatitis B vaccination continues to be recommended, along with
post vaccination testing for surface antibody within 1 to 2 months following the final inoculation.
Booster inoculation for individuals who have lost surface antibody titers continues not to be
recommended.
Work restrictions for health care personnel occupationally exposed to or infected
with infectious diseases. NEW. The use of standard precautions is effective in preventing
transmission of an infectious agent from provider to patient. Under certain circumstances,
however, health care facilities may need to implement additional measures to prevent further
transmission of infection that warrant exclusion of personnel from work or patient contact.
Decisions on work restrictions are based on the mode of transmission and the epidemiology
of the disease. Exclusion policies should be written, include a statement of authority defining
who may exclude personnel (e.g., personal physician), and be clearly communicated to
personnel through education and training. Policies also need to be designed to encourage
personnel to report their illnesses or exposures and not to penalize them with loss of wages,
benefits or job status.
32
Bloodborne Pathogens Appendix B
Management of occupational exposures to bloodborne pathogens, including
postexposure prophylaxis (PEP). NEW. Follow current CDC recommendations for
postexposure management and prophylaxis after percutaneous, mucous membrane, or nonintact skin exposure to blood or blood-contaminated saliva. Many effective antiviral therapies
were discovered over the past decade resulting in modified approaches to PEP. The US Public
Health Service (USPHS) published several guidelines for the management of exposures to
HBV, HCV, or HIV that included considerations for PEP and management.
The USPHS consolidated into one set of guidelines (MMWR June 29, 2001/ Vol. 50/ No. RR11) all previous USPHS recommendations. Current guidelines reflect the availability of new
antiretroviral agents, new information about the use and safety of HIV PEP, and considerations
about employing HIV PEP when resistance of the source patient’s virus to antiretroviral agents
is known or suspected. In addition, the 2001 document provides guidance to clinicians and
exposed HCP on deciding when to consider HIV PEP and recommendations for PEP regimens.
Selection and use of devices with features engineered to prevent sharps injury. NEW.
Improved safety devices continue to emerge for the prevention of percutaneous injuries, and
DHCPs are encouraged to use and evaluate these new devices as they become available (e.g.,
safer anesthetic syringes, blunt suture needle, retractable scalpel, needleless IV system).
Hand hygiene. UPDATED. Reduction of the bioburden on the skin of hands is one of the most
important methods of reducing microbial transmission in a health care setting. When hands
are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood
or other body fluids, perform hand hygiene with either a non-antimicrobial soap and water or
an antimicrobial soap and water. If hands are not visibly soiled, a nonantimicrobial soap, an
antimicrobial soap or an alcohol-based hand rub may be used.
Contact dermatitis and latex hypersensitivity. NEW. Dental health care providers must
familiarize themselves about the signs, symptoms, and diagnoses of skin reactions associated
with frequent hand hygiene and glove use. Immediate and delayed hypersensitivities have
been associated with natural rubber latex (NRL) proteins and processing chemicals used in the
manufacture of NRL gloves. Lotions should be used to prevent skin dryness associated with hand
washing at the end of the workday. Lotions must be compatible with antiseptic products and must
not compromise the integrity of gloves. Petroleum-based lotions will degrade NRL gloves.
Flash sterilization. NEW. Patient care items routinely should not be sterilized unwrapped.
Use must be limited to emergency situations where time does not permit wrapped, full cycle
heat sterilization.
Boil-water advisories. NEW. While a boil-water advisory is in effect do not deliver water
from the public water system to the patient through the dental operative unit, ultrasonic scaler,
or other dental equipment that uses the public water system. Do not use water from the
public water system for dental treatment, patient rinsing or hand washing. Use antimicrobialcontaining products for hand washing that does not require water for use such as alcoholbased hand rubs. If hands are visibly soiled, use bottled water and soap for hand washing or
a detergent-containing towelette. When the boil-water advisory is cancelled follow guidance
given by the local water utility on proper flushing of waterlines. If no guidance is provided, flush
dental waterlines and faucets for 1 to 5 minutes before using for patient care. Disinfect dental
waterlines as recommended by the dental unit manufacturer.
33
Bloodborne Pathogens Appendix B
Aseptic technique for parenteral medications. NEW. Medication from a single-dose syringe
must not be administered to multiple patients even if the needle on the syringe is changed.
Use single-dose vials for parenteral additives or medications when possible. Do not combine
the leftover content of single-use vials for later use. If multiple dose vials are used, cleanse the
access diaphragm of multiple dose vials with 70% alcohol before inserting a device into the vial.
Use a sterile device to access a multiple dose vial and avoid touch contamination of the device
before penetrating the access diaphragm. Refrigerate multiple dose vials after they are opened
if recommended by the manufacturer. Discard a multiple dose vial if sterility is compromised. All
fluid infusion and administration sets (IV tubing and connections) are single patient use.
Pre-procedural mouth rinsing for patients. NEW. To date, no scientific evidence indicates that
pre-procedural mouth rinsing prevents clinical infections among DHCP or patients. Therefore,
only guidance is provided without recommendation. However, studies have shown that a
pre-procedural rinse with a long-lasting antimicrobial (e.g., chlorhexidine gluconate, essential oils,
povidone-iodine) can reduce the level of oral microorganisms generated during routine dental
procedures with rotary instruments (e.g., dental handpieces, ultrasonic scalers). Pre-procedural
mouth rinses may be most beneficial before a procedure using a prophylaxis cup or ultrasonic
scaler because rubber dams cannot be used to minimize aerosol and spatter generation; unless
the provider has an assistant, high-volume evacuation is not commonly used.
Transmissible spongiform encephalopathies (TSEs). NEW. There is no evidence to
indicate that TSEs are transmissible in a dental setting. Nevertheless, guidances but not
recommendations are provided for preventing the transmission of prionic protein from an
infected patient requiring dental care. The use of disposable items is encouraged along with
chemical pretreatment followed by prolonged steam sterilization for non-disposable items.
Handling of Extracted Teeth. UPDATED. Extracted teeth containing amalgam should not
be disposed of in regulated medical waste intended for incineration. Incineration will vaporize
mercury.
Program evaluation. NEW. Dental facilities should establish an infection control program
evaluation, based on evaluation of performance indicators at an established frequency. The
primary goal of an infection control program is to prevent errors and provide a safe working
environment that will reduce the risk of health-care-associated infections among patients
and occupational exposures among DHCP. Medical errors are caused by faulty systems,
processes, and conditions that lead people to make mistakes or fail to prevent them. Effective
program evaluation is a systematic way to improve and account for safe public health actions
by involving procedures that are useful, feasible, ethical, and accurate.
34
Bloodborne Pathogens Appendix B
Bloodborne Pathogens Appendix C
66
MMWR
December 19, 2003
Appendix C
Methods for Sterilizing and Disinfecting Patient-Care Items
and Environmental Surfaces*
Health-care application
Process
Sterilization
Result
Destroys all microorganisms, including bacterial
spores.
Method
Heat-automated
High temperature
Examples
Type of
patient-care item
Environmental
surfaces
Not applicable
Steam, dry heat, unsaturated chemical vapor
Heat-tolerant critical
and semicritical
Ethylene oxide gas, plasma sterilization
Heat-sensitive critical
and semicritical
Liquid immersion†
Chemical sterilants. Glutaraldehyde,
glutaraldehydes with phenol, hydrogen
peroxide, hydrogen peroxide with peracetic acid,
peracetic acid
Heat-sensitive critical
and semicritical
Destroys all microorganisms, but not necessarily
high numbers of bacterial
spores.
Heat-automated
Washer-disinfector
Heat-sensitive
semicritical
Not applicable
Liquid immersion†
Chemical sterilants/high-level disinfectants.
Glutaraldehyde, glutaraldehyde with phenol,
hydrogen peroxide, hydrogen peroxide with
peracetic acid, ortho-phthalaldehyde
Intermediatelevel
disinfection
Destroys vegetative bacteria
and the majority of fungi and
viruses. Inactivates
Mycobacterium bovis.§ Not
necessarily capable of killing
bacterial spores.
Liquid contact
U.S. Environmental Protection Agency (EPA)registered hospital disinfectant with label claim
of tuberculocidal activity (e.g., chlorinecontaining products, quaternary ammonium
compounds with alcohol, phenolics, iodophors,
EPA-registered chlorine-based product¶)
Noncritical with visible
blood
Clinical contact
surfaces; blood
spills on
housekeeping
surfaces
Low-level
disinfection
Destroys the majority of
vegetative bacteria, certain
fungi, and viruses. Does not
inactivate Mycobacterium
bovis .§
Liquid contact
EPA-registered hospital disinfectant with no
label claim regarding tuberculocidal activity.**
The Occupational Safety and Health Administration also requires label claims of human
immunodeficiency virus (HIV) and hepatitis B
virus (HBV) potency for clinical contact surfaces
(e.g., quaternary ammonium compounds, some
phenolics, some iodophors)
Noncritical without
visible blood
Clinical contact
surfaces;
housekeeping
surfaces
Low temperature
High-level
disinfection
* EPA and the Food and Drug Administration (FDA) regulate chemical germicides used in health-care settings. FDA regulates chemical sterilants used on critical and semicritical
medical devices, and the EPA regulates gaseous sterilants and liquid chemical disinfectants used on noncritical surfaces. FDA also regulates medical devices, including
sterilizers. More information is available at 1) http://www.epa.gov/oppad001/chemregindex.htm, 2) http://www.fda.gov/cdrh/index.html, and 3) http://www.fda.gov/cdrh/ode/
germlab.html.
† Contact time is the single critical variable distinguishing the sterilization process from high-level disinfection with FDA-cleared liquid chemical sterilants. FDA defines a high-level
disinfectant as a sterilant used under the same contact conditions as sterilization except for a shorter immersion time (C-1).
§ The tuberculocidal claim is used as a benchmark to measure germicidal potency. Tuberculosis (TB) is transmitted via the airborne route rather than by environmental surfaces
and, accordingly, use of such products on environmental surfaces plays no role in preventing the spread of TB. Because mycobacteria have among the highest intrinsic levels of
resistance among vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e., an intermediate-level disinfectant) is considered capable of
inactivating a broad spectrum of pathogens, including much less resistant organisms, including bloodborne pathogens (e.g., HBV, hepatitis C virus [HCV], and HIV). It is this
broad-spectrum capability, rather than the product’s specific potency against mycobacteria, that is the basis for protocols and regulations dictating use of tuberculocidal
chemicals for surface disinfection.
¶ Chlorine-based products that are EPA-registered as intermediate-level disinfectants are available commercially. In the absence of an EPA-registered chlorine-based product, a
fresh solution of sodium hypochlorite (e.g., household bleach) is an inexpensive and effective intermediate-level germicide. Concentrations ranging from 500 ppm to 800 ppm of
chlorine (1:100 dilution of 5.25% bleach and tap water, or approximately ¼ cup of 5.25% bleach to 1 gallon of water) are effective on environmental surfaces that have been
cleaned of visible contamination. Appropriate personal protective equipment (e.g., gloves and goggles) should be worn when preparing hypochlorite solutions (C-2,C-3). Caution
should be exercised, because chlorine solutions are corrosive to metals, especially aluminum.
** Germicides labeled as “hospital disinfectant” without a tuberculocidal claim pass potency tests for activity against three representative microorganisms: Pseudomonas aeruginosa,
Staphylococcus aureus, and Salmonella choleraesuis.
References
C-1. Food and Drug Administration. Guidance for industry and FDA
reviewers: content and format of premarket notification [510(k)] submissions for liquid chemical sterilants/high level disinfectants. Rockville,
MD: US Department of Health and Human Services, Food and Drug
Administration, 2000. Available at http://www.fda.gov/cdrh/ode/
397.pdf.
C-2. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne
pathogens; needlesticks and other sharps injuries; final rule. Federal
Register 2001;66:5317–25. As amended from and includes 29 CFR
Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64174–82. Available at http://www.
osha.gov/SLTC/dentistry/index.html.
C-3. CDC. Guidelines for environmental infection control in health-care
facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003;52(No.
RR-10).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[&
Bloodborne Pathogens Appendix D
Morbidity and Mortality Weekly Report
Recommendations and Reports
December 19, 2003 / Vol. 52 / No. RR-17
Guidelines for Infection Control
in Dental Health-Care Settings — 2003
INSIDE: Continuing Education Examination
depar
tment of health and human ser
vices
department
services
Centers for Disease Control and Prevention
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
MMWR
CONTENTS
The MMWR series of publications is published by the
Epidemiology Program Office, Centers for Disease
Control and Prevention (CDC), U.S. Department of
Health and Human Services, Atlanta, GA 30333.
SUGGESTED CITATION
Centers for Disease Control and Prevention. Guidelines
for Infection Control in Dental Health-Care Settings
— 2003. MMWR 2003;52(No. RR-17):[inclusive page
numbers].
Centers for Disease Control and Prevention
Julie L. Gerberding, M.D., M.P.H.
Director
Dixie E. Snider, Jr., M.D., M.P.H.
(Acting) Deputy Director for Public Health Science
Susan Y. Chu, Ph.D., M.S.P.H.
(Acting) Associate Director for Science
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc.
Director
Office of Scientific and Health Communications
John W. Ward, M.D.
Director
Editor, MMWR Series
Suzanne M. Hewitt, M.P.A.
Managing Editor, MMWR Series
C. Kay Smith-Akin, M.Ed.
Lead Technical Writer/Editor
C. Kay Smith-Akin, M.Ed.
Douglas W. Weatherwax
Project Editors
Beverly J. Holland
Lead Visual Information Specialist
Malbea A. LaPete
Visual Information Specialist
Kim L. Bright, M.B.A.
Quang M. Doan, M.B.A.
Erica R. Shaver
Information Technology Specialists
Introduction ......................................................................... 1
Background ......................................................................... 2
Previous Recommendations .............................................. 3
Selected Definitions .......................................................... 4
Review of Science Related to Dental Infection Control ......... 6
Personnel Health Elements of an Infection-Control
Program .......................................................................... 6
Preventing Transmission
of Bloodborne Pathogens ................................................ 10
Hand Hygiene ................................................................ 14
Personal Protective Equipment ........................................ 16
Contact Dermatitis and Latex Hypersensitivity ................. 19
Sterilization and Disinfection of Patient-Care Items ......... 20
Environmental Infection Control ..................................... 25
Dental Unit Waterlines, Biofilm, and Water Quality ......... 28
Special Considerations ...................................................... 30
Dental Handpieces and Other Devices Attached
to Air and Waterlines .................................................... 30
Saliva Ejectors ................................................................ 31
Dental Radiology ............................................................ 31
Aseptic Technique for Parenteral Medications ................. 31
Single-Use or Disposable Devices ................................... 32
Preprocedural Mouth Rinses ........................................... 32
Oral Surgical Procedures ................................................ 32
Handling of Biopsy Specimens ........................................ 33
Handling of Extracted Teeth ............................................ 33
Dental Laboratory ........................................................... 33
Laser/Electrosurgery Plumes or Surgical Smoke .............. 34
M. tuberculosis ................................................................. 35
Creutzfeldt-Jakob Disease and Other Prion Diseases ...... 36
Program Evaluation ........................................................ 37
Infection-Control Research Considerations ..................... 38
Recommendations ............................................................. 39
Infection-Control Internet Resources ................................. 48
Acknowledgement ............................................................. 48
References ......................................................................... 48
Appendix A ....................................................................... 62
Appendix B ........................................................................ 65
Appendix C ....................................................................... 66
Continuing Education Activity* ....................................... CE-1
* For Continuing Dental Education (CDE), see http://www.ada.org.
To request additional copies of this report, contact CDC's Division
of Oral Health by e-mail: [email protected]; telephone: 770-4886054; or fax: 770-488-6080.
Disclosure of Relationship
Our subject matter experts wish to disclose they have no financial
interests or other relationships with the manufacture of commercial
products, providers of commercial services, or commercial supporters.
This report does not include any discussion of the unlabeled use of
commercial products or products for investigational use.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
1
Guidelines for Infection Control
in Dental Health-Care Settings — 2003
Prepared by
William G. Kohn, D.D.S.1
Amy S. Collins, M.P.H.1
Jennifer L. Cleveland, D.D.S.1
Jennifer A. Harte, D.D.S.2
Kathy J. Eklund, M.H.P.3
Dolores M. Malvitz, Dr.P.H.1
1
Division of Oral Health
National Center for Chronic Disease Prevention and Health Promotion, CDC
2
United States Air Force Dental Investigation Service
Great Lakes, Illinois
3
The Forsyth Institute
Boston, Massachusetts
Summary
This report consolidates previous recommendations and adds new ones for infection control in dental settings. Recommendations
are provided regarding 1) educating and protecting dental health-care personnel; 2) preventing transmission of bloodborne pathogens; 3) hand hygiene; 4) personal protective equipment; 5) contact dermatitis and latex hypersensitivity; 6) sterilization and
disinfection of patient-care items; 7) environmental infection control; 8) dental unit waterlines, biofilm, and water quality; and
9) special considerations (e.g., dental handpieces and other devices, radiology, parenteral medications, oral surgical procedures, and
dental laboratories). These recommendations were developed in collaboration with and after review by authorities on infection
control from CDC and other public agencies, academia, and private and professional organizations.
Introduction
This report consolidates recommendations for preventing
and controlling infectious diseases and managing personnel
health and safety concerns related to infection control in dental settings. This report 1) updates and revises previous CDC
recommendations regarding infection control in dental settings (1,2); 2) incorporates relevant infection-control measures
from other CDC guidelines; and 3) discusses concerns not
addressed in previous recommendations for dentistry. These
updates and additional topics include the following:
• application of standard precautions rather than universal
precautions;
• work restrictions for health-care personnel (HCP) infected
with or occupationally exposed to infectious diseases;
• management of occupational exposures to bloodborne
pathogens, including postexposure prophylaxis (PEP) for
work exposures to hepatitis B virus (HBV), hepatitis C
virus (HCV); and human immunodeficiency virus (HIV);
• selection and use of devices with features designed to prevent sharps injury;
The material in this report originated in the National Center for Chronic
Disease Prevention and Health Promotion, James S. Marks, M.D.,
M.P.H., Director; and the Division of Oral Health, William R. Maas,
D.D.S., M.P.H., Director.
•
•
•
•
hand-hygiene products and surgical hand antisepsis;
contact dermatitis and latex hypersensitivity;
sterilization of unwrapped instruments;
dental water-quality concerns (e.g., dental unit waterline
biofilms; delivery of water of acceptable biological quality
for patient care; usefulness of flushing waterlines; use of
sterile irrigating solutions for oral surgical procedures;
handling of community boil-water advisories);
• dental radiology;
• aseptic technique for parenteral medications;
• preprocedural mouth rinsing for patients;
• oral surgical procedures;
• laser/electrosurgery plumes;
• tuberculosis (TB);
• Creutzfeldt-Jakob disease (CJD) and other prion-related
diseases;
• infection-control program evaluation; and
• research considerations.
These guidelines were developed by CDC staff members in
collaboration with other authorities on infection control. Draft
documents were reviewed by other federal agencies and professional organizations from the fields of dental health care, public
health, and hospital epidemiology and infection control. A Federal Register notice elicited public comments that were considered in the decision-making process. Existing guidelines and
published research pertinent to dental infection-control prin-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
2
MMWR
ciples and practices were reviewed. Wherever possible, recommendations are based on data from well-designed scientific studies. However, only a limited number of studies have characterized
risk factors and the effectiveness of prevention measures for
infections associated with dental health-care practices.
Some infection-control practices routinely used by healthcare practitioners cannot be rigorously examined for ethical or
logistical reasons. In the absence of scientific evidence for such
practices, certain recommendations are based on strong theoretical rationale, suggestive evidence, or opinions of respected
authorities based on clinical experience, descriptive studies, or
committee reports. In addition, some recommendations are
derived from federal regulations. No recommendations are
offered for practices for which insufficient scientific evidence
or lack of consensus supporting their effectiveness exists.
Background
In the United States, an estimated 9 million persons work in
health-care professions, including approximately 168,000 dentists, 112,000 registered dental hygienists, 218,000 dental
assistants (3), and 53,000 dental laboratory technicians (4).
In this report, dental health-care personnel (DHCP) refers to
all paid and unpaid personnel in the dental health-care setting
who might be occupationally exposed to infectious materials,
including body substances and contaminated supplies, equipment, environmental surfaces, water, or air. DHCP include
dentists, dental hygienists, dental assistants, dental laboratory
technicians (in-office and commercial), students and trainees,
contractual personnel, and other persons not directly involved
in patient care but potentially exposed to infectious agents (e.g.,
administrative, clerical, housekeeping, maintenance, or volunteer personnel). Recommendations in this report are
designed to prevent or reduce potential for disease transmission from patient to DHCP, from DHCP to patient, and from
patient to patient. Although these guidelines focus mainly on
outpatient, ambulatory dental health-care settings, the recommended infection-control practices are applicable to all settings in which dental treatment is provided.
Dental patients and DHCP can be exposed to pathogenic
microorganisms including cytomegalovirus (CMV), HBV,
HCV, herpes simplex virus types 1 and 2, HIV, Mycobacterium tuberculosis, staphylococci, streptococci, and other viruses
and bacteria that colonize or infect the oral cavity and respiratory tract. These organisms can be transmitted in dental settings through 1) direct contact with blood, oral fluids, or other
patient materials; 2) indirect contact with contaminated
objects (e.g., instruments, equipment, or environmental surfaces); 3) contact of conjunctival, nasal, or oral mucosa with
December 19, 2003
droplets (e.g., spatter) containing microorganisms generated
from an infected person and propelled a short distance (e.g.,
by coughing, sneezing, or talking); and 4) inhalation of airborne microorganisms that can remain suspended in the air
for long periods (5).
Infection through any of these routes requires that all of the
following conditions be present:
• a pathogenic organism of sufficient virulence and in
adequate numbers to cause disease;
• a reservoir or source that allows the pathogen to survive
and multiply (e.g., blood);
• a mode of transmission from the source to the host;
• a portal of entry through which the pathogen can enter
the host; and
• a susceptible host (i.e., one who is not immune).
Occurrence of these events provides the chain of infection (6).
Effective infection-control strategies prevent disease transmission by interrupting one or more links in the chain.
Previous CDC recommendations regarding infection control for dentistry focused primarily on the risk of transmission
of bloodborne pathogens among DHCP and patients and use
of universal precautions to reduce that risk (1,2,7,8). Universal precautions were based on the concept that all blood and
body fluids that might be contaminated with blood should be
treated as infectious because patients with bloodborne infections can be asymptomatic or unaware they are infected (9,10).
Preventive practices used to reduce blood exposures, particularly percutaneous exposures, include 1) careful handling of
sharp instruments, 2) use of rubber dams to minimize blood
spattering; 3) handwashing; and 4) use of protective barriers
(e.g., gloves, masks, protective eyewear, and gowns).
The relevance of universal precautions to other aspects of
disease transmission was recognized, and in 1996, CDC
expanded the concept and changed the term to standard precautions. Standard precautions integrate and expand the elements of universal precautions into a standard of care designed
to protect HCP and patients from pathogens that can be spread
by blood or any other body fluid, excretion, or secretion (11).
Standard precautions apply to contact with 1) blood; 2) all
body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) nonintact skin; and 4)
mucous membranes. Saliva has always been considered a
potentially infectious material in dental infection control; thus,
no operational difference exists in clinical dental practice
between universal precautions and standard precautions.
In addition to standard precautions, other measures (e.g.,
expanded or transmission-based precautions) might be necessary to prevent potential spread of certain diseases (e.g., TB,
influenza, and varicella) that are transmitted through airborne,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
droplet, or contact transmission (e.g., sneezing, coughing, and
contact with skin) (11). When acutely ill with these diseases,
patients do not usually seek routine dental outpatient care.
Nonetheless, a general understanding of precautions for diseases transmitted by all routes is critical because 1) some DHCP
are hospital-based or work part-time in hospital settings;
2) patients infected with these diseases might seek urgent treatment at outpatient dental offices; and 3) DHCP might
become infected with these diseases. Necessary transmissionbased precautions might include patient placement (e.g., isolation), adequate room ventilation, respiratory protection (e.g.,
N-95 masks) for DHCP, or postponement of nonemergency
dental procedures.
DHCP should be familiar also with the hierarchy of controls that categorizes and prioritizes prevention strategies (12).
For bloodborne pathogens, engineering controls that eliminate or isolate the hazard (e.g., puncture-resistant sharps containers or needle-retraction devices) are the primary strategies
for protecting DHCP and patients. Where engineering controls are not available or appropriate, work-practice controls
that result in safer behaviors (e.g., one-hand needle recapping
or not using fingers for cheek retraction while using sharp
instruments or suturing), and use of personal protective equipment (PPE) (e.g., protective eyewear, gloves, and mask) can
prevent exposure (13). In addition, administrative controls
(e.g., policies, procedures, and enforcement measures targeted
at reducing the risk of exposure to infectious persons) are a
priority for certain pathogens (e.g., M. tuberculosis), particularly those spread by airborne or droplet routes.
Dental practices should develop a written infection-control
program to prevent or reduce the risk of disease transmission.
Such a program should include establishment and implementation of policies, procedures, and practices (in conjunction
with selection and use of technologies and products) to prevent work-related injuries and illnesses among DHCP as well
as health-care–associated infections among patients. The program should embody principles of infection control and
occupational health, reflect current science, and adhere to relevant federal, state, and local regulations and statutes. An
infection-control coordinator (e.g., dentist or other DHCP)
knowledgeable or willing to be trained should be assigned
responsibility for coordinating the program. The effectiveness
of the infection-control program should be evaluated on a dayto-day basis and over time to help ensure that policies, procedures, and practices are useful, efficient, and successful (see
Program Evaluation).
Although the infection-control coordinator remains responsible for overall management of the program, creating and maintaining a safe work environment ultimately requires the
3
commitment and accountability of all DHCP. This report is
designed to provide guidance to DHCP for preventing disease
transmission in dental health-care settings, for promoting a safe
working environment, and for assisting dental practices in
developing and implementing infection-control programs. These
programs should be followed in addition to practices and procedures for worker protection required by the Occupational
Safety and Health Administration’s (OSHA) standards for
occupational exposure to bloodborne pathogens (13),
including instituting controls to protect employees from
exposure to blood or other potentially infectious materials
(OPIM), and requiring implementation of a written exposurecontrol plan, annual employee training, HBV vaccinations, and
postexposure follow-up (13). Interpretations and enforcement
procedures are available to help DHCP apply this OSHA standard in practice (14). Also, manufacturer’s Material Safety Data
Sheets (MSDS) should be consulted regarding correct procedures for handling or working with hazardous chemicals (15).
Previous Recommendations
This report includes relevant infection-control measures from
the following previously published CDC guidelines and recommendations:
• CDC. Guideline for disinfection and sterilization in
health-care facilities: recommendations of CDC and the
Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR (in press).
• CDC. Guidelines for environmental infection control in
health-care facilities: recommendations of CDC and the
Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003;52(No. RR-10).
• CDC. Guidelines for the prevention of intravascular
catheter-related infections. MMWR 2002;51(No. RR-10).
• CDC. Guideline for hand hygiene in health-care settings:
recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/
APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51
(No. RR-16).
• CDC. Updated U.S. Public Health Service guidelines for
the management of occupational exposures to HBV, HCV,
and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(No. RR-11).
• Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis
WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection,
1999. Infect Control Hosp Epidemiol 1999;20:250–78.
• Bolyard EA, Tablan OC, Williams WW, Pearson ML,
Shapiro CN, Deitchman SD, Hospital Infection Control
Practices Advisory Committee. Guideline for infection
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
4
MMWR
•
•
•
•
•
•
•
•
control in health care personnel, 1998. Am J Infect Control 1998;26:289–354.
CDC. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices
Advisory Committee (HICPAC). MMWR 1997;46(No.
RR-18).
Rutala WA, Association for Professionals in Infection
Control and Epidemiology, Inc. APIC guideline for selection and use of disinfectants. Am J Infect Control
1996;24:313–42.
Garner JS, Hospital Infection Control Practices Advisory
Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53–80.
Larson EL, 1992, 1993, and 1994 Guidelines Committee.
APIC guideline for handwashing and hand antisepsis in
health-care settings. Am J Infect Control 1995;23:251–69.
CDC. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in health-care facilities, 1994.
MMWR 1994;43(No. RR-13).
CDC. Recommendations for preventing transmission of
human immunodeficiency virus and hepatitis B virus to
patients during exposure-prone invasive procedures.
MMWR 1991;40(No. RR-8).
Garner JS. CDC guideline for prevention of surgical
wound infections, 1985. Supersedes guideline for prevention of surgical wound infections published in 1982.
(Originally published in November 1985). Revised.
Infect Control 1986;7:193–200.
Garner JS, Favero MS. CDC guideline for handwashing
and hospital environmental control, 1985. Infect Control
1986;7:231–43.
Selected Definitions
Alcohol-based hand rub: An alcohol-containing preparation
designed for reducing the number of viable microorganisms
on the hands.
Antimicrobial soap: A detergent containing an antiseptic agent.
Antiseptic: A germicide used on skin or living tissue for the
purpose of inhibiting or destroying microorganisms (e.g.,
alcohols, chlorhexidine, chlorine, hexachlorophene, iodine,
chloroxylenol [PCMX], quaternary ammonium compounds,
and triclosan).
Bead sterilizer: A device using glass beads 1.2–1.5 mm
diameter and temperatures 217ºC–232ºC for brief exposures
(e.g., 45 seconds) to inactivate microorganisms. (This term is
actually a misnomer because it has not been cleared by the
Food and Drug Administration [FDA] as a sterilizer).
December 19, 2003
Bioburden: Microbiological load (i.e., number of viable
organisms in or on an object or surface) or organic material on
a surface or object before decontamination, or sterilization.
Also known as bioload or microbial load.
Colony-forming unit (CFU): The minimum number (i.e.,
tens of millions) of separable cells on the surface of or in semisolid agar medium that give rise to a visible colony of progeny.
CFUs can consist of pairs, chains, clusters, or as single cells
and are often expressed as colony-forming units per milliliter
(CFUs/mL).
Decontamination: Use of physical or chemical means to
remove, inactivate, or destroy pathogens on a surface or item
so that they are no longer capable of transmitting infectious
particles and the surface or item is rendered safe for handling,
use, or disposal.
Dental treatment water: Nonsterile water used during dental
treatment, including irrigation of nonsurgical operative sites
and cooling of high-speed rotary and ultrasonic instruments.
Disinfectant: A chemical agent used on inanimate objects
(e.g., floors, walls, or sinks) to destroy virtually all recognized
pathogenic microorganisms, but not necessarily all microbial
forms (e.g., bacterial endospores). The U.S. Environmental
Protection Agency (EPA) groups disinfectants on the basis of
whether the product label claims limited, general, or hospital
disinfectant capabilities.
Disinfection: Destruction of pathogenic and other kinds of
microorganisms by physical or chemical means. Disinfection
is less lethal than sterilization, because it destroys the majority
of recognized pathogenic microorganisms, but not necessarily
all microbial forms (e.g., bacterial spores). Disinfection does
not ensure the degree of safety associated with sterilization
processes.
Droplet nuclei: Particles <5 µm in diameter formed by dehydration of airborne droplets containing microorganisms that
can remain suspended in the air for long periods of time.
Droplets: Small particles of moisture (e.g., spatter) generated
when a person coughs or sneezes, or when water is converted
to a fine mist by an aerator or shower head. These particles,
intermediate in size between drops and droplet nuclei, can
contain infectious microorganisms and tend to quickly settle
from the air such that risk of disease transmission is usually
limited to persons in close proximity to the droplet source.
Endotoxin: The lipopolysaccharide of gram-negative bacteria, the toxic character of which resides in the lipid protein.
Endotoxins can produce pyrogenic reactions in persons
exposed to their bacterial component.
Germicide: An agent that destroys microorganisms, especially
pathogenic organisms. Terms with the same suffix (e.g., virucide, fungicide, bactericide, tuberculocide, and sporicide) indi-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
cate agents that destroy the specific microorganism identified
by the prefix. Germicides can be used to inactivate microorganisms in or on living tissue (i.e., antiseptics) or on environmental surfaces (i.e., disinfectants).
Hand hygiene: General term that applies to handwashing,
antiseptic handwash, antiseptic hand rub, or surgical hand
antisepsis.
Health-care–associated infection: Any infection associated with
a medical or surgical intervention. The term health-care–
associated replaces nosocomial, which is limited to adverse
infectious outcomes occurring in hospitals.
Hepatitis B immune globulin (HBIG): Product used for prophylaxis against HBV infection. HBIG is prepared from plasma
containing high titers of hepatitis B surface antibody (antiHBs) and provides protection for 3–6 mos.
Hepatitis B surface antigen (HBsAg): Serologic marker on the
surface of HBV detected in high levels during acute or chronic
hepatitis. The body normally produces antibodies to surface
antigen as a normal immune response to infection.
Hepatitis B e antigen (HBeAg): Secreted product of the nucleocapsid gene of HBV found in serum during acute and chronic
HBV infection. Its presence indicates that the virus is replicating and serves as a marker of increased infectivity.
Hepatitis B surface antibody (anti-HBs): Protective antibody
against HBsAg. Presence in the blood can indicate past infection with, and immunity to, HBV, or immune response from
hepatitis B vaccine.
Heterotrophic bacteria: Those bacteria requiring an organic
carbon source for growth (i.e., deriving energy and carbon from
organic compounds).
High-level disinfection: Disinfection process that inactivates
vegetative bacteria, mycobacteria, fungi, and viruses but not
necessarily high numbers of bacterial spores. FDA further
defines a high-level disinfectant as a sterilant used for a shorter
contact time.
Hospital disinfectant: Germicide registered by EPA for use
on inanimate objects in hospitals, clinics, dental offices, and
other medical-related facilities. Efficacy is demonstrated against
Salmonella choleraesuis, Staphylococcus aureus, and Pseudomonas aeruginosa.
Iatrogenic: Induced inadvertently by HCP, medical (including dental) treatment, or diagnostic procedures. Used particularly in reference to an infectious disease or other complication
of treatment.
Immunization: Process by which a person becomes immune,
or protected against a disease. Vaccination is defined as the
process of administering a killed or weakened infectious
organism or a toxoid; however, vaccination does not always
result in immunity.
5
Implantable device: Device placed into a surgically or naturally formed cavity of the human body and intended to
remain there for >30 days.
Independent water reservoir: Container used to hold water or
other solutions and supply it to handpieces and air and water
syringes attached to a dental unit. The independent reservoir,
which isolates the unit from the public water system, can be
provided as original equipment or as a retrofitted device.
Intermediate-level disinfection: Disinfection process that
inactivates vegetative bacteria, the majority of fungi, mycobacteria, and the majority of viruses (particularly enveloped
viruses) but not bacterial spores.
Intermediate-level disinfectant: Liquid chemical germicide
registered with EPA as a hospital disinfectant and with a label
claim of potency as tuberculocidal (Appendix A).
Latex: Milky white fluid extracted from the rubber tree
Hevea brasiliensis that contains the rubber material cis-1,4
polyisoprene.
Low-level disinfection: Process that inactivates the majority
of vegetative bacteria, certain fungi, and certain viruses, but
cannot be relied on to inactivate resistant microorganisms (e.g.,
mycobacteria or bacterial spores).
Low-level disinfectant: Liquid chemical germicide registered
with EPA as a hospital disinfectant. OSHA requires low-level
hospital disinfectants also to have a label claim for potency
against HIV and HBV if used for disinfecting clinical contact
surfaces (Appendix A).
Microfilter: Membrane filter used to trap microorganisms
suspended in water. Filters are usually installed on dental unit
waterlines as a retrofit device. Microfiltration commonly
occurs at a filter pore size of 0.03–10 µm. Sediment filters
commonly found in dental unit water regulators have pore
sizes of 20–90 µm and do not function as microbiological
filters.
Nosocomial: Infection acquired in a hospital as a result of
medical care.
Occupational exposure: Reasonably anticipated skin, eye,
mucous membrane, or parenteral contact with blood or OPIM
that can result from the performance of an employee’s duties.
OPIM: Other potentially infectious materials. OPIM is an
OSHA term that refers to 1) body fluids including semen,
vaginal secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva
in dental procedures; any body fluid visibly contaminated with
blood; and all body fluids in situations where differentiating
between body fluids is difficult or impossible; 2) any unfixed
tissue or organ (other than intact skin) from a human (living
or dead); and 3) HIV-containing cell or tissue cultures, organ
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
6
MMWR
cultures; HIV- or HBV-containing culture medium or other
solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Parenteral: Means of piercing mucous membranes or skin
barrier through such events as needlesticks, human bites, cuts,
and abrasions.
Persistent activity: Prolonged or extended activity that prevents or inhibits proliferation or survival of microorganisms
after application of a product. This activity can be demonstrated by sampling a site minutes or hours after application
and demonstrating bacterial antimicrobial effectiveness when
compared with a baseline level. Previously, this property was
sometimes termed residual activity.
Prion: Protein particle lacking nucleic acid that has been
implicated as the cause of certain neurodegenerative diseases
(e.g., scrapie, CJD, and bovine spongiform encephalopathy
[BSE]).
Retraction: Entry of oral fluids and microorganisms into
waterlines through negative water pressure.
Seroconversion: The change of a serological test from negative to positive indicating the development of antibodies in
response to infection or immunization.
Sterile: Free from all living microorganisms; usually described
as a probability (e.g., the probability of a surviving microorganism being 1 in 1 million).
Sterilization: Use of a physical or chemical procedure to
destroy all microorganisms including substantial numbers of
resistant bacterial spores.
Surfactants: Surface-active agents that reduce surface tension
and help cleaning by loosening, emulsifying, and holding soil
in suspension, to be more readily rinsed away.
Ultrasonic cleaner: Device that removes debris by a process
called cavitation, in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces.
Vaccination: See immunization.
Vaccine: Product that induces immunity, therefore protecting the body from the disease. Vaccines are administered
through needle injections, by mouth, and by aerosol.
Washer-disinfector: Automatic unit that cleans and thermally
disinfects instruments, by using a high-temperature cycle rather
than a chemical bath.
Wicking: Absorption of a liquid by capillary action along a
thread or through the material (e.g., penetration of liquids
through undetected holes in a glove).
December 19, 2003
Review of Science Related
to Dental Infection Control
Personnel Health Elements
of an Infection-Control Program
A protective health component for DHCP is an integral part
of a dental practice infection-control program. The objectives
are to educate DHCP regarding the principles of infection
control, identify work-related infection risks, institute preventive measures, and ensure prompt exposure management and
medical follow-up. Coordination between the dental practice’s
infection-control coordinator and other qualified health-care
professionals is necessary to provide DHCP with appropriate
services. Dental programs in institutional settings, (e.g., hospitals, health centers, and educational institutions) can coordinate with departments that provide personnel health services.
However, the majority of dental practices are in ambulatory,
private settings that do not have licensed medical staff and
facilities to provide complete on-site health service programs.
In such settings, the infection-control coordinator should
establish programs that arrange for site-specific infectioncontrol services from external health-care facilities and providers before DHCP are placed at risk for exposure. Referral
arrangements can be made with qualified health-care professionals in an occupational health program of a hospital, with
educational institutions, or with health-care facilities that
offer personnel health services.
Education and Training
Personnel are more likely to comply with an infectioncontrol program and exposure-control plan if they understand
its rationale (5,13,16). Clearly written policies, procedures,
and guidelines can help ensure consistency, efficiency, and
effective coordination of activities. Personnel subject to occupational exposure should receive infection-control training on
initial assignment, when new tasks or procedures affect their
occupational exposure, and at a minimum, annually (13).
Education and training should be appropriate to the assigned
duties of specific DHCP (e.g., techniques to prevent crosscontamination or instrument sterilization). For DHCP who
perform tasks or procedures likely to result in occupational
exposure to infectious agents, training should include 1) a
description of their exposure risks; 2) review of prevention strategies and infection-control policies and procedures; 3) discussion regarding how to manage work-related illness and injuries,
including PEP; and 4) review of work restrictions for the
exposure or infection. Inclusion of DHCP with minimal
exposure risks (e.g., administrative employees) in education
and training programs might enhance facilitywide understand-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
ing of infection-control principles and the importance of the
program. Educational materials should be appropriate in content and vocabulary for each person’s educational level, literacy, and language, as well as be consistent with existing federal,
state, and local regulations (5,13).
Immunization Programs
DHCP are at risk for exposure to, and possible infection
with, infectious organisms. Immunizations substantially
reduce both the number of DHCP susceptible to these diseases and the potential for disease transmission to other DHCP
and patients (5,17). Thus, immunizations are an essential part
of prevention and infection-control programs for DHCP, and
a comprehensive immunization policy should be implemented
for all dental health-care facilities (17,18). The Advisory Committee on Immunization Practices (ACIP) provides national
guidelines for immunization of HCP, which includes DHCP
(17). Dental practice immunization policies should incorporate current state and federal regulations as well as recommendations from the U.S. Public Health Service and professional
organizations (17) (Appendix B).
On the basis of documented health-care–associated transmission, HCP are considered to be at substantial risk for
acquiring or transmitting hepatitis B, influenza, measles,
mumps, rubella, and varicella. All of these diseases are vaccine-preventable. ACIP recommends that all HCP be vaccinated or have documented immunity to these diseases (5,17).
ACIP does not recommend routine immunization of HCP
against TB (i.e., inoculation with bacille Calmette-Guérin vaccine) or hepatitis A (17). No vaccine exists for HCV. ACIP
guidelines also provide recommendations regarding immunization of HCP with special conditions (e.g., pregnancy, HIV
infection, or diabetes) (5,17).
Immunization of DHCP before they are placed at risk for
exposure remains the most efficient and effective use of vaccines in health-care settings. Some educational institutions and
infection-control programs provide immunization schedules
for students and DHCP. OSHA requires that employers make
hepatitis B vaccination available to all employees who have
potential contact with blood or OPIM. Employers are also
required to follow CDC recommendations for vaccinations,
evaluation, and follow-up procedures (13). Nonpatient-care
staff (e.g., administrative or housekeeping) might be included,
depending on their potential risk of coming into contact with
blood or OPIM. Employers are also required to ensure that
employees who decline to accept hepatitis B vaccination sign
an appropriate declination statement (13). DHCP unable or
unwilling to be vaccinated as required or recommended should
be educated regarding their exposure risks, infection-control
policies and procedures for the facility, and the management
7
of work-related illness and work restrictions (if appropriate)
for exposed or infected DHCP.
Exposure Prevention and Postexposure
Management
Avoiding exposure to blood and OPIM, as well as protection by immunization, remain primary strategies for reducing
occupationally acquired infections, but occupational exposures
can still occur (19). A combination of standard precautions,
engineering, work practice, and administrative controls is the
best means to minimize occupational exposures. Written policies and procedures to facilitate prompt reporting, evaluation,
counseling, treatment, and medical follow-up of all occupational exposures should be available to all DHCP. Written
policies and procedures should be consistent with federal, state,
and local requirements addressing education and training,
postexposure management, and exposure reporting (see Preventing Transmission of Bloodborne Pathogens).
DHCP who have contact with patients can also be exposed
to persons with infectious TB, and should have a baseline tuberculin skin test (TST), preferably by using a two-step test,
at the beginning of employment (20). Thus, if an unprotected
occupational exposure occurs, TST conversions can be distinguished from positive TST results caused by previous exposures (20,21). The facility’s level of TB risk will determine the
need for routine follow-up TSTs (see Special Considerations).
Medical Conditions, Work-Related Illness,
and Work Restrictions
DHCP are responsible for monitoring their own health status. DHCP who have acute or chronic medical conditions
that render them susceptible to opportunistic infection should
discuss with their personal physicians or other qualified
authority whether the condition might affect their ability to
safely perform their duties. However, under certain circumstances, health-care facility managers might need to exclude
DHCP from work or patient contact to prevent further transmission of infection (22). Decisions concerning work restrictions are based on the mode of transmission and the period of
infectivity of the disease (5) (Table 1). Exclusion policies should
1) be written, 2) include a statement of authority that defines
who can exclude DHCP (e.g., personal physicians), and 3) be
clearly communicated through education and training. Policies should also encourage DHCP to report illnesses or exposures without jeopardizing wages, benefits, or job status.
With increasing concerns regarding bloodborne pathogens and
introduction of universal precautions, use of latex gloves among
HCP has increased markedly (7,23). Increased use of these gloves
has been accompanied by increased reports of allergic reactions
to natural rubber latex among HCP, DHCP, and patients
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
8
MMWR
December 19, 2003
TABLE 1. Suggested work restrictions for health-care personnel infected with or exposed to major infectious diseases in healthcare settings, in the absence of state and local regulations*
Disease/problem
Duration
Work restriction
Conjunctivitis
Restrict from patient contact and contact with patient’s
environment.
Cytomegalovirus infection
No restriction
Until discharge ceases
Diarrheal disease
Acute stage (diarrhea with other symptoms)
Restrict from patient contact, contact with patient’s
environment, and food-handling.
Until symptoms resolve
Convalescent stage, Salmonella species
Restrict from care of patients at high risk.
Until symptoms resolve; consult with local and state health
authorities regarding need for negative stool cultures
Enteroviral infection
Restrict from care of infants, neonates, and
immunocompromised patients and their environments.
Until symptoms resolve
Hepatitis A
Restrict from patient contact, contact with patient’s
environment, and food-handing.
Until 7 days after onset of jaundice
Hepatitis B
Personnel with acute or chronic hepatitis B
surface antigenemia who do not perform
exposure-prone procedures
No restriction†; refer to state regulations. Standard
precautions should always be followed.
Personnel with acute or chronic hepatitis B
e antigenemia who perform exposure-prone
procedures
Do not perform exposure-prone invasive procedures until
counsel from a review panel has been sought; panel
should review and recommend procedures that personnel
can perform, taking into account specific procedures as
well as skill and technique. Standard precautions should
always be observed. Refer to state and local regulations
or recommendations.
Until hepatitis B e antigen is negative
No restrictions on professional activity.† HCV-positive
health-care personnel should follow aseptic technique
and standard precautions.
Hepatitis C
Herpes simplex
Genital
No restriction
Hands (herpetic whitlow)
Restrict from patient contact and contact with patient’s
environment.
Orofacial
Evaluate need to restrict from care of patients at high risk.
Human immunodeficiency virus; personnel who
perform exposure-prone procedures
Until lesions heal
Do not perform exposure-prone invasive procedures until
counsel from an expert review panel has been sought;
panel should review and recommend procedures that
personnel can perform, taking into account specific
procedures as well as skill and technique. Standard
precautions should always be observed. Refer to state
and local regulations or recommendations.
Measles
Active
Exclude from duty
Until 7 days after the rash appears
Postexposure (susceptible personnel)
Exclude from duty
From fifth day after first exposure through twenty-first day
after last exposure, or 4 days after rash appears
Exclude from duty
Until 24 hours after start of effective therapy
Active
Exclude from duty
Until 9 days after onset of parotitis
Postexposure (susceptible personnel)
Exclude from duty
From twelfth day after first exposure through twenty-sixth
day after last exposure, or until 9 days after onset of
parotitis
Meningococcal infection
Mumps
Source: Adapted from Bolyard EA, Hospital Infection Control Practices Advisory Committee. Guidelines for infection control in health care personnel, 1998. Am J Infect Control
1998;26:289–354.
* Modified from recommendations of the Advisory Committee on Immunization Practices (ACIP).
†
Unless epidemiologically linked to transmission of infection.
§
Those susceptible to varicella and who are at increased risk of complications of varicella (e.g., neonates and immunocompromised persons of any age).
¶
Patients at high risk as defined by ACIP for complications of influenza.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
9
TABLE 1. (Continued) Suggested work restrictions for health-care personnel infected with or exposed to major infectious diseases
in health-care settings, in the absence of state and local regulations*
Disease/problem
Pediculosis
Work restriction
Duration
Restrict from patient contact
Until treated and observed to be free of adult and
immature lice
Active
Exclude from duty
From beginning of catarrhal stage through third week
after onset of paroxysms, or until 5 days after start of
effective antibiotic therapy
Postexposure (asymptomatic personnel)
No restriction, prophylaxis recommended
Postexposure (symptomatic personnel)
Exclude from duty
Until 5 days after start of effective antibiotic therapy
Active
Exclude from duty
Until 5 days after rash appears
Postexposure (susceptible personnel)
Exclude from duty
From seventh day after first exposure through twenty-first
day after last exposure
Active, draining skin lesions
Restrict from contact with patients and patient’s
environment or food handling.
Until lesions have resolved
Carrier state
No restriction unless personnel are epidemiologically
linked to transmission of the organism
Pertussis
Rubella
Staphylococcus aureus infection
Restrict from patient care, contact with patient’s
environment, and food-handling.
Until 24 hours after adequate treatment started
Active disease
Exclude from duty
Until proved noninfectious
PPD converter
No restriction
Streptococcal infection, group A
Tuberculosis
Varicella (chicken pox)
Active
Exclude from duty
Until all lesions dry and crust
Postexposure (susceptible personnel)
Exclude from duty
From tenth day after first exposure through twenty-first
day (twenty-eighth day if varicella-zoster immune globulin
[VZIG] administered) after last exposure.
Localized, in healthy person
Cover lesions, restrict from care of patients§ at high risk
Until all lesions dry and crust
Generalized or localized in immunosuppressed person
Restrict from patient contact
Until all lesions dry and crust
Postexposure (susceptible personnel)
Restrict from patient contact
From tenth day after first exposure through twenty-first day
(twenty-eighth day if VZIG administered) after last exposure;
or, if varicella occurs, when lesions crust and dry
Consider excluding from the care of patients at high risk¶
or contact with such patients’ environments during
community outbreak of respiratory syncytial virus and
influenza
Until acute symptoms resolve
Zoster (shingles)
Viral respiratory infection, acute febrile
Source: Adapted from Bolyard EA, Hospital Infection Control Practices Advisory Committee. Guidelines for infection control in health care personnel, 1998. Am J Infect Control
1998;26:289–354.
* Modified from recommendations of the Advisory Committee on Immunization Practices (ACIP).
†
Unless epidemiologically linked to transmission of infection.
§
Those susceptible to varicella and who are at increased risk of complications of varicella (e.g., neonates and immunocompromised persons of any age).
¶
Patients at high risk as defined by ACIP for complications of influenza.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
10
MMWR
(24–30), as well as increased reports of irritant and allergic contact dermatitis from frequent and repeated use of hand-hygiene
products, exposure to chemicals, and glove use.
DHCP should be familiar with the signs and symptoms of
latex sensitivity (5,31–33). A physician should evaluate DHCP
exhibiting symptoms of latex allergy, because further exposure
could result in a serious allergic reaction. A diagnosis is made
through medical history, physical examination, and diagnostic tests. Procedures should be in place for minimizing latexrelated health problems among DHCP and patients while
protecting them from infectious materials. These procedures
should include 1) reducing exposures to latex-containing
materials by using appropriate work practices, 2) training and
educating DHCP, 3) monitoring symptoms, and 4) substituting nonlatex products where appropriate (32) (see Contact
Dermatitis and Latex Hypersensitivity).
Maintenance of Records, Data Management,
and Confidentiality
The health status of DHCP can be monitored by maintaining records of work-related medical evaluations, screening tests,
immunizations, exposures, and postexposure management.
Such records must be kept in accordance with all applicable
state and federal laws. Examples of laws that might apply
include the Privacy Rule of the Health Insurance Portability
and Accountability Act (HIPAA) of 1996, 45 CFR 160 and
164, and the OSHA Occupational Exposure to Bloodborne
Pathogens; Final Rule 29 CFR 1910.1030(h)(1)(i–iv) (34,13).
The HIPAA Privacy Rule applies to covered entities, including certain defined health providers, health-care clearinghouses,
and health plans. OSHA requires employers to ensure that
certain information contained in employee medical records is
1) kept confidential; 2) not disclosed or reported without the
employee’s express written consent to any person within or
outside the workplace except as required by the OSHA standard; and 3) maintained by the employer for at least the duration of employment plus 30 years. Dental practices that
coordinate their infection-control program with off-site providers might consult OSHA’s Bloodborne Pathogen standard
and employee Access to Medical and Exposure Records standard, as well as other applicable local, state, and federal laws,
to determine a location for storing health records (13,35).
Preventing Transmission
of Bloodborne Pathogens
Although transmission of bloodborne pathogens (e.g., HBV,
HCV, and HIV) in dental health-care settings can have serious consequences, such transmission is rare. Exposure to
December 19, 2003
infected blood can result in transmission from patient to
DHCP, from DHCP to patient, and from one patient to
another. The opportunity for transmission is greatest from
patient to DHCP, who frequently encounter patient blood and
blood-contaminated saliva during dental procedures.
Since 1992, no HIV transmission from DHCP to patients
has been reported, and the last HBV transmission from DHCP
to patients was reported in 1987. HCV transmission from
DHCP to patients has not been reported. The majority of
DHCP infected with a bloodborne virus do not pose a risk to
patients because they do not perform activities meeting the
necessary conditions for transmission. For DHCP to pose a
risk for bloodborne virus transmission to patients, DHCP must
1) be viremic (i.e., have infectious virus circulating in the bloodstream); 2) be injured or have a condition (e.g., weeping dermatitis) that allows direct exposure to their blood or other
infectious body fluids; and 3) enable their blood or infectious
body fluid to gain direct access to a patient’s wound, traumatized tissue, mucous membranes, or similar portal of entry.
Although an infected DHCP might be viremic, unless the second and third conditions are also met, transmission cannot
occur.
The risk of occupational exposure to bloodborne viruses is
largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and
body fluids through percutaneous or permucosal routes of
exposure. The risk of infection after exposure to a bloodborne
virus is influenced by inoculum size, route of exposure, and
susceptibility of the exposed HCP (12). The majority of
attention has been placed on the bloodborne pathogens HBV,
HCV, and HIV, and these pathogens present different levels
of risk to DHCP.
Hepatitis B Virus
HBV is a well-recognized occupational risk for HCP (36,37).
HBV is transmitted by percutaneous or mucosal exposure to
blood or body fluids of a person with either acute or chronic
HBV infection. Persons infected with HBV can transmit the
virus for as long as they are HBsAg-positive. The risk of HBV
transmission is highly related to the HBeAg status of the source
person. In studies of HCP who sustained injuries from needles
contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was positive for both HBsAg
and HBeAg was 22%–31%; the risk of developing serologic
evidence of HBV infection was 37%–62% (19). By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was
1%–6%, and the risk of developing serologic evidence of HBV
infection, 23%–37% (38).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
Blood contains the greatest proportion of HBV infectious
particle titers of all body fluids and is the most critical vehicle
of transmission in the health-care setting. HBsAg is also found
in multiple other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen,
sweat, and synovial fluid. However, the majority of body fluids are not efficient vehicles for transmission because they contain low quantities of infectious HBV, despite the presence of
HBsAg (19). The concentration of HBsAg in body fluids can
be 100–1,000-fold greater than the concentration of infectious HBV particles (39).
Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably
account for only a minority of HBV infections among HCP.
In multiple investigations of nosocomial hepatitis B outbreaks,
the majority of infected HCP could not recall an overt percutaneous injury (40,41), although in certain studies, approximately one third of infected HCP recalled caring for a patient
who was HBsAg-positive (42,43). In addition, HBV has been
demonstrated to survive in dried blood at room temperature
on environmental surfaces for <1 week (44). Thus, HBV
infections that occur in HCP with no history of nonoccupational exposure or occupational percutaneous injury might have
resulted from direct or indirect blood or body fluid exposures
that inoculated HBV into cutaneous scratches, abrasions,
burns, other lesions, or on mucosal surfaces (45–47). The
potential for HBV transmission through contact with environmental surfaces has been demonstrated in investigations of
HBV outbreaks among patients and HCP in hemodialysis units
(48–50).
Since the early 1980s, occupational infections among HCP
have declined because of vaccine use and adherence to universal precautions (51). Among U.S. dentists, >90% have been
vaccinated, and serologic evidence of past HBV infection
decreased from prevaccine levels of 14% in 1972 to approximately 9% in 1992 (52). During 1993–2001, levels remained
relatively unchanged (Chakwan Siew, Ph.D., American Dental Association, Chicago, Illinois, personal communication,
June 2003). Infection rates can be expected to decline further
as vaccination rates remain high among young dentists and as
older dentists with lower vaccination rates and higher rates of
infection retire.
Although the potential for transmission of bloodborne
infections from DHCP to patients is considered limited
(53–55), precise risks have not been quantified by carefully
designed epidemiologic studies (53,56,57). Reports published
during 1970–1987 describe nine clusters in which patients
were thought to be infected with HBV through treatment by
an infected DHCP (58–67). However, transmission of HBV
11
from dentist to patient has not been reported since 1987, possibly reflecting such factors as 1) adoption of universal precautions, 2) routine glove use, 3) increased levels of immunity as
a result of hepatitis B vaccination of DHCP, 4) implementation of the 1991 OSHA bloodborne pathogen standard (68),
and 5) incomplete ascertainment and reporting. Only one case
of patient-to-patient transmission of HBV in the dental setting has been documented (CDC, unpublished data, 2003).
In this case, appropriate office infection-control procedures
were being followed, and the exact mechanism of transmission was undetermined.
Because of the high risk of HBV infection among HCP,
DHCP who perform tasks that might involve contact with
blood, blood-contaminated body substances, other body fluids, or sharps should be vaccinated (2,13,17,19,69). Vaccination can protect both DHCP and patients from HBV infection
and, whenever possible, should be completed when dentists
or other DHCP are in training and before they have contact
with blood.
Prevaccination serological testing for previous infection is
not indicated, although it can be cost-effective where prevalence of infection is expected to be high in a group of potential
vacinees (e.g., persons who have emigrated from areas with
high rates of HBV infection). DHCP should be tested for antiHBs 1–2 months after completion of the 3-dose vaccination
series (17). DHCP who do not develop an adequate antibody
response (i.e., anti-HBs <10 mIU/mL) to the primary vaccine
series should complete a second 3-dose vaccine series or be
evaluated to determine if they are HBsAg-positive (17).
Revaccinated persons should be retested for anti-HBs at the
completion of the second vaccine series. Approximately half
of nonresponders to the primary series will respond to a second 3-dose series. If no antibody response occurs after the
second series, testing for HBsAg should be performed (17).
Persons who prove to be HBsAg-positive should be counseled
regarding how to prevent HBV transmission to others and
regarding the need for medical evaluation. Nonresponders to
vaccination who are HBsAg-negative should be considered
susceptible to HBV infection and should be counseled regarding precautions to prevent HBV infection and the need to
obtain HBIG prophylaxis for any known or probable parenteral
exposure to HBsAg-positive blood.
Vaccine-induced antibodies decline gradually over time, and
60% of persons who initially respond to vaccination will lose
detectable antibodies over 12 years. Even so, immunity continues to prevent clinical disease or detectable viral infection
(17). Booster doses of vaccine and periodic serologic testing to
monitor antibody concentrations after completion of the vaccine series are not necessary for vaccine responders (17).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
12
MMWR
Hepatitis D Virus
An estimated 4% of persons with acute HBV infection are
also infected with hepatitis Delta virus (HDV). Discovered in
1977, HDV is a defective bloodborne virus requiring the presence of HBV to replicate. Patients coinfected with HBV and
HDV have substantially higher mortality rates than those
infected with HBV alone. Because HDV infection is dependent on HBV for replication, immunization to prevent HBV
infection, through either pre- or postexposure prophylaxis, can
also prevent HDV infection (70).
Hepatitis C Virus
Hepatitis C virus appears not to be transmitted efficiently
through occupational exposures to blood. Follow-up studies
of HCP exposed to HCV-infected blood through percutaneous or other sharps injuries have determined a low incidence
of seroconversion (mean: 1.8%; range, 0%–7%) (71–74). One
study determined transmission occurred from hollow-bore
needles but not other sharps (72). Although these studies have
not documented seroconversion associated with mucous membrane or nonintact skin exposure, at least two cases of HCV
transmission from a blood splash to the conjunctiva (75,76)
and one case of simultaneous transmission of HCV and HIV
after nonintact skin exposure have been reported (77).
Data are insufficient to estimate the occupational risk of
HCV infection among HCP, but the majority of studies indicate the prevalence of HCV infection among dentists, surgeons, and hospital-based HCP is similar to that among the
general population, approximately 1%–2% (78–86). In a study
that evaluated risk factors for infection, a history of unintentional needlesticks was the only occupational risk factor independently associated with HCV infection (80).
No studies of transmission from HCV-infected DHCP to
patients have been reported, and the risk for such transmission appears limited. Multiple reports have been published
describing transmission from HCV-infected surgeons, which
apparently occurred during performance of invasive procedures;
the overall risk for infection averaged 0.17% (87–90).
Human Immunodeficiency Virus
In the United States, the risk of HIV transmission in dental
settings is extremely low. As of December 2001, a total of 57
cases of HIV seroconversion had been documented among
HCP, but none among DHCP, after occupational exposure to
a known HIV-infected source (91). Transmission of HIV to
six patients of a single dentist with AIDS has been reported,
but the mode of transmission could not be determined
(2,92,93). As of September 30, 1993, CDC had information
regarding test results of >22,000 patients of 63 HIV-infected
December 19, 2003
HCP, including 33 dentists or dental students (55,93). No
additional cases of transmission were documented.
Prospective studies worldwide indicate the average risk of
HIV infection after a single percutaneous exposure to
HIV-infected blood is 0.3% (range: 0.2%–0.5%) (94). After
an exposure of mucous membranes in the eye, nose, or mouth,
the risk is approximately 0.1% (76). The precise risk of transmission after skin exposure remains unknown but is believed
to be even smaller than that for mucous membrane exposure.
Certain factors affect the risk of HIV transmission after an
occupational exposure. Laboratory studies have determined if
needles that pass through latex gloves are solid rather than
hollow-bore, or are of small gauge (e.g., anesthetic needles
commonly used in dentistry), they transfer less blood (36). In
a retrospective case-control study of HCP, an increased risk
for HIV infection was associated with exposure to a relatively
large volume of blood, as indicated by a deep injury with a
device that was visibly contaminated with the patient’s blood,
or a procedure that involved a needle placed in a vein or artery
(95). The risk was also increased if the exposure was to blood
from patients with terminal illnesses, possibly reflecting the
higher titer of HIV in late-stage AIDS.
Exposure Prevention Methods
Avoiding occupational exposures to blood is the primary
way to prevent transmission of HBV, HCV, and HIV, to HCP
in health-care settings (19,96,97). Exposures occur through
percutaneous injury (e.g., a needlestick or cut with a sharp
object), as well as through contact between potentially infectious blood, tissues, or other body fluids and mucous membranes of the eye, nose, mouth, or nonintact skin (e.g., exposed
skin that is chapped, abraded, or shows signs of dermatitis).
Observational studies and surveys indicate that percutaneous injuries among general dentists and oral surgeons occur
less frequently than among general and orthopedic surgeons
and have decreased in frequency since the mid-1980s (98–102).
This decline has been attributed to safer work practices, safer
instrumentation or design, and continued DHCP education
(103,104). Percutaneous injuries among DHCP usually
1) occur outside the patient’s mouth, thereby posing less risk
for recontact with patient tissues; 2) involve limited amounts
of blood; and 3) are caused by burs, syringe needles, laboratory knives, and other sharp instruments (99–102,105,106).
Injuries among oral surgeons might occur more frequently
during fracture reductions using wires (104,107). Experience,
as measured by years in practice, does not appear to affect the
risk of injury among general dentists or oral surgeons
(100,104,107).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
The majority of exposures in dentistry are preventable, and
methods to reduce the risk of blood contacts have included
use of standard precautions, use of devices with features engineered to prevent sharp injuries, and modifications of work
practices. These approaches might have contributed to the
decrease in percutaneous injuries among dentists during
recent years (98–100,103). However, needlesticks and other
blood contacts continue to occur, which is a concern because
percutaneous injuries pose the greatest risk of transmission.
Standard precautions include use of PPE (e.g., gloves, masks,
protective eyewear or face shield, and gowns) intended to prevent skin and mucous membrane exposures. Other protective
equipment (e.g., finger guards while suturing) might also
reduce injuries during dental procedures (104).
Engineering controls are the primary method to reduce
exposures to blood and OPIM from sharp instruments and
needles. These controls are frequently technology-based and
often incorporate safer designs of instruments and devices (e.g.,
self-sheathing anesthetic needles and dental units designed to
shield burs in handpieces) to reduce percutaneous injuries
(101,103,108).
Work-practice controls establish practices to protect DHCP
whose responsibilities include handling, using, assembling, or
processing sharp devices (e.g., needles, scalers, laboratory utility knives, burs, explorers, and endodontic files) or sharps disposal containers. Work-practice controls can include removing
burs before disassembling the handpiece from the dental unit,
restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia, and minimizing potentially uncontrolled movements of such instruments
as scalers or laboratory knives (101,105).
As indicated, needles are a substantial source of percutaneous injury in dental practice, and engineering and workpractice controls for needle handling are of particular
importance. In 2001, revisions to OSHA’s bloodborne pathogens standard as mandated by the Needlestick Safety and Prevention Act of 2000 became effective. These revisions clarify
the need for employers to consider safer needle devices as they
become available and to involve employees directly responsible for patient care (e.g., dentists, hygienists, and dental
assistants) in identifying and choosing such devices (109). Safer
versions of sharp devices used in hospital settings have become
available (e.g., blunt suture needles, phlebotomy devices, and
butterfly needles), and their impact on reducing injuries has
been documented (110–112). Aspirating anesthetic syringes
that incorporate safety features have been developed for dental procedures, but the low injury rates in dentistry limit
assessment of their effect on reducing injuries among DHCP.
13
Work-practice controls for needles and other sharps include
placing used disposable syringes and needles, scalpel blades,
and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were used
(2,7,13,113–115). In addition, used needles should never be
recapped or otherwise manipulated by using both hands, or
any other technique that involves directing the point of a needle
toward any part of the body (2,7,13,97,113,114). A onehanded scoop technique, a mechanical device designed for
holding the needle cap to facilitate one-handed recapping, or
an engineered sharps injury protection device (e.g., needles
with resheathing mechanisms) should be employed for recapping needles between uses and before disposal
(2,7,13,113,114). DHCP should never bend or break needles
before disposal because this practice requires unnecessary
manipulation. Before attempting to remove needles from
nondisposable aspirating syringes, DHCP should recap them
to prevent injuries. For procedures involving multiple injections with a single needle, the practitioner should recap the
needle between injections by using a one-handed technique or
use a device with a needle-resheathing mechanism. Passing a
syringe with an unsheathed needle should be avoided because
of the potential for injury.
Additional information for developing a safety program and
for identifying and evaluating safer dental devices is available at
• http://www.cdc.gov/OralHealth/infectioncontrol/
forms.htm (forms for screening and evaluating safer dental devices), and
• http://www.cdc.gov/niosh/topics/bbp (state legislation on
needlestick safety).
Postexposure Management and Prophylaxis
Postexposure management is an integral component of a
complete program to prevent infection after an occupational
exposure to blood. During dental procedures, saliva is predictably contaminated with blood (7,114). Even when blood
is not visible, it can still be present in limited quantities and
therefore is considered a potentially infectious material by
OSHA (13,19). A qualified health-care professional should
evaluate any occupational exposure incident to blood or OPIM,
including saliva, regardless of whether blood is visible, in dental settings (13).
Dental practices and laboratories should establish written,
comprehensive programs that include hepatitis B vaccination
and postexposure management protocols that 1) describe the
types of contact with blood or OPIM that can place DHCP at
risk for infection; 2) describe procedures for promptly reporting and evaluating such exposures; and 3) identify a health-
The portion of these 2003 Guidelines pertaining to HIV Recommendations has been superseded by the Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Post-Exposure Prophylaxis – 2005 (see
Bloodborne Pathogens Appendix F, page 95). The 2005 Guidelines only
update the Recommendations for HIV, not for Hepatitis B and C.
Bloodborne Pathogens Appendix D - Page 51
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
14
MMWR
care professional who is qualified to provide counseling and
perform all medical evaluations and procedures in accordance
with current recommendations of the U.S. Public Health Service (PHS), including PEP with chemotherapeutic drugs when
indicated. DHCP, including students, who might reasonably
be considered at risk for occupational exposure to blood or
OPIM should be taught strategies to prevent contact with blood
or OPIM and the principles of postexposure management,
including PEP options, as part of their job orientation and
training. Educational programs for DHCP and students should
emphasize reporting all exposures to blood or OPIM as soon
as possible, because certain interventions have to be initiated
promptly to be effective. Policies should be consistent with
the practices and procedures for worker protection required
by OSHA and with current PHS recommendations for managing occupational exposures to blood (13,19).
After an occupational blood exposure, first aid should be
administered as necessary. Puncture wounds and other injuries to the skin should be washed with soap and water;
mucous membranes should be flushed with water. No evidence
exists that using antiseptics for wound care or expressing fluid
by squeezing the wound further reduces the risk of bloodborne
pathogen transmission; however, use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach)
or the injection of antiseptics or disinfectants into the wound
is not recommended (19). Exposed DHCP should immediately report the exposure to the infection-control coordinator
or other designated person, who should initiate referral to the
qualified health-care professional and complete necessary
reports. Because multiple factors contribute to the risk of
infection after an occupational exposure to blood, the following information should be included in the exposure report,
recorded in the exposed person’s confidential medical record,
and provided to the qualified health-care professional:
• Date and time of exposure.
• Details of the procedure being performed, including where
and how the exposure occurred and whether the exposure
involved a sharp device, the type and brand of device, and
how and when during its handling the exposure occurred.
• Details of the exposure, including its severity and the type
and amount of fluid or material. For a percutaneous injury,
severity might be measured by the depth of the wound,
gauge of the needle, and whether fluid was injected; for a
skin or mucous membrane exposure, the estimated volume of material, duration of contact, and the condition
of the skin (e.g., chapped, abraded, or intact) should be
noted.
• Details regarding whether the source material was known
to contain HIV or other bloodborne pathogens, and, if
December 19, 2003
the source was infected with HIV, the stage of disease,
history of antiretroviral therapy, and viral load, if known.
• Details regarding the exposed person (e.g., hepatitis B vaccination and vaccine-response status).
• Details regarding counseling, postexposure management,
and follow-up.
Each occupational exposure should be evaluated individually
for its potential to transmit HBV, HCV, and HIV, based on
the following:
• The type and amount of body substance involved.
• The type of exposure (e.g., percutaneous injury, mucous
membrane or nonintact skin exposure, or bites resulting
in blood exposure to either person involved).
• The infection status of the source.
• The susceptibility of the exposed person (19).
All of these factors should be considered in assessing the risk
for infection and the need for further follow-up (e.g., PEP).
During 1990–1998, PHS published guidelines for PEP and
other management of health-care worker exposures to HBV,
HCV, or HIV (69,116–119). In 2001, these recommendations were updated and consolidated into one set of PHS guidelines (19). The new guidelines reflect the availability of new
antiretroviral agents, new information regarding the use and
safety of HIV PEP, and considerations regarding employing
HIV PEP when resistance of the source patient’s virus to
antiretroviral agents is known or suspected. In addition, the
2001 guidelines provide guidance to clinicians and exposed
HCP regarding when to consider HIV PEP and recommendations for PEP regimens (19).
Hand Hygiene
Hand hygiene (e.g., handwashing, hand antisepsis, or surgical hand antisepsis) substantially reduces potential pathogens
on the hands and is considered the single most critical measure for reducing the risk of transmitting organisms to
patients and HCP (120–123). Hospital-based studies have
demonstrated that noncompliance with hand hygiene practices is associated with health-care–associated infections and
the spread of multiresistant organisms. Noncompliance also
has been a major contributor to outbreaks (123). The prevalence of health-care–associated infections decreases as adherence of HCP to recommended hand hygiene measures
improves (124–126).
The microbial flora of the skin, first described in 1938, consist of transient and resident microorganisms (127). Transient
flora, which colonize the superficial layers of the skin, are easier
to remove by routine handwashing. They are often acquired
by HCP during direct contact with patients or contaminated
environmental surfaces; these organisms are most frequently
Bloodborne Pathogens Appendix D - Page 52
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
associated with health-care–associated infections. Resident flora
attached to deeper layers of the skin are more resistant to
removal and less likely to be associated with such infections.
The preferred method for hand hygiene depends on the type
of procedure, the degree of contamination, and the desired
persistence of antimicrobial action on the skin (Table 2). For
routine dental examinations and nonsurgical procedures,
handwashing and hand antisepsis is achieved by using either a
plain or antimicrobial soap and water. If the hands are not
visibly soiled, an alcohol-based hand rub is adequate.
The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident flora for the duration of a procedure to prevent introduction of organisms in the operative
wound, if gloves become punctured or torn. Skin bacteria can
rapidly multiply under surgical gloves if hands are washed with
soap that is not antimicrobial (127,128). Thus, an antimicrobial soap or alcohol hand rub with persistent activity should
be used before surgical procedures (129–131).
Agents used for surgical hand antisepsis should substantially
reduce microorganisms on intact skin, contain a nonirritating
antimicrobial preparation, have a broad spectrum of activity,
be fast-acting, and have a persistent effect (121,132–135).
Persistence (i.e., extended antimicrobial activity that prevents
or inhibits survival of microorganisms after the product is
15
applied) is critical because microorganisms can colonize on
hands in the moist environment underneath gloves (122).
Alcohol hand rubs are rapidly germicidal when applied to
the skin but should include such antiseptics as chlorhexidine,
quaternary ammonium compounds, octenidine, or triclosan
to achieve persistent activity (130). Factors that can influence
the effectiveness of the surgical hand antisepsis in addition to
the choice of antiseptic agent include duration and technique
of scrubbing, as well as condition of the hands, and techniques
used for drying and gloving. CDC’s 2002 guideline on hand
hygiene in health-care settings provides more complete information (123).
Selection of Antiseptic Agents
Selecting the most appropriate antiseptic agent for hand
hygiene requires consideration of multiple factors. Essential
performance characteristics of a product (e.g., the spectrum
and persistence of activity and whether or not the agent is fastacting) should be determined before selecting a product.
Delivery system, cost per use, reliable vendor support and supply are also considerations. Because HCP acceptance is a
major factor regarding compliance with recommended hand
hygiene protocols (122,123,147,148), considering DHCP
needs is critical and should include possible chemical allergies,
TABLE 2. Hand-hygiene methods and indications
Method
Agent
Purpose
Duration (minimum)
seconds§
Routine handwash
Water and nonantimicrobial soap (e.g.,
plain soap†)
Remove soil and transient
microorganisms
15
Antiseptic handwash
Water and antimicrobial soap (e.g.,
chlorhexidine, iodine and iodophors,
chloroxylenol [PCMX], triclosan)
Remove or destroy
transient microorganisms
and reduce resident flora
15 seconds§
Antiseptic hand rub
Alcohol-based hand rub¶
Remove or destroy
transient microorganisms
and reduce resident flora
Rub hands until the
agent is dry¶
Surgical antisepsis
Water and antimicrobial soap (e.g.,
chlorhexidine, iodine and iodophors,
chloroxylenol [PCMX], triclosan)
Remove or destroy
transient microorganisms
and reduce resident flora
(persistent effect)
2–6 minutes
Water and non-antimicrobial soap (e.g.,
plain soap†) followed by an alcohol-based
surgical hand-scrub product with
persistent activity
Indication*
Before and after treating each patient
(e.g., before glove placement and after
glove removal). After barehanded
touching of inanimate objects likely to be
contaminated by blood or saliva. Before
leaving the dental operatory or the dental
laboratory. When visibly soiled.¶ Before
regloving after removing gloves that are
torn, cut, or punctured.
Before donning sterile surgeon’s gloves
for surgical procedures††
Follow manufacturer
instructions for
surgical hand-scrub
product with
persistent activity¶**
* (7,9,11,13,113,120–123,125,126,136–138).
Pathogenic organisms have been found on or around bar soap during and after use (139). Use of liquid soap with hands-free dispensing controls is preferable.
§ Time reported as effective in removing most transient flora from the skin. For most procedures, a vigorous rubbing together of all surfaces of premoistened lathered hands and
fingers for >15 seconds, followed by rinsing under a stream of cool or tepid water is recommended (9,120,123,140,141). Hands should always be dried thoroughly before
donning gloves.
¶ Alcohol-based hand rubs should contain 60%–95% ethanol or isopropanol and should not be used in the presence of visible soil or organic material. If using an alcohol-based
hand rub, apply adequate amount to palm of one hand and rub hands together, covering all surfaces of the hands and fingers, until hands are dry. Follow manufacturer’s
recommendations regarding the volume of product to use. If hands feel dry after rubbing them together for 10–15 seconds, an insufficient volume of product likely was applied.
The drying effect of alcohol can be reduced or eliminated by adding 1%–3% glycerol or other skin-conditioning agents (123).
** After application of alcohol-based surgical hand-scrub product with persistent activity as recommended, allow hands and forearms to dry thoroughly and immediately don sterile
surgeon’s gloves (144,145). Follow manufacturer instructions (122,123,137,146).
†† Before beginning surgical hand scrub, remove all arm jewelry and any hand jewelry that may make donning gloves more difficult, cause gloves to tear more readily (142,143),
or interfere with glove usage (e.g., ability to wear the correct-sized glove or altered glove integrity).
†
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
16
MMWR
skin integrity after repeated use, compatibility with lotions used,
and offensive agent ingredients (e.g., scent). Discussing specific preparations or ingredients used for hand antisepsis is
beyond the scope of this report. DHCP should choose from
commercially available HCP handwashes when selecting agents
for hand antisepsis or surgical hand antisepsis.
Storage and Dispensing of Hand Care
Products
Handwashing products, including plain (i.e., nonantimicrobial) soap and antiseptic products, can become contaminated or support the growth of microorganisms (122).
Liquid products should be stored in closed containers and dispensed from either disposable containers or containers that
are washed and dried thoroughly before refilling. Soap should
not be added to a partially empty dispenser, because this practice of topping off might lead to bacterial contamination
(149,150). Store and dispense products according to manufacturers’ directions.
Lotions
The primary defense against infection and transmission of
pathogens is healthy, unbroken skin. Frequent handwashing
with soaps and antiseptic agents can cause chronic irritant contact dermatitis among DHCP. Damage to the skin changes
skin flora, resulting in more frequent colonization by staphylococci and gram-negative bacteria (151,152). The potential
of detergents to cause skin irritation varies considerably, but
can be reduced by adding emollients. Lotions are often recommended to ease the dryness resulting from frequent
handwashing and to prevent dermatitis from glove use
(153,154). However, petroleum-based lotion formulations can
weaken latex gloves and increase permeability. For that reason,
lotions that contain petroleum or other oil emollients should
only be used at the end of the work day (122,155). Dental
practitioners should obtain information from lotion manufacturers regarding interaction between lotions, gloves, dental
materials, and antimicrobial products.
Fingernails and Artificial Nails
Although the relationship between fingernail length and
wound infection is unknown, keeping nails short is considered key because the majority of flora on the hands are found
under and around the fingernails (156). Fingernails should be
short enough to allow DHCP to thoroughly clean underneath
them and prevent glove tears (122). Sharp nail edges or broken nails are also likely to increase glove failure. Long artificial
or natural nails can make donning gloves more difficult and
can cause gloves to tear more readily. Hand carriage of gramnegative organisms has been determined to be greater among
December 19, 2003
wearers of artificial nails than among nonwearers, both before
and after handwashing (157–160). In addition, artificial fingernails or extenders have been epidemiologically implicated
in multiple outbreaks involving fungal and bacterial infections
in hospital intensive-care units and operating rooms (161–
164). Freshly applied nail polish on natural nails does not
increase the microbial load from periungual skin if fingernails
are short; however, chipped nail polish can harbor added bacteria (165,166).
Jewelry
Studies have demonstrated that skin underneath rings is more
heavily colonized than comparable areas of skin on fingers
without rings (167–170). In a study of intensive-care nurses,
multivariable analysis determined rings were the only substantial risk factor for carriage of gram-negative bacilli and Staphylococcus aureus, and the concentration of organisms correlated
with the number of rings worn (170). However, two other
studies demonstrated that mean bacterial colony counts on
hands after handwashing were similar among persons wearing
rings and those not wearing rings (169,171). Whether wearing rings increases the likelihood of transmitting a pathogen is
unknown; further studies are needed to establish whether rings
result in higher transmission of pathogens in health-care settings. However, rings and decorative nail jewelry can make
donning gloves more difficult and cause gloves to tear more
readily (142,143). Thus, jewelry should not interfere with glove
use (e.g., impair ability to wear the correct-sized glove or alter
glove integrity).
Personal Protective Equipment
PPE is designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of DHCP from exposure
to blood or OPIM. Use of rotary dental and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water
syringes creates a visible spray that contains primarily largeparticle droplets of water, saliva, blood, microorganisms, and
other debris. This spatter travels only a short distance and settles
out quickly, landing on the floor, nearby operatory surfaces,
DHCP, or the patient. The spray also might contain certain
aerosols (i.e., particles of respirable size, <10 µm). Aerosols can
remain airborne for extended periods and can be inhaled. However, they should not be confused with the large-particle spatter that makes up the bulk of the spray from handpieces and
ultrasonic scalers. Appropriate work practices, including use of
dental dams (172) and high-velocity air evacuation, should
minimize dissemination of droplets, spatter, and aerosols (2).
Primary PPE used in oral health-care settings includes gloves,
surgical masks, protective eyewear, face shields, and protective
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
clothing (e.g., gowns and jackets). All PPE should be removed
before DHCP leave patient-care areas (13). Reusable PPE (e.g.,
clinician or patient protective eyewear and face shields) should
be cleaned with soap and water, and when visibly soiled, disinfected between patients, according to the manufacturer’s
directions (2,13). Wearing gloves, surgical masks, protective
eyewear, and protective clothing in specified circumstances to
reduce the risk of exposures to bloodborne pathogens is mandated by OSHA (13). General work clothes (e.g., uniforms,
scrubs, pants, and shirts) are neither intended to protect against
a hazard nor considered PPE.
Masks, Protective Eyewear, Face Shields
A surgical mask that covers both the nose and mouth and
protective eyewear with solid side shields or a face shield should
be worn by DHCP during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids. Protective eyewear for patients shields their eyes from
spatter or debris generated during dental procedures. A surgical mask protects against microorganisms generated by the
wearer, with >95% bacterial filtration efficiency, and also protects DHCP from large-particle droplet spatter that might
contain bloodborne pathogens or other infectious microorganisms (173). The mask’s outer surface can become contaminated with infectious droplets from spray of oral fluids or from
touching the mask with contaminated fingers. Also, when a
mask becomes wet from exhaled moist air, the resistance to
airflow through the mask increases, causing more airflow to
pass around edges of the mask. If the mask becomes wet, it
should be changed between patients or even during patient
treatment, when possible (2,174).
When airborne infection isolation precautions (expanded
or transmission-based) are necessary (e.g., for TB patients), a
National Institute for Occupational Safety and Health
(NIOSH)-certified particulate-filter respirator (e.g., N95, N99,
or N100) should be used (20). N95 refers to the ability to
filter 1-µm particles in the unloaded state with a filter efficiency of >95% (i.e., filter leakage <5%), given flow rates of
<50 L/min (i.e., approximate maximum airflow rate of HCP
during breathing). Available data indicate infectious droplet
nuclei measure 1–5 µm; therefore, respirators used in healthcare settings should be able to efficiently filter the smallest
particles in this range.
The majority of surgical masks are not NIOSH-certified as
respirators, do not protect the user adequately from exposure
to TB, and do not satisfy OSHA requirements for respiratory
protection (174,175). However, certain surgical masks (i.e.,
surgical N95 respirator) do meet the requirements and are certified by NIOSH as respirators. The level of protection a respirator provides is determined by the efficiency of the filter
17
material for incoming air and how well the face piece fits or
seals to the face (e.g., qualitatively or quantitatively tested in a
reliable way to obtain a face-seal leakage of <10% and to fit
the different facial sizes and characteristics of HCP).
When respirators are used while treating patients with diseases requiring airborne-transmission precautions (e.g., TB),
they should be used in the context of a complete respiratory
protection program (175). This program should include training and fit testing to ensure an adequate seal between the edges
of the respirator and the wearer’s face. Detailed information
regarding respirator programs, including fit-test procedures are
available at http://www.cdc.gov/niosh/99-143.html (174,176).
Protective Clothing
Protective clothing and equipment (e.g., gowns, lab coats,
gloves, masks, and protective eyewear or face shield) should be
worn to prevent contamination of street clothing and to protect the skin of DHCP from exposures to blood and body
substances (2,7,10,11,13,137). OSHA bloodborne pathogens
standard requires sleeves to be long enough to protect the forearms when the gown is worn as PPE (i.e., when spatter and
spray of blood, saliva, or OPIM to the forearms is anticipated)
(13,14). DHCP should change protective clothing when it
becomes visibly soiled and as soon as feasible if penetrated by
blood or other potentially infectious fluids (2,13,14,137). All
protective clothing should be removed before leaving the work
area (13).
Gloves and Gloving
DHCP wear gloves to prevent contamination of their hands
when touching mucous membranes, blood, saliva, or OPIM,
and also to reduce the likelihood that microorganisms present
on the hands of DHCP will be transmitted to patients during
surgical or other patient-care procedures (1,2,7,10). Medical
gloves, both patient examination and surgeon’s gloves, are
manufactured as single-use disposable items that should be
used for only one patient, then discarded. Gloves should be
changed between patients and when torn or punctured.
Wearing gloves does not eliminate the need for handwashing.
Hand hygiene should be performed immediately before donning gloves. Gloves can have small, unapparent defects or can
be torn during use, and hands can become contaminated during glove removal (122,177–187). These circumstances increase
the risk of operative wound contamination and exposure of
the DHCP’s hands to microorganisms from patients. In addition, bacteria can multiply rapidly in the moist environments
underneath gloves, and thus, the hands should be dried thoroughly before donning gloves and washed again immediately
after glove removal.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
18
MMWR
Types of Gloves
Because gloves are task-specific, their selection should be
based on the type of procedure to be performed (e.g., surgery
or patient examination) (Table 3). Sterile surgeon’s gloves must
meet standards for sterility assurance established by FDA and
are less likely than patient examination gloves to harbor pathogens that could contaminate an operative wound (188).
Appropriate gloves in the correct size should be readily accessible (13).
Glove Integrity
Limited studies of the penetrability of different glove materials under conditions of use have been conducted in the dental environment. Consistent with observations in clinical
medicine, leakage rates vary by glove material (e.g., latex, vinyl,
and nitrile), duration of use, and type of procedure performed
(182,184,186,189–191), as well as by manufacturer (192–
194). The frequency of perforations in surgeon’s gloves used
during outpatient oral surgical procedures has been determined
to range from 6% to 16% (181,185,195,196).
Studies have demonstrated that HCP and DHCP are frequently unaware of minute tears in gloves that occur during
use (186,190,191,197). These studies determined that gloves
developed defects in 30 minutes–3 hours, depending on type
of glove and procedure. Investigators did not determine an
optimal time for changing gloves during procedures.
During dental procedures, patient examination and surgeon’s
gloves commonly contact multiple types of chemicals and
materials (e.g., disinfectants and antiseptics, composite resins,
and bonding agents) that can compromise the integrity of
latex as well as vinyl, nitrile, and other synthetic glove materials (198–206). In addition, latex gloves can interfere with the
setting of vinyl polysiloxane impression materials (207–209),
although the setting is apparently not adversely affected by
synthetic vinyl gloves (207,208). Given the diverse selection
of dental materials on the market, dental practitioners should
consult glove manufacturers regarding the chemical compatibility of glove materials.
If the integrity of a glove is compromised (e.g., punctured),
it should be changed as soon as possible (13,210,211). Washing latex gloves with plain soap, chlorhexidine, or alcohol can
lead to the formation of glove micropunctures (177,212,213)
and subsequent hand contamination (138). Because this condition, known as wicking, can allow penetration of liquids
through undetected holes, washing gloves is not recommended.
After a hand rub with alcohol, the hands should be thoroughly
TABLE 3. Glove types and indications
Glove
Commercially available glove materials*
Indication
Comment
Patient
examination
gloves§
Patient care, examinations,
other nonsurgical procedures involving contact with
mucous membranes, and
laboratory procedures
Medical device regulated by the Food and Drug
Administration (FDA).
Surgeon’s
gloves§
Surgical procedures
Medical device regulated by the FDA.
Nonmedical
gloves
Housekeeping procedures
(e.g., cleaning and
disinfection)
Nonsterile and sterile single-use disposable. Use
for one patient and discard appropriately.
Sterile and single-use disposable. Use for one
patient and discard appropriately.
Handling contaminated
sharps or chemicals
Not for use during patient
care
December 19, 2003
Not a medical device regulated by the FDA.
Commonly referred to as utility, industrial, or
general purpose gloves. Should be puncture- or
chemical-resistant, depending on the task. Latex
gloves do not provide adequate chemical
protection.
Material
Attributes†
Natural-rubber latex (NRL)
Nitrile
Nitrile and chloroprene (neoprene) blends
Nitrile & NRL blends
Butadiene methyl methacrylate
Polyvinyl chloride (PVC, vinyl)
Polyurethane
Styrene-based copolymer
1, 2
2, 3
2, 3
1, 2, 3
2, 3
4
4
4, 5
NRL
Nitrile
Chloroprene (neoprene)
NRL and nitrile or chloroprene blends
Synthetic polyisoprene
Styrene-based copolymer
Polyurethane
1, 2
2, 3
2, 3
2, 3
2
4, 5
4
NRL and nitrile or chloroprene blends
Chloroprene (neoprene)
Nitrile
Butyl rubber
Fluoroelastomer
Polyethylene and ethylene vinyl alcohol copolymer
2, 3
2, 3
2, 3
2, 3
3, 4, 6
3, 4, 6
Sanitize after use.
* Physical properties can vary by material, manufacturer, and protein and chemical composition.
†
1 contains allergenic NRL proteins.
2 vulcanized rubber, contains allergenic rubber processing chemicals.
3 likely to have enhanced chemical or puncture resistance.
4 nonvulcanized and does not contain rubber processing chemicals.
5 inappropriate for use with methacrylates.
6 resistant to most methacrylates.
§
Medical or dental gloves include patient-examination gloves and surgeon’s (i.e., surgical) gloves and are medical devices regulated by the FDA. Only FDA-cleared medical or
dental patient-examination gloves and surgical gloves can be used for patient care.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
dried before gloving, because hands still wet with an alcoholbased hand hygiene product can increase the risk of glove perforation (192).
FDA regulates the medical glove industry, which includes
gloves marketed as sterile surgeon’s and sterile or nonsterile
patient examination gloves. General-purpose utility gloves are
also used in dental health-care settings but are not regulated
by FDA because they are not promoted for medical use. More
rigorous standards are applied to surgeon’s than to examination gloves. FDA has identified acceptable quality levels (e.g.,
maximum defects allowed) for glove manufacturers (214), but
even intact gloves eventually fail with exposure to mechanical
(e.g., sharps, fingernails, or jewelry) and chemical (e.g.,
dimethyacrylates) hazards and over time. These variables can
be controlled, ultimately optimizing glove performance, by
1) maintaining short fingernails, 2) minimizing or eliminating hand jewelry, and 3) using engineering and work-practice
controls to avoid injuries with sharps.
Sterile Surgeon’s Gloves and Double-Gloving
During Oral Surgical Procedures
Certain limited studies have determined no difference in
postoperative infection rates after routine tooth extractions
when surgeons wore either sterile or nonsterile gloves
(215,216). However, wearing sterile surgeon’s gloves during
surgical procedures is supported by a strong theoretical rationale (2,7,137). Sterile gloves minimize transmission of microorganisms from the hands of surgical DHCP to patients and
prevent contamination of the hands of surgical DHCP with
the patient’s blood and body fluids (137). In addition, sterile
surgeon’s gloves are more rigorously regulated by FDA and
therefore might provide an increased level of protection for
the provider if exposure to blood is likely.
Although the effectiveness of wearing two pairs of gloves in
preventing disease transmission has not been demonstrated,
the majority of studies among HCP and DHCP have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeon’s hands when double gloves are worn
(181,185,195,196,198,217–219). In one study evaluating
double gloves during oral surgical and dental hygiene procedures, the perforation of outer latex gloves was greater during
longer procedures (i.e., >45 minutes), with the highest rate
(10%) of perforation occurring during oral surgery procedures
(196). Based on these studies, double gloving might provide
additional protection from occupational blood contact (220).
Double gloving does not appear to substantially reduce either
manual dexterity or tactile sensitivity (221–223). Additional
protection might also be provided by specialty products (e.g.,
orthopedic surgical gloves and glove liners) (224).
19
Contact Dermatitis and Latex
Hypersensitivity
Occupationally related contact dermatitis can develop from
frequent and repeated use of hand hygiene products, exposure
to chemicals, and glove use. Contact dermatitis is classified as
either irritant or allergic. Irritant contact dermatitis is common, nonallergic, and develops as dry, itchy, irritated areas on
the skin around the area of contact. By comparison, allergic
contact dermatitis (type IV hypersensitivity) can result from
exposure to accelerators and other chemicals used in the manufacture of rubber gloves (e.g., natural rubber latex, nitrile, and
neoprene), as well as from other chemicals found in the dental
practice setting (e.g., methacrylates and glutaraldehyde).
Allergic contact dermatitis often manifests as a rash beginning
hours after contact and, similar to irritant dermatitis, is usually confined to the area of contact.
Latex allergy (type I hypersensitivity to latex proteins) can
be a more serious systemic allergic reaction, usually beginning
within minutes of exposure but sometimes occurring hours
later and producing varied symptoms. More common reactions include runny nose, sneezing, itchy eyes, scratchy throat,
hives, and itchy burning skin sensations. More severe symptoms include asthma marked by difficult breathing, coughing
spells, and wheezing; cardiovascular and gastrointestinal ailments; and in rare cases, anaphylaxis and death (32,225). The
American Dental Association (ADA) began investigating the
prevalence of type I latex hypersensitivity among DHCP at
the ADA annual meeting in 1994. In 1994 and 1995,
approximately 2,000 dentists, hygienists, and assistants volunteered for skin-prick testing. Data demonstrated that 6.2%
of those tested were positive for type I latex hypersensitivity
(226). Data from the subsequent 5 years of this ongoing crosssectional study indicated a decline in prevalence from 8.5% to
4.3% (227). This downward trend is similar to that reported
by other studies and might be related to use of latex gloves
with lower allergen content (228–230).
Natural rubber latex proteins responsible for latex allergy
are attached to glove powder. When powdered latex gloves are
worn, more latex protein reaches the skin. In addition, when
powdered latex gloves are donned or removed, latex protein/
powder particles become aerosolized and can be inhaled, contacting mucous membranes (231). As a result, allergic patients
and DHCP can experience cutaneous, respiratory, and conjunctival symptoms related to latex protein exposure. DHCP
can become sensitized to latex protein with repeated exposure
(232–236). Work areas where only powder-free, low-allergen
latex gloves are used demonstrate low or undetectable amounts
of latex allergy-causing proteins (237–239) and fewer symptoms among HCP related to natural rubber latex allergy.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
20
MMWR
Because of the role of glove powder in exposure to latex protein, NIOSH recommends that if latex gloves are chosen, HCP
should be provided with reduced protein, powder-free gloves
(32). Nonlatex (e.g., nitrile or vinyl) powder-free and lowprotein gloves are also available (31,240). Although rare,
potentially life-threatening anaphylactic reactions to latex can
occur; dental practices should be appropriately equipped and
have procedures in place to respond to such emergencies.
DHCP and dental patients with latex allergy should not have
direct contact with latex-containing materials and should be
in a latex-safe environment with all latex-containing products
removed from their vicinity (31). Dental patients with histories of latex allergy can be at risk from dental products (e.g.,
prophylaxis cups, rubber dams, orthodontic elastics, and medication vials) (241). Any latex-containing devices that cannot
be removed from the treatment environment should be
adequately covered or isolated. Persons might also be allergic
to chemicals used in the manufacture of natural rubber latex
and synthetic rubber gloves as well as metals, plastics, or other
materials used in dental care. Taking thorough health histories
for both patients and DHCP, followed by avoidance of contact with potential allergens can minimize the possibility of
adverse reactions. Certain common predisposing conditions
for latex allergy include previous history of allergies, a history
of spina bifida, urogenital anomalies, or allergies to avocados,
kiwis, nuts, or bananas. The following precautions should be
considered to ensure safe treatment for patients who have possible or documented latex allergy:
• Be aware that latent allergens in the ambient air can cause
respiratory or anaphylactic symptoms among persons with
latex hypersensitivity. Patients with latex allergy can be
scheduled for the first appointment of the day to minimize their inadvertent exposure to airborne latex particles.
• Communicate with other DHCP regarding patients with
latex allergy (e.g., by oral instructions, written protocols,
and posted signage) to prevent them from bringing latexcontaining materials into the treatment area.
• Frequently clean all working areas contaminated with
latex powder or dust.
December 19, 2003
• Have emergency treatment kits with latex-free products
available at all times.
• If latex-related complications occur during or after a procedure, manage the reaction and seek emergency assistance
as indicated. Follow current medical emergency response
recommendations for management of anaphylaxis (32).
Sterilization and Disinfection
of Patient-Care Items
Patient-care items (dental instruments, devices, and equipment) are categorized as critical, semicritical, or noncritical,
depending on the potential risk for infection associated with
their intended use (Table 4) (242). Critical items used to penetrate soft tissue or bone have the greatest risk of transmitting
infection and should be sterilized by heat. Semicritical items
touch mucous membranes or nonintact skin and have a lower
risk of transmission; because the majority of semicritical items
in dentistry are heat-tolerant, they also should be sterilized by
using heat. If a semicritical item is heat-sensitive, it should, at
a minimum, be processed with high-level disinfection (2).
Noncritical patient-care items pose the least risk of transmission of infection, contacting only intact skin, which can
serve as an effective barrier to microorganisms. In the majority
of cases, cleaning, or if visibly soiled, cleaning followed by disinfection with an EPA-registered hospital disinfectant is adequate.
When the item is visibly contaminated with blood or OPIM,
an EPA-registered hospital disinfectant with a tuberculocidal
claim (i.e., intermediate-level disinfectant) should be used
(2,243,244). Cleaning or disinfection of certain noncritical
patient-care items can be difficult or damage the surfaces; therefore, use of disposable barrier protection of these surfaces might
be a preferred alternative.
FDA-cleared sterilant/high-level disinfectants and EPAregistered disinfectants must have clear label claims for intended
use, and manufacturer instructions for use must be followed
(245). A more complete description of the regulatory framework in the United States by which liquid chemical germicides are evaluated and regulated is included (Appendix A).
TABLE 4. Infection-control categories of patient-care instruments
Category
Definition
Dental instrument or item
Critical
Penetrates soft tissue, contacts bone, enters into or contacts the bloodstream or other normally sterile tissue.
Surgical instruments, periodontal scalers, scalpel blades, surgical dental
burs
Semicritical
Contacts mucous membranes or nonintact skin; will not penetrate soft
tissue, contact bone, enter into or contact the bloodstream or other
normally sterile tissue.
Dental mouth mirror, amalgam condenser, reusable dental impression
trays, dental handpieces*
Noncritical
Contacts intact skin.
Radiograph head/cone, blood pressure cuff, facebow, pulse oximeter
* Although dental handpieces are considered a semicritical item, they should always be heat-sterilized between uses and not high-level disinfected (246). See Dental Handpieces
and Other Devices Attached to Air or Waterlines for detailed information.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
Three levels of disinfection, high, intermediate, and low, are
used for patient-care devices that do not require sterility and
two levels, intermediate and low, for environmental surfaces
(242). The intended use of the patient-care item should determine the recommended level of disinfection. Dental practices
should follow the product manufacturer’s directions regarding
concentrations and exposure time for disinfectant activity relative to the surface to be disinfected (245). A summary of sterilization and disinfection methods is included (Appendix C).
Transporting and Processing Contaminated
Critical and Semicritical Patient-Care Items
DHCP can be exposed to microorganisms on contaminated
instruments and devices through percutaneous injury, contact
with nonintact skin on the hands, or contact with mucous
membranes of the eyes, nose, or mouth. Contaminated
instruments should be handled carefully to prevent exposure
to sharp instruments that can cause a percutaneous injury.
Instruments should be placed in an appropriate container at
the point of use to prevent percutaneous injuries during transport to the instrument processing area (13).
Instrument processing requires multiple steps to achieve sterilization or high-level disinfection. Sterilization is a complex
process requiring specialized equipment, adequate space, qualified DHCP who are provided with ongoing training, and regular monitoring for quality assurance (247). Correct cleaning,
packaging, sterilizer loading procedures, sterilization methods,
or high-level disinfection methods should be followed to
ensure that an instrument is adequately processed and safe for
reuse on patients.
Instrument Processing Area
DHCP should process all instruments in a designated central processing area to more easily control quality and ensure
safety (248). The central processing area should be divided
into sections for 1) receiving, cleaning, and decontamination;
2) preparation and packaging; 3) sterilization; and 4) storage.
Ideally, walls or partitions should separate the sections to control traffic flow and contain contaminants generated during
processing. When physical separation of these sections cannot
be achieved, adequate spatial separation might be satisfactory
if the DHCP who process instruments are trained in work
practices to prevent contamination of clean areas (248). Space
should be adequate for the volume of work anticipated and
the items to be stored (248).
Receiving, Cleaning, and Decontamination
Reusable instruments, supplies, and equipment should be
received, sorted, cleaned, and decontaminated in one section
of the processing area. Cleaning should precede all disinfection
21
and sterilization processes; it should involve removal of debris
as well as organic and inorganic contamination. Removal of
debris and contamination is achieved either by scrubbing with
a surfactant, detergent, and water, or by an automated process
(e.g., ultrasonic cleaner or washer-disinfector) using chemical
agents. If visible debris, whether inorganic or organic matter, is
not removed, it will interfere with microbial inactivation and
can compromise the disinfection or sterilization process
(244,249–252). After cleaning, instruments should be rinsed
with water to remove chemical or detergent residue. Splashing
should be minimized during cleaning and rinsing (13). Before
final disinfection or sterilization, instruments should be handled
as though contaminated.
Considerations in selecting cleaning methods and equipment
include 1) efficacy of the method, process, and equipment;
2) compatibility with items to be cleaned; and 3) occupational
health and exposure risks. Use of automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) does not
require presoaking or scrubbing of instruments and can
increase productivity, improve cleaning effectiveness, and
decrease worker exposure to blood and body fluids. Thus,
using automated equipment can be safer and more efficient
than manually cleaning contaminated instruments (253).
If manual cleaning is not performed immediately, placing
instruments in a puncture-resistant container and soaking them
with detergent, a disinfectant/detergent, or an enzymatic
cleaner will prevent drying of patient material and make cleaning easier and less time-consuming. Use of a liquid chemical
sterilant/high-level disinfectant (e.g., glutaraldehyde) as a holding solution is not recommended (244). Using work-practice
controls (e.g., long-handled brush) to keep the scrubbing hand
away from sharp instruments is recommended (14). To avoid
injury from sharp instruments, DHCP should wear punctureresistant, heavy-duty utility gloves when handling or manually cleaning contaminated instruments and devices (6).
Employees should not reach into trays or containers holding
sharp instruments that cannot be seen (e.g., sinks filled with
soapy water in which sharp instruments have been placed).
Work-practice controls should include use of a strainer-type
basket to hold instruments and forceps to remove the items.
Because splashing is likely to occur, a mask, protective eyewear
or face shield, and gown or jacket should be worn (13).
Preparation and Packaging
In another section of the processing area, cleaned instruments and other dental supplies should be inspected, assembled
into sets or trays, and wrapped, packaged, or placed into container systems for sterilization. Hinged instruments should be
processed open and unlocked. An internal chemical indicator
should be placed in every package. In addition, an external
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
22
MMWR
chemical indicator (e.g., chemical indicator tape) should be
used when the internal indicator cannot be seen from outside
the package. For unwrapped loads, at a minimum, an internal
chemical indicator should be placed in the tray or cassette with
items to be sterilized (254) (see Sterilization of Unwrapped
Instruments). Dental practices should refer to the
manufacturer’s instructions regarding use and correct placement of chemical indicators (see Sterilization Monitoring).
Critical and semicritical instruments that will be stored should
be wrapped or placed in containers (e.g., cassettes or organizing trays) designed to maintain sterility during storage
(2,247,255–257).
Packaging materials (e.g., wraps or container systems) allow
penetration of the sterilization agent and maintain sterility of
the processed item after sterilization. Materials for maintaining sterility of instruments during transport and storage
include wrapped perforated instrument cassettes, peel pouches
of plastic or paper, and sterilization wraps (i.e., woven and
nonwoven). Packaging materials should be designed for the
type of sterilization process being used (256–259).
Sterilization
The sterilization section of the processing area should
include the sterilizers and related supplies, with adequate space
for loading, unloading, and cool down. The area can also
include incubators for analyzing spore tests and enclosed storage for sterile items and disposable (single-use) items (260).
Manufacturer and local building code specifications will
determine placement and room ventilation requirements.
Sterilization Procedures. Heat-tolerant dental instruments
usually are sterilized by 1) steam under pressure (autoclaving),
2) dry heat, or 3) unsaturated chemical vapor. All sterilization
should be performed by using medical sterilization equipment
cleared by FDA. The sterilization times, temperatures, and
other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct
use of containers, wraps, and chemical or biological indicators, should always be followed (243,247).
Items to be sterilized should be arranged to permit free circulation of the sterilizing agent (e.g., steam, chemical vapor,
or dry heat); manufacturer’s instructions for loading the sterilizer should be followed (248,260). Instrument packs should
be allowed to dry inside the sterilizer chamber before removing and handling. Packs should not be touched until they are
cool and dry because hot packs act as wicks, absorbing moisture, and hence, bacteria from hands (247). The ability of
equipment to attain physical parameters required to achieve
sterilization should be monitored by mechanical, chemical,
and biological indicators. Sterilizers vary in their types of
indicators and their ability to provide readings on the mechani-
December 19, 2003
cal or physical parameters of the sterilization process (e.g., time,
temperature, and pressure). Consult with the sterilizer manufacturer regarding selection and use of indicators.
Steam Sterilization. Among sterilization methods, steam
sterilization, which is dependable and economical, is the most
widely used for wrapped and unwrapped critical and
semicritical items that are not sensitive to heat and moisture
(260). Steam sterilization requires exposure of each item to
direct steam contact at a required temperature and pressure
for a specified time needed to kill microorganisms. Two basic
types of steam sterilizers are the gravity displacement and the
high-speed prevacuum sterilizer.
The majority of tabletop sterilizers used in a dental practice
are gravity displacement sterilizers, although prevacuum sterilizers are becoming more widely available. In gravity displacement sterilizers, steam is admitted through steam lines, a steam
generator, or self-generation of steam within the chamber.
Unsaturated air is forced out of the chamber through a vent in
the chamber wall. Trapping of air is a concern when using
saturated steam under gravity displacement; errors in packaging items or overloading the sterilizer chamber can result in
cool air pockets and items not being sterilized.
Prevacuum sterilizers are fitted with a pump to create a
vacuum in the chamber and ensure air removal from the sterilizing chamber before the chamber is pressurized with steam.
Relative to gravity displacement, this procedure allows faster
and more positive steam penetration throughout the entire
load. Prevacuum sterilizers should be tested periodically for
adequate air removal, as recommended by the manufacturer.
Air not removed from the chamber will interfere with steam
contact. If a sterilizer fails the air removal test, it should not be
used until inspected by sterilizer maintenance personnel and
it passes the test (243,247). Manufacturer’s instructions, with
specific details regarding operation and user maintenance
information, should be followed.
Unsaturated Chemical-Vapor Sterilization. Unsaturated
chemical-vapor sterilization involves heating a chemical solution of primarily alcohol with 0.23% formaldehyde in a closed
pressurized chamber. Unsaturated chemical vapor sterilization
of carbon steel instruments (e.g., dental burs) causes less corrosion than steam sterilization because of the low level of
water present during the cycle. Instruments should be dry
before sterilizing. State and local authorities should be consulted for hazardous waste disposal requirements for the sterilizing solution.
Dry-Heat Sterilization. Dry heat is used to sterilize materials that might be damaged by moist heat (e.g., burs and certain orthodontic instruments). Although dry heat has the
advantages of low operating cost and being noncorrosive, it is
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
a prolonged process and the high temperatures required are
not suitable for certain patient-care items and devices (261).
Dry-heat sterilizers used in dentistry include static-air and
forced-air types.
• The static-air type is commonly called an oven-type sterilizer. Heating coils in the bottom or sides of the unit cause hot
air to rise inside the chamber through natural convection.
• The forced-air type is also known as a rapid heat-transfer
sterilizer. Heated air is circulated throughout the chamber
at a high velocity, permitting more rapid transfer of
energy from the air to the instruments, thereby reducing
the time needed for sterilization.
Sterilization of Unwrapped Instruments. An unwrapped
cycle (sometimes called flash sterilization) is a method for sterilizing unwrapped patient-care items for immediate use. The
time required for unwrapped sterilization cycles depends on
the type of sterilizer and the type of item (i.e., porous or nonporous) to be sterilized (243). The unwrapped cycle in tabletop sterilizers is preprogrammed by the manufacturer to a
specific time and temperature setting and can include a drying
phase at the end to produce a dry instrument with much of
the heat dissipated. If the drying phase requirements are unclear,
the operation manual or manufacturer of the sterilizer should
be consulted. If the unwrapped sterilization cycle in a steam
sterilizer does not include a drying phase, or has only a minimal drying phase, items retrieved from the sterilizer will be
hot and wet, making aseptic transport to the point of use more
difficult. For dry-heat and chemical-vapor sterilizers, a drying
phase is not required.
Unwrapped sterilization should be used only under certain
conditions: 1) thorough cleaning and drying of instruments
precedes the unwrapped sterilization cycle; 2) mechanical
monitors are checked and chemical indicators used for each
cycle; 3) care is taken to avoid thermal injury to DHCP or
patients; and 4) items are transported aseptically to the point
of use to maintain sterility (134,258,262). Because all implantable devices should be quarantined after sterilization until the
results of biological monitoring are known, unwrapped or flash
sterilization of implantable items is not recommended (134).
Critical instruments sterilized unwrapped should be transferred immediately by using aseptic technique, from the sterilizer to the actual point of use. Critical instruments should not
be stored unwrapped (260). Semicritical instruments that are
sterilized unwrapped on a tray or in a container system should
be used immediately or within a short time. When sterile items
are open to the air, they will eventually become contaminated.
Storage, even temporary, of unwrapped semicritical instruments
is discouraged because it permits exposure to dust, airborne
organisms, and other unnecessary contamination before use
on a patient (260). A carefully written protocol for minimiz-
23
ing the risk of contaminating unwrapped instruments should
be prepared and followed (260).
Other Sterilization Methods. Heat-sensitive critical and
semicritical instruments and devices can be sterilized by
immersing them in liquid chemical germicides registered by
FDA as sterilants. When using a liquid chemical germicide for
sterilization, certain poststerilization procedures are essential.
Items need to be 1) rinsed with sterile water after removal to
remove toxic or irritating residues; 2) handled using sterile
gloves and dried with sterile towels; and 3) delivered to the
point of use in an aseptic manner. If stored before use, the
instrument should not be considered sterile and should be sterilized again just before use. In addition, the sterilization process with liquid chemical sterilants cannot be verified with
biological indicators (263).
Because of these limitations and because liquid chemical sterilants can require approximately 12 hours of complete
immersion, they are almost never used to sterilize instruments.
Rather, these chemicals are more often used for high-level disinfection (249). Shorter immersion times (12–90 minutes) are
used to achieve high-level disinfection of semicritical instruments or items. These powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) are highly
toxic (244,264,265). Manufacturer instructions (e.g., regarding dilution, immersion time, and temperature) and safety
precautions for using chemical sterilants/high-level disinfectants must be followed precisely (15,245). These chemicals
should not be used for applications other than those indicated
in their label instructions. Misapplications include use as an
environmental surface disinfectant or instrument-holding
solution.
When using appropriate precautions (e.g., closed containers to limit vapor release, chemically resistant gloves and aprons,
goggles, and face shields), glutaraldehyde-based products can
be used without tissue irritation or adverse health effects. However, dermatologic, eye irritation, respiratory effects, and skin
sensitization have been reported (266–268). Because of their
lack of chemical resistance to glutaraldehydes, medical gloves
are not an effective barrier (200,269,270). Other factors might
apply (e.g., room exhaust ventilation or 10 air exchanges/hour)
to ensure DHCP safety (266,271). For all of these reasons,
using heat-sensitive semicritical items that must be processed
with liquid chemical germicides is discouraged; heat-tolerant
or disposable alternatives are available for the majority of such
items.
Low-temperature sterilization with ethylene oxide gas (ETO)
has been used extensively in larger health-care facilities. Its
primary advantage is the ability to sterilize heat- and moisture-sensitive patient-care items with reduced deleterious
effects. However, extended sterilization times of 10–48 hours
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
24
MMWR
and potential hazards to patients and DHCP requiring stringent health and safety requirements (272–274) make this
method impractical for private-practice settings. Handpieces
cannot be effectively sterilized with this method because of
decreased penetration of ETO gas flow through a small lumen
(250,275). Other types of low-temperature sterilization (e.g.,
hydrogen peroxide gas plasma) exist but are not yet practical
for dental offices.
Bead sterilizers have been used in dentistry to sterilize small
metallic instruments (e.g., endodontic files). FDA has determined that a risk of infection exists with these devices because
of their potential failure to sterilize dental instruments and has
required their commercial distribution cease unless the manufacturer files a premarket approval application. If a bead sterilizer is employed, DHCP assume the risk of employing a
dental device FDA has deemed neither safe nor effective (276).
Sterilization Monitoring. Monitoring of sterilization procedures should include a combination of process parameters,
including mechanical, chemical, and biological (247,248,277).
These parameters evaluate both the sterilizing conditions and
the procedure’s effectiveness.
Mechanical techniques for monitoring sterilization include
assessing cycle time, temperature, and pressure by observing
the gauges or displays on the sterilizer and noting these
parameters for each load (243,248). Some tabletop sterilizers
have recording devices that print out these parameters. Correct readings do not ensure sterilization, but incorrect readings can be the first indication of a problem with the
sterilization cycle.
Chemical indicators, internal and external, use sensitive
chemicals to assess physical conditions (e.g., time and temperature) during the sterilization process. Although chemical
indicators do not prove sterilization has been achieved, they
allow detection of certain equipment malfunctions, and they
can help identify procedural errors. External indicators applied
to the outside of a package (e.g., chemical indicator tape or
special markings) change color rapidly when a specific parameter is reached, and they verify that the package has been
exposed to the sterilization process. Internal chemical indicators should be used inside each package to ensure the sterilizing agent has penetrated the packaging material and actually
reached the instruments inside. A single-parameter internal
chemical indicator provides information regarding only one
sterilization parameter (e.g., time or temperature). Multiparameter internal chemical indicators are designed to react to
>2 parameters (e.g., time and temperature; or time, temperature, and the presence of steam) and can provide a more reliable indication that sterilization conditions have been met
(254). Multiparameter internal indicators are available only
for steam sterilizers (i.e., autoclaves).
December 19, 2003
Because chemical indicator test results are received when the
sterilization cycle is complete, they can provide an early indication of a problem and where in the process the problem
might exist. If either mechanical indicators or internal or
external chemical indicators indicate inadequate processing,
items in the load should not be used until reprocessed (134).
Biological indicators (BIs) (i.e., spore tests) are the most
accepted method for monitoring the sterilization process
(278,279) because they assess it directly by killing known highly
resistant microorganisms (e.g., Geobacillus or Bacillus species),
rather than merely testing the physical and chemical conditions necessary for sterilization (243). Because spores used in
BIs are more resistant and present in greater numbers than the
common microbial contaminants found on patient-care equipment, an inactivated BI indicates other potential pathogens in
the load have been killed (280).
Correct functioning of sterilization cycles should be verified
for each sterilizer by the periodic use (at least weekly) of BIs
(2,9,134,243,278,279). Every load containing implantable
devices should be monitored with such indicators (248), and
the items quarantined until BI results are known. However, in
an emergency, placing implantable items in quarantine until
spore tests are known to be negative might be impossible.
Manufacturer’s directions should determine the placement
and location of BI in the sterilizer. A control BI, from the
same lot as the test indicator and not processed through the
sterilizer, should be incubated with the test BI; the control BI
should yield positive results for bacterial growth.
In-office biological monitoring is available; mail-in sterilization monitoring services (e.g., from private companies or
dental schools) can also be used to test both the BI and the
control. Although some DHCP have expressed concern that
delays caused by mailing specimens might cause false-negatives,
studies have determined that mail delays have no substantial
effect on final test results (281,282).
Procedures to follow in the event of a positive spore test
have been developed (243,247). If the mechanical (e.g., time,
temperature, and pressure) and chemical (i.e., internal or
external) indicators demonstrate that the sterilizer is functioning correctly, a single positive spore test probably does not
indicate sterilizer malfunction. Items other than implantable
devices do not necessarily need to be recalled; however the
spore test should be repeated immediately after correctly loading the sterilizer and using the same cycle that produced the
failure. The sterilizer should be removed from service, and all
records reviewed of chemical and mechanical monitoring since
the last negative BI test. Also, sterilizer operating procedures
should be reviewed, including packaging, loading, and spore
testing, with all persons who work with the sterilizer to determine whether operator error could be responsible (9,243,247).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
Overloading, failure to provide adequate package separation,
and incorrect or excessive packaging material are all common
reasons for a positive BI in the absence of mechanical failure
of the sterilizer unit (260). A second monitored sterilizer in
the office can be used, or a loaner from a sales or repair company obtained, to minimize office disruption while waiting
for the repeat BI.
If the repeat test is negative and chemical and mechanical
monitoring indicate adequate processing, the sterilizer can be
put back into service. If the repeat BI test is positive, and packaging, loading, and operating procedures have been confirmed
as performing correctly, the sterilizer should remain out of service until it has been inspected, repaired, and rechallenged with
BI tests in three consecutive empty chamber sterilization cycles
(9,243). When possible, items from suspect loads dating back
to the last negative BI should be recalled, rewrapped, and
resterilized (9,283).
A more conservative approach has been recommended (247)
in which any positive spore test is assumed to represent sterilizer malfunction and requires that all materials processed in
that sterilizer, dating from the sterilization cycle having the
last negative biologic indicator to the next cycle indicating satisfactory biologic indicator results, should be considered
nonsterile and retrieved, if possible, and reprocessed or held in
quarantine until the results of the repeat BI are known. This
approach is considered conservative because the margin of
safety in steam sterilization is sufficient enough that infection
risk, associated with items in a load indicating spore growth, is
minimal, particularly if the item was properly cleaned and the
temperature was achieved (e.g., as demonstrated by acceptable chemical indicator or temperature chart) (243). Published
studies are not available that document disease transmission
through a nonretrieved surgical instrument after a steam sterilization cycle with a positive biological indicator (243). This
more conservative approach should always be used for sterilization methods other than steam (e.g., dry heat, unsaturated
chemical vapor, ETO, or hydrogen peroxide gas plasma) (243).
Results of biological monitoring should be recorded and sterilization monitoring records (i.e., mechanical, chemical, and
biological) retained long enough to comply with state and
local regulations. Such records are a component of an overall
dental infection-control program (see Program Evaluation).
Storage of Sterilized Items and Clean Dental
Supplies
The storage area should contain enclosed storage for sterile
items and disposable (single-use) items (173). Storage practices for wrapped sterilized instruments can be either date- or
event-related. Packages containing sterile supplies should be
inspected before use to verify barrier integrity and dryness.
25
Although some health-care facilities continue to date every
sterilized package and use shelf-life practices, other facilities
have switched to event-related practices (243). This approach
recognizes that the product should remain sterile indefinitely,
unless an event causes it to become contaminated (e.g., torn
or wet packaging) (284). Even for event-related packaging,
minimally, the date of sterilization should be placed on the
package, and if multiple sterilizers are used in the facility, the
sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in
the event of a sterilization failure (247). If packaging is compromised, the instruments should be recleaned, packaged in
new wrap, and sterilized again.
Clean supplies and instruments should be stored in closed
or covered cabinets, if possible (285). Dental supplies and
instruments should not be stored under sinks or in other locations where they might become wet.
Environmental Infection Control
In the dental operatory, environmental surfaces (i.e., a surface or equipment that does not contact patients directly) can
become contaminated during patient care. Certain surfaces,
especially ones touched frequently (e.g., light handles, unit
switches, and drawer knobs) can serve as reservoirs of microbial contamination, although they have not been associated
directly with transmission of infection to either DHCP or
patients. Transfer of microorganisms from contaminated
environmental surfaces to patients occurs primarily through
DHCP hand contact (286,287). When these surfaces are
touched, microbial agents can be transferred to instruments,
other environmental surfaces, or to the nose, mouth, or eyes
of workers or patients. Although hand hygiene is key to minimizing this transferal, barrier protection or cleaning and disinfecting of environmental surfaces also protects against
health-care–associated infections.
Environmental surfaces can be divided into clinical contact
surfaces and housekeeping surfaces (249). Because housekeeping surfaces (e.g., floors, walls, and sinks) have limited risk of
disease transmission, they can be decontaminated with less rigorous methods than those used on dental patient-care items
and clinical contact surfaces (244). Strategies for cleaning and
disinfecting surfaces in patient-care areas should consider the
1) potential for direct patient contact; 2) degree and frequency
of hand contact; and 3) potential contamination of the surface with body substances or environmental sources of microorganisms (e.g., soil, dust, or water).
Cleaning is the necessary first step of any disinfection process. Cleaning is a form of decontamination that renders the
environmental surface safe by removing organic matter, salts,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
26
MMWR
and visible soils, all of which interfere with microbial inactivation. The physical action of scrubbing with detergents and
surfactants and rinsing with water removes substantial numbers of microorganisms. If a surface is not cleaned first, the
success of the disinfection process can be compromised.
Removal of all visible blood and inorganic and organic matter
can be as critical as the germicidal activity of the disinfecting
agent (249). When a surface cannot be cleaned adequately, it
should be protected with barriers (2).
Clinical Contact Surfaces
Clinical contact surfaces can be directly contaminated from
patient materials either by direct spray or spatter generated
during dental procedures or by contact with DHCP’s gloved
hands. These surfaces can subsequently contaminate other
instruments, devices, hands, or gloves. Examples of such surfaces include
• light handles,
• switches,
• dental radiograph equipment,
• dental chairside computers,
• reusable containers of dental materials,
• drawer handles,
• faucet handles,
• countertops,
• pens,
• telephones, and
• doorknobs.
Barrier protection of surfaces and equipment can prevent
contamination of clinical contact surfaces, but is particularly
effective for those that are difficult to clean. Barriers include
clear plastic wrap, bags, sheets, tubing, and plastic-backed
paper or other materials impervious to moisture (260,288).
Because such coverings can become contaminated, they should
be removed and discarded between patients, while DHCP are
still gloved. After removing the barrier, examine the surface to
make sure it did not become soiled inadvertently. The surface
needs to be cleaned and disinfected only if contamination is
evident. Otherwise, after removing gloves and performing hand
hygiene, DHCP should place clean barriers on these surfaces
before the next patient (1,2,288).
If barriers are not used, surfaces should be cleaned and disinfected between patients by using an EPA-registered hospital
disinfectant with an HIV, HBV claim (i.e., low-level disinfectant) or a tuberculocidal claim (i.e., intermediate-level disinfectant). Intermediate-level disinfectant should be used when
the surface is visibly contaminated with blood or OPIM
(2,244). Also, general cleaning and disinfection are recommended for clinical contact surfaces, dental unit surfaces, and
countertops at the end of daily work activities and are required
December 19, 2003
if surfaces have become contaminated since their last cleaning
(13). To facilitate daily cleaning, treatment areas should be
kept free of unnecessary equipment and supplies.
Manufacturers of dental devices and equipment should provide information regarding material compatibility with liquid
chemical germicides, whether equipment can be safely
immersed for cleaning, and how it should be decontaminated
if servicing is required (289). Because of the risks associated
with exposure to chemical disinfectants and contaminated surfaces, DHCP who perform environmental cleaning and disinfection should wear gloves and other PPE to prevent
occupational exposure to infectious agents and hazardous
chemicals. Chemical- and puncture-resistant utility gloves
offer more protection than patient examination gloves when
using hazardous chemicals.
Housekeeping Surfaces
Evidence does not support that housekeeping surfaces (e.g.,
floors, walls, and sinks) pose a risk for disease transmission in
dental health-care settings. Actual, physical removal of microorganisms and soil by wiping or scrubbing is probably as critical, if not more so, than any antimicrobial effect provided by
the agent used (244,290). The majority of housekeeping surfaces need to be cleaned only with a detergent and water or an
EPA-registered hospital disinfectant/detergent, depending on
the nature of the surface and the type and degree of contamination. Schedules and methods vary according to the area (e.g.,
dental operatory, laboratory, bathrooms, or reception rooms),
surface, and amount and type of contamination.
Floors should be cleaned regularly, and spills should be
cleaned up promptly. An EPA-registered hospital disinfectant/
detergent designed for general housekeeping purposes should
be used in patient-care areas if uncertainty exists regarding the
nature of the soil on the surface (e.g., blood or body fluid
contamination versus routine dust or dirt). Unless contamination is reasonably anticipated or apparent, cleaning or disinfecting walls, window drapes, and other vertical surfaces is
unnecessary. However, when housekeeping surfaces are visibly
contaminated by blood or OPIM, prompt removal and surface disinfection is appropriate infection-control practice and
required by OSHA (13).
Part of the cleaning strategy is to minimize contamination
of cleaning solutions and cleaning tools (e.g., mop heads or
cleaning cloths). Mops and cloths should be cleaned after use
and allowed to dry before reuse, or single-use, disposable mop
heads and cloths should be used to avoid spreading contamination. Cost, safety, product-surface compatibility, and acceptability by housekeepers can be key criteria for selecting a
cleaning agent or an EPA-registered hospital disinfectant/
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
detergent. PPE used during cleaning and housekeeping procedures followed should be appropriate to the task.
In the cleaning process, another reservoir for microorganisms can be dilute solutions of detergents or disinfectants,
especially if prepared in dirty containers, stored for long periods of time, or prepared incorrectly (244). Manufacturers’
instructions for preparation and use should be followed. Making fresh cleaning solution each day, discarding any remaining
solution, and allowing the container to dry will minimize bacterial contamination. Preferred cleaning methods produce
minimal mists and aerosols or dispersion of dust in patientcare areas.
Cleaning and Disinfection Strategies
for Blood Spills
The majority of blood contamination events in dentistry
result from spatter during dental procedures using rotary or
ultrasonic instrumentation. Although no evidence supports
that HBV, HCV, or HIV have been transmitted from a housekeeping surface, prompt removal and surface disinfection of
an area contaminated by either blood or OPIM are appropriate infection-control practices and required by OSHA (13,291).
Strategies for decontaminating spills of blood and other body
fluids differ by setting and volume of the spill (113,244). Blood
spills on either clinical contact or housekeeping surfaces should
be contained and managed as quickly as possible to reduce the
risk of contact by patients and DHCP (244,292). The person
assigned to clean the spill should wear gloves and other PPE as
needed. Visible organic material should be removed with
absorbent material (e.g., disposable paper towels discarded in
a leak-proof, appropriately labeled container). Nonporous surfaces should be cleaned and then decontaminated with either
an EPA-registered hospital disinfectant effective against HBV
and HIV or an EPA-registered hospital disinfectant with a
tuberculocidal claim (i.e., intermediate-level disinfectant). If
sodium hypochlorite is chosen, an EPA-registered sodium
hypochlorite product is preferred. However, if such products
are unavailable, a 1:100 dilution of sodium hypochlorite (e.g.,
approximately ¼ cup of 5.25% household chlorine bleach to
1 gallon of water) is an inexpensive and effective disinfecting
agent (113).
Carpeting and Cloth Furnishings
Carpeting is more difficult to clean than nonporous hardsurface flooring, and it cannot be reliably disinfected, especially after spills of blood and body substances. Studies have
documented the presence of diverse microbial populations,
primarily bacteria and fungi, in carpeting (293–295). Cloth
furnishings pose similar contamination risks in areas of direct
patient care and places where contaminated materials are man-
27
aged (e.g., dental operatory, laboratory, or instrument processing areas). For these reasons, use of carpeted flooring and fabric-upholstered furnishings in these areas should be avoided.
Nonregulated and Regulated Medical Waste
Studies have compared microbial load and diversity of
microorganisms in residential waste with waste from multiple
health-care settings. General waste from hospitals or other
health-care facilities (e.g., dental practices or clinical/research
laboratories) is no more infective than residential waste
(296,297). The majority of soiled items in dental offices are
general medical waste and thus can be disposed of with ordinary waste. Examples include used gloves, masks, gowns, lightly
soiled gauze or cotton rolls, and environmental barriers (e.g.,
plastic sheets or bags) used to cover equipment during treatment (298).
Although any item that has had contact with blood, exudates, or secretions might be infective, treating all such waste
as infective is neither necessary nor practical (244). Infectious
waste that carries a substantial risk of causing infection during
handling and disposal is regulated medical waste. A complete
definition of regulated waste is included in OSHA’s bloodborne
pathogens standard (13).
Regulated medical waste is only a limited subset of waste:
9%–15% of total waste in hospitals and 1%–2% of total waste
in dental offices (298,299). Regulated medical waste requires
special storage, handling, neutralization, and disposal and is
covered by federal, state, and local rules and regulations
(6,297,300,301). Examples of regulated waste found in dental-practice settings are solid waste soaked or saturated with
blood or saliva (e.g., gauze saturated with blood after surgery),
extracted teeth, surgically removed hard and soft tissues, and
contaminated sharp items (e.g., needles, scalpel blades, and
wires) (13).
Regulated medical waste requires careful containment for
treatment or disposal. A single leak-resistant biohazard bag is
usually adequate for containment of nonsharp regulated medical waste, provided the bag is sturdy and the waste can be
discarded without contaminating the bag’s exterior. Exterior
contamination or puncturing of the bag requires placement in
a second biohazard bag. All bags should be securely closed for
disposal. Puncture-resistant containers with a biohazard label,
located at the point of use (i.e., sharps containers), are used as
containment for scalpel blades, needles, syringes, and unused
sterile sharps (13).
Dental health-care facilities should dispose of medical waste
regularly to avoid accumulation. Any facility generating regulated medical waste should have a plan for its management
that complies with federal, state, and local regulations to
ensure health and environmental safety.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
28
MMWR
Discharging Blood or Other Body Fluids
to Sanitary Sewers or Septic Tanks
All containers with blood or saliva (e.g., suctioned fluids)
can be inactivated in accordance with state-approved treatment technologies, or the contents can be carefully poured
down a utility sink, drain, or toilet (6). Appropriate PPE (e.g.,
gloves, gown, mask, and protective eyewear) should be worn
when performing this task (13). No evidence exists that
bloodborne diseases have been transmitted from contact with
raw or treated sewage. Multiple bloodborne pathogens, particularly viruses, are not stable in the environment for long
periods (302), and the discharge of limited quantities of blood
and other body fluids into the sanitary sewer is considered a
safe method for disposing of these waste materials (6). State
and local regulations vary and dictate whether blood or other
body fluids require pretreatment or if they can be discharged
into the sanitary sewer and in what volume.
Dental Unit Waterlines, Biofilm,
and Water Quality
Studies have demonstrated that dental unit waterlines (i.e.,
narrow-bore plastic tubing that carries water to the high-speed
handpiece, air/water syringe, and ultrasonic scaler) can become
colonized with microorganisms, including bacteria, fungi, and
protozoa (303–309). Protected by a polysaccharide slime layer
known as a glycocalyx, these microorganisms colonize and replicate on the interior surfaces of the waterline tubing and form
a biofilm, which serves as a reservoir that can amplify the number of free-floating (i.e., planktonic) microorganisms in water
used for dental treatment. Although oral flora (303,310,311)
and human pathogens (e.g., Pseudomonas aeruginosa
[303,305,312,313], Legionella species [303,306,313], and
nontuberculous Mycobacterium species [303,304]), have been
isolated from dental water systems, the majority of organisms
recovered from dental waterlines are common heterotrophic
water bacteria (305,314,315). These exhibit limited pathogenic potential for immunocompetent persons.
Clinical Implications
Certain reports associate waterborne infections with dental
water systems, and scientific evidence verifies the potential for
transmission of waterborne infections and disease in hospital
settings and in the community (306,312,316). Infection or
colonization caused by Pseudomonas species or nontuberculous
mycobacteria can occur among susceptible patients through
direct contact with water (317–320) or after exposure to
residual waterborne contamination of inadequately reprocessed
medical instruments (321–323). Nontuberculous mycobacteria can also be transmitted to patients from tap water aero-
December 19, 2003
sols (324). Health-care–associated transmission of pathogenic
agents (e.g., Legionella species) occurs primarily through inhalation of infectious aerosols generated from potable water
sources or through use of tap water in respiratory therapy equipment (325–327). Disease outbreaks in the community have
also been reported from diverse environmental aerosolproducing sources, including whirlpool spas (328), swimming
pools (329), and a grocery store mist machine (330). Although
the majority of these outbreaks are associated with species of
Legionella and Pseudomonas (329), the fungus Cladosporium
(331) has also been implicated.
Researchers have not demonstrated a measurable risk of
adverse health effects among DHCP or patients from exposure to dental water. Certain studies determined DHCP had
altered nasal flora (332) or substantially greater titers of
Legionella antibodies in comparisons with control populations;
however, no cases of legionellosis were identified among
exposed DHCP (333,334). Contaminated dental water might
have been the source for localized Pseudomonas aeruginosa
infections in two immunocompromised patients (312).
Although transient carriage of P. aeruginosa was observed in
78 healthy patients treated with contaminated dental treatment water, no illness was reported among the group. In this
same study, a retrospective review of dental records also failed
to identify infections (312).
Concentrations of bacterial endotoxin <1,000 endotoxin
units/mL from gram-negative water bacteria have been detected
in water from colonized dental units (335). No standards exist
for an acceptable level of endotoxin in drinking water, but the
maximum level permissible in United States Pharmacopeia
(USP) sterile water for irrigation is only 0.25 endotoxin units/
mL (336). Although the consequences of acute and chronic
exposure to aerosolized endotoxin in dental health-care settings have not been investigated, endotoxin has been associated with exacerbation of asthma and onset of hypersensitivity
pneumonitis in other occupational settings (329,337).
Dental Unit Water Quality
Research has demonstrated that microbial counts can reach
<200,000 colony-forming units (CFU)/mL within 5 days
after installation of new dental unit waterlines (305), and levels of microbial contamination <106 CFU/mL of dental unit
water have been documented (309,338). These counts can
occur because dental unit waterline factors (e.g., system design,
flow rates, and materials) promote both bacterial growth and
development of biofilm.
Although no epidemiologic evidence indicates a public health
problem, the presence of substantial numbers of pathogens in
dental unit waterlines generates concern. Exposing patients or
DHCP to water of uncertain microbiological quality, despite
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
the lack of documented adverse health effects, is inconsistent
with accepted infection-control principles. Thus in 1995, ADA
addressed the dental water concern by asking manufacturers
to provide equipment with the ability to deliver treatment water
with <200 CFU/mL of unfiltered output from waterlines (339).
This threshold was based on the quality assurance standard
established for dialysate fluid, to ensure that fluid delivery systems in hemodialysis units have not been colonized by indigenous waterborne organisms (340).
Standards also exist for safe drinking water quality as established by EPA, the American Public Health Association
(APHA), and the American Water Works Association
(AWWA); they have set limits for heterotrophic bacteria of
<500 CFU/mL of drinking water (341,342). Thus, the number of bacteria in water used as a coolant/irrigant for nonsurgical dental procedures should be as low as reasonably
achievable and, at a minimum, <500 CFU/mL, the regulatory
standard for safe drinking water established by EPA and APHA/
AWWA.
Strategies To Improve Dental
Unit Water Quality
In 1993, CDC recommended that dental waterlines be
flushed at the beginning of the clinic day to reduce the microbial load (2). However, studies have demonstrated this practice does not affect biofilm in the waterlines or reliably improve
the quality of water used during dental treatment
(315,338,343). Because the recommended value of <500 CFU/
mL cannot be achieved by using this method, other strategies
should be employed. Dental unit water that remains untreated
or unfiltered is unlikely to meet drinking water standards (303–
309). Commercial devices and procedures designed to improve
the quality of water used in dental treatment are available (316);
methods demonstrated to be effective include self-contained
water systems combined with chemical treatment, in-line
microfilters, and combinations of these treatments. Simply
using source water containing <500 CFU/mL of bacteria (e.g.,
tap, distilled, or sterile water) in a self-contained water system
will not eliminate bacterial contamination in treatment water
if biofilms in the water system are not controlled. Removal or
inactivation of dental waterline biofilms requires use of chemical germicides.
Patient material (e.g., oral microorganisms, blood, and saliva)
can enter the dental water system during patient treatment
(311,344). Dental devices that are connected to the dental
water system and that enter the patient’s mouth (e.g.,
handpieces, ultrasonic scalers, or air/water syringes) should be
operated to discharge water and air for a minimum of 20–30
seconds after each patient (2). This procedure is intended to
physically flush out patient material that might have entered
29
the turbine, air, or waterlines. The majority of recently manufactured dental units are engineered to prevent retraction of
oral fluids, but some older dental units are equipped with
antiretraction valves that require periodic maintenance. Users
should consult the owner’s manual or contact the manufacturer to determine whether testing or maintenance of
antiretraction valves or other devices is required. Even with
antiretraction valves, flushing devices for a minimum of 20–
30 seconds after each patient is recommended.
Maintenance and Monitoring
of Dental Unit Water
DHCP should be trained regarding water quality, biofilm
formation, water treatment methods, and appropriate maintenance protocols for water delivery systems. Water treatment
and monitoring products require strict adherence to maintenance protocols, and noncompliance with treatment regimens
has been associated with persistence of microbial contamination in treated systems (345). Clinical monitoring of water
quality can ensure that procedures are correctly performed and
that devices are working in accordance with the manufacturer’s
previously validated protocol.
Dentists should consult with the manufacturer of their dental
unit or water delivery system to determine the best method for
maintaining acceptable water quality (i.e., <500 CFU/mL) and
the recommended frequency of monitoring. Monitoring of dental water quality can be performed by using commercial selfcontained test kits or commercial water-testing laboratories.
Because methods used to treat dental water systems target the
entire biofilm, no rationale exists for routine testing for such
specific organisms as Legionella or Pseudomonas, except when
investigating a suspected waterborne disease outbreak (244).
Delivery of Sterile Surgical Irrigation
Sterile solutions (e.g., sterile saline or sterile water) should be
used as a coolant/irrigation in the performance of oral surgical
procedures where a greater opportunity exists for entry of
microorganisms, exogenous and endogenous, into the vascular
system and other normally sterile areas that support the oral
cavity (e.g., bone or subcutaneous tissue) and increased potential exists for localized or systemic infection (see Oral Surgical
Procedures). Conventional dental units cannot reliably deliver
sterile water even when equipped with independent water reservoirs because the water-bearing pathway cannot be reliably
sterilized. Delivery devices (e.g., bulb syringe or sterile, singleuse disposable products) should be used to deliver sterile water
(2,121). Oral surgery and implant handpieces, as well as ultrasonic scalers, are commercially available that bypass the dental
unit to deliver sterile water or other solutions by using singleuse disposable or sterilizable tubing (316).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
30
MMWR
Boil-Water Advisories
A boil-water advisory is a public health announcement that
the public should boil tap water before drinking it. When
issued, the public should assume the water is unsafe to drink.
Advisories can be issued after 1) failure of or substantial interruption in water treatment processes that result in increased
turbidity levels or particle counts and mechanical or equipment failure; 2) positive test results for pathogens (e.g.,
Cryptosporidium, Giardia, or Shigella) in water; 3) violations
of the total coliform rule or the turbidity standard of the surface water treatment rule; 4) circumstances that compromise
the distribution system (e.g., watermain break) coupled with
an indication of a health hazard; or 5) a natural disaster (e.g.,
flood, hurricane, or earthquake) (346). In recent years,
increased numbers of boil-water advisories have resulted from
contamination of public drinking water systems with waterborne pathogens. Most notable was the outbreak of
cryptosporidiosis in Milwaukee, Wisconsin, where the
municipal water system was contaminated with the protozoan
parasite Cryptosporidium parvum. An estimated 403,000 persons became ill (347,348).
During a boil-water advisory, water should not be delivered
to patients through the dental unit, ultrasonic scaler, or other
dental equipment that uses the public water system. This
restriction does not apply if the water source is isolated from
the municipal water system (e.g., a separate water reservoir or
other water treatment device cleared for marketing by FDA).
Patients should rinse with bottled or distilled water until the
boil-water advisory has been cancelled. During these advisory
periods, tap water should not be used to dilute germicides or
for hand hygiene unless the water has been brought to a rolling boil for >1 minute and cooled before use (346,349–351).
For hand hygiene, antimicrobial products that do not require
water (e.g., alcohol-based hand rubs) can be used until the
boil-water notice is cancelled. If hands are visibly contaminated, bottled water and soap should be used for handwashing;
if bottled water is not immediately available, an antiseptic
towelette should be used (13,122).
When the advisory is cancelled, the local water utility should
provide guidance for flushing of waterlines to reduce residual
microbial contamination. All incoming waterlines from the
public water system inside the dental office (e.g., faucets, waterlines, and dental equipment) should be flushed. No consensus
exists regarding the optimal duration for flushing procedures
after cancellation of the advisory; recommendations range from
1 to 5 minutes (244,346,351,352). The length of time needed
can vary with the type and length of the plumbing system leading to the office. After the incoming public water system lines
are flushed, dental unit waterlines should be disinfected according to the manufacturer’s instructions (346).
December 19, 2003
Special Considerations
Dental Handpieces and Other Devices
Attached to Air and Waterlines
Multiple semicritical dental devices that touch mucous membranes are attached to the air or waterlines of the dental unit.
Among these devices are high- and low-speed handpieces, prophylaxis angles, ultrasonic and sonic scaling tips, air abrasion
devices, and air and water syringe tips. Although no epidemiologic evidence implicates these instruments in disease transmission (353), studies of high-speed handpieces using dye
expulsion have confirmed the potential for retracting oral fluids into internal compartments of the device (354–358). This
determination indicates that retained patient material can be
expelled intraorally during subsequent uses. Studies using laboratory models also indicate the possibility for retention of viral
DNA and viable virus inside both high-speed handpieces and
prophylaxis angles (356,357,359). The potential for contamination of the internal surfaces of other devices (e.g., low-speed
handpieces and ultrasonic scalers), has not been studied, but
restricted physical access limits their cleaning. Accordingly, any
dental device connected to the dental air/water system that
enters the patient’s mouth should be run to discharge water,
air, or a combination for a minimum of 20–30 seconds after
each patient (2). This procedure is intended to help physically
flush out patient material that might have entered the turbine
and air and waterlines (2,356,357).
Heat methods can sterilize dental handpieces and other intraoral devices attached to air or waterlines (246,275,356,
357,360). For processing any dental device that can be
removed from the dental unit air or waterlines, neither surface
disinfection nor immersion in chemical germicides is an
acceptable method. Ethylene oxide gas cannot adequately sterilize internal components of handpieces (250,275). In clinical
evaluations of high-speed handpieces, cleaning and lubrication were the most critical factors in determining performance
and durability (361–363). Manufacturer’s instructions for
cleaning, lubrication, and sterilization should be followed
closely to ensure both the effectiveness of the process and the
longevity of handpieces.
Some components of dental instruments are permanently
attached to dental unit waterlines and although they do not
enter the patient’s oral cavity, they are likely to become contaminated with oral fluids during treatment procedures. Such
components (e.g., handles or dental unit attachments of saliva
ejectors, high-speed air evacuators, and air/water syringes)
should be covered with impervious barriers that are changed
after each use. If the item becomes visibly contaminated during use, DHCP should clean and disinfect with an EPA-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
registered hospital disinfectant (intermediate-level) before use
on the next patient.
Saliva Ejectors
Backflow from low-volume saliva ejectors occurs when the
pressure in the patient’s mouth is less than that in the evacuator. Studies have reported that backflow in low-volume suction lines can occur and microorganisms be present in the lines
retracted into the patient’s mouth when a seal around the
saliva ejector is created (e.g., by a patient closing lips around
the tip of the ejector, creating a partial vacuum) (364–366).
This backflow can be a potential source of cross-contamination; occurrence is variable because the quality of the seal
formed varies between patients. Furthermore, studies have demonstrated that gravity pulls fluid back toward the patient’s
mouth whenever a length of the suction tubing holding the
tip is positioned above the patient’s mouth, or during simultaneous use of other evacuation (high-volume) equipment (364–
366). Although no adverse health effects associated with the
saliva ejector have been reported, practitioners should be aware
that in certain situations, backflow could occur when using a
saliva ejector.
Dental Radiology
When taking radiographs, the potential to cross-contaminate equipment and environmental surfaces with blood or
saliva is high if aseptic technique is not practiced. Gloves should
be worn when taking radiographs and handling contaminated
film packets. Other PPE (e.g., mask, protective eyewear, and
gowns) should be used if spattering of blood or other body
fluids is likely (11,13,367). Heat-tolerant versions of intraoral
radiograph accessories are available and these semicritical items
(e.g., film-holding and positioning devices) should be heatsterilized before patient use.
After exposure of the radiograph and before glove removal,
the film should be dried with disposable gauze or a paper towel
to remove blood or excess saliva and placed in a container (e.g.,
disposable cup) for transport to the developing area. Alternatively, if FDA-cleared film barrier pouches are used, the film
packets should be carefully removed from the pouch to avoid
contamination of the outside film packet and placed in the
clean container for transport to the developing area.
Various methods have been recommended for aseptic transport of exposed films to the developing area, and for removing
the outer film packet before exposing and developing the film.
Other information regarding dental radiography infection
control is available (260,367,368). However, care should be
taken to avoid contamination of the developing equipment.
Protective barriers should be used, or any surfaces that
31
become contaminated should be cleaned and disinfected with
an EPA-registered hospital disinfectant of low- (i.e., HIV and
HBV claim) to intermediate-level (i.e., tuberculocidal claim)
activity. Radiography equipment (e.g., radiograph tubehead
and control panel) should be protected with surface barriers
that are changed after each patient. If barriers are not used,
equipment that has come into contact with DHCP’s gloved
hands or contaminated film packets should be cleaned and
then disinfected after each patient use.
Digital radiography sensors and other high-technology
instruments (e.g., intraoral camera, electronic periodontal
probe, occlusal analyzers, and lasers) come into contact with
mucous membranes and are considered semicritical devices.
They should be cleaned and ideally heat-sterilized or highlevel disinfected between patients. However, these items vary
by manufacturer or type of device in their ability to be sterilized or high-level disinfected. Semicritical items that cannot
be reprocessed by heat sterilization or high-level disinfection
should, at a minimum, be barrier protected by using an FDAcleared barrier to reduce gross contamination during use. Use
of a barrier does not always protect from contamination (369–
374). One study determined that a brand of commercially
available plastic barriers used to protect dental digital radiography sensors failed at a substantial rate (44%). This rate
dropped to 6% when latex finger cots were used in conjunction with the plastic barrier (375). To minimize the potential
for device-associated infections, after removing the barrier, the
device should be cleaned and disinfected with an EPAregistered hospital disinfectant (intermediate-level) after each
patient. Manufacturers should be consulted regarding appropriate barrier and disinfection/sterilization procedures for digital radiography sensors, other high-technology intraoral devices,
and computer components.
Aseptic Technique for Parenteral
Medications
Safe handling of parenteral medications and fluid infusion
systems is required to prevent health-care–associated infections
among patients undergoing conscious sedation. Parenteral
medications can be packaged in single-dose ampules, vials or
prefilled syringes, usually without bacteriostatic/preservative
agents, and intended for use on a single patient. Multidose
vials, used for more than one patient, can have a preservative,
but both types of containers of medication should be handled
with aseptic techniques to prevent contamination.
Single-dose vials should be used for parenteral medications
whenever possible (376,377). Single-dose vials might pose a
risk for contamination if they are punctured repeatedly. The
leftover contents of a single-dose vial should be discarded and
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
32
MMWR
never combined with medications for use on another patient
(376,377). Medication from a single-dose syringe should not
be administered to multiple patients, even if the needle on the
syringe is changed (378).
The overall risk for extrinsic contamination of multidose
vials is probably minimal, although the consequences of contamination might result in life-threatening infection (379). If
necessary to use a multidose vial, its access diaphragm should
be cleansed with 70% alcohol before inserting a sterile device
into the vial (380,381). A multidose vial should be discarded
if sterility is compromised (380,381).
Medication vials, syringes, or supplies should not be carried
in uniform or clothing pockets. If trays are used to deliver
medications to individual patients, they should be cleaned
between patients. To further reduce the chance of contamination, all medication vials should be restricted to a centralized
medication preparation area separate from the treatment area
(382).
All fluid infusion and administration sets (e.g., IV bags, tubing, and connections) are single-patient use because sterility
cannot be guaranteed when an infusion or administration set
is used on multiple patients. Aseptic technique should be used
when preparing IV infusion and administration sets, and
entry into or breaks in the tubing should be minimized (378).
Single-Use or Disposable Devices
A single-use device, also called a disposable device, is
designed to be used on one patient and then discarded, not
reprocessed for use on another patient (e.g., cleaned, disinfected, or sterilized) (383). Single-use devices in dentistry are
usually not heat-tolerant and cannot be reliably cleaned.
Examples include syringe needles, prophylaxis cups and
brushes, and plastic orthodontic brackets. Certain items (e.g.,
prophylaxis angles, saliva ejectors, high-volume evacuator tips,
and air/water syringe tips) are commonly available in a disposable form and should be disposed of appropriately after each
use. Single-use devices and items (e.g., cotton rolls, gauze, and
irrigating syringes) for use during oral surgical procedures
should be sterile at the time of use.
Because of the physical construction of certain devices (e.g.,
burs, endodontic files, and broaches) cleaning can be difficult.
In addition, deterioration can occur on the cutting surfaces of
some carbide/diamond burs and endodontic files during processing (384) and after repeated processing cycles, leading to
potential breakage during patient treatment (385–388). These
factors, coupled with the knowledge that burs and endodontic instruments exhibit signs of wear during normal use, might
make it practical to consider them as single-use devices.
December 19, 2003
Preprocedural Mouth Rinses
Antimicrobial mouth rinses used by patients before a dental
procedure are intended to reduce the number of microorganisms the patient might release in the form of aerosols or spatter that subsequently can contaminate DHCP and equipment
operatory surfaces. In addition, preprocedural rinsing can
decrease the number of microorganisms introduced in the
patient’s bloodstream during invasive dental procedures
(389,390).
No scientific evidence indicates that preprocedural mouth
rinsing prevents clinical infections among DHCP or patients,
but studies have demonstrated that a preprocedural rinse with
an antimicrobial product (e.g., chlorhexidine gluconate,
essential oils, or povidone-iodine) can reduce the level of oral
microorganisms in aerosols and spatter generated during routine dental procedures with rotary instruments (e.g., dental
handpieces or ultrasonic scalers) (391–399). Preprocedural
mouth rinses can be most beneficial before a procedure that
requires using a prophylaxis cup or ultrasonic scaler because
rubber dams cannot be used to minimize aerosol and spatter
generation and, unless the provider has an assistant, highvolume evacuation is not commonly used (173).
The science is unclear concerning the incidence and nature
of bacteremias from oral procedures, the relationship of these
bacteremias to disease, and the preventive benefit of antimicrobial rinses. In limited studies, no substantial benefit has
been demonstrated for mouth rinsing in terms of reducing
oral microorganisms in dental-induced bacteremias (400,401).
However, the American Heart Association’s recommendations
regarding preventing bacterial endocarditis during dental procedures (402) provide limited support concerning
preprocedural mouth rinsing with an antimicrobial as an
adjunct for patients at risk for bacterial endocarditis. Insufficient data exist to recommend preprocedural mouth rinses to
prevent clinical infections among patients or DHCP.
Oral Surgical Procedures
The oral cavity is colonized with numerous microorganisms.
Oral surgical procedures present an opportunity for entry of
microorganisms (i.e., exogenous and endogenous) into the
vascular system and other normally sterile areas of the oral
cavity (e.g., bone or subcutaneous tissue); therefore, an
increased potential exists for localized or systemic infection.
Oral surgical procedures involve the incision, excision, or
reflection of tissue that exposes the normally sterile areas of
the oral cavity. Examples include biopsy, periodontal surgery,
apical surgery, implant surgery, and surgical extractions of teeth
(e.g., removal of erupted or nonerupted tooth requiring elevation of mucoperiosteal flap, removal of bone or section of tooth,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
and suturing if needed) (see Hand Hygiene, PPE, Single Use
or Disposable Devices, and Dental Unit Water Quality).
Handling of Biopsy Specimens
To protect persons handling and transporting biopsy specimens, each specimen must be placed in a sturdy, leakproof
container with a secure lid for transportation (13). Care should
be taken when collecting the specimen to avoid contaminating the outside of the container. If the outside of the container
becomes visibly contaminated, it should be cleaned and disinfected or placed in an impervious bag (2,13). The container
must be labeled with the biohazard symbol during storage,
transport, shipment, and disposal (13,14).
Handling of Extracted Teeth
Disposal
Extracted teeth that are being discarded are subject to the
containerization and labeling provisions outlined by OSHA’s
bloodborne pathogens standard (13). OSHA considers
extracted teeth to be potentially infectious material that should
be disposed in medical waste containers. Extracted teeth sent
to a dental laboratory for shade or size comparisons should be
cleaned, surface-disinfected with an EPA-registered hospital
disinfectant with intermediate-level activity (i.e., tuberculocidal
claim), and transported in a manner consistent with OSHA
regulations. However, extracted teeth can be returned to
patients on request, at which time provisions of the standard
no longer apply (14). Extracted teeth containing dental amalgam should not be placed in a medical waste container that
uses incineration for final disposal. Commercial metalrecycling companies also might accept extracted teeth with
metal restorations, including amalgam. State and local regulations should be consulted regarding disposal of the amalgam.
Educational Settings
Extracted teeth are occasionally collected for use in preclinical educational training. These teeth should be cleaned of visible blood and gross debris and maintained in a hydrated state
in a well-constructed closed container during transport. The
container should be labeled with the biohazard symbol (13,14).
Because these teeth will be autoclaved before clinical exercises
or study, use of the most economical storage solution (e.g.,
water or saline) might be practical. Liquid chemical germicides can also be used but do not reliably disinfect both external surface and interior pulp tissue (403,404).
Before being used in an educational setting, the teeth should
be heat-sterilized to allow safe handling. Microbial growth can
be eliminated by using an autoclave cycle for 40 minutes (405),
33
but because preclinical educational exercises simulate clinical
experiences, students enrolled in dental programs should still
follow standard precautions. Autoclaving teeth for preclinical
laboratory exercises does not appear to alter their physical properties sufficiently to compromise the learning experience
(405,406). However, whether autoclave sterilization of
extracted teeth affects dentinal structure to the point that the
chemical and microchemical relationship between dental
materials and the dentin would be affected for research purposes on dental materials is unknown (406).
Use of teeth that do not contain amalgam is preferred in
educational settings because they can be safely autoclaved
(403,405). Extracted teeth containing amalgam restorations
should not be heat-sterilized because of the potential health
hazard from mercury vaporization and exposure. If extracted
teeth containing amalgam restorations are to be used, immersion in 10% formalin solution for 2 weeks should be effective
in disinfecting both the internal and external structures of the
teeth (403). If using formalin, manufacturer MSDS should be
reviewed for occupational safety and health concerns and to
ensure compliance with OSHA regulations (15).
Dental Laboratory
Dental prostheses, appliances, and items used in their fabrication (e.g., impressions, occlusal rims, and bite registrations)
are potential sources for cross-contamination and should be
handled in a manner that prevents exposure of DHCP, patients,
or the office environment to infectious agents. Effective communication and coordination between the laboratory and dental practice will ensure that appropriate cleaning and
disinfection procedures are performed in the dental office or
laboratory, materials are not damaged or distorted because of
disinfectant overexposure, and effective disinfection procedures
are not unnecessarily duplicated (407,408).
When a laboratory case is sent off-site, DHCP should provide written information regarding the methods (e.g., type of
disinfectant and exposure time) used to clean and disinfect
the material (e.g., impression, stone model, or appliance)
(2,407,409). Clinical materials that are not decontaminated
are subject to OSHA and U.S. Department of Transportation
regulations regarding transportation and shipping of infectious
materials (13,410).
Appliances and prostheses delivered to the patient should
be free of contamination. Communication between the laboratory and the dental practice is also key at this stage to determine which one is responsible for the final disinfection process.
If the dental laboratory staff provides the disinfection, an EPAregistered hospital disinfectant (low to intermediate) should
be used, written documentation of the disinfection method
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
34
MMWR
provided, and the item placed in a tamper-evident container
before returning it to the dental office. If such documentation
is not provided, the dental office is responsible for final disinfection procedures.
Dental prostheses or impressions brought into the laboratory can be contaminated with bacteria, viruses, and fungi
(411,412). Dental prostheses, impressions, orthodontic
appliances, and other prosthodontic materials (e.g., occlusal
rims, temporary prostheses, bite registrations, or extracted
teeth) should be thoroughly cleaned (i.e., blood and bioburden
removed), disinfected with an EPA-registered hospital disinfectant with a tuberculocidal claim, and thoroughly rinsed
before being handled in the in-office laboratory or sent to an
off-site laboratory (2,244,249,407). The best time to clean
and disinfect impressions, prostheses, or appliances is as soon
as possible after removal from the patient’s mouth before drying of blood or other bioburden can occur. Specific guidance
regarding cleaning and disinfecting techniques for various
materials is available (260,413–416). DHCP are advised to
consult with manufacturers regarding the stability of specific
materials during disinfection.
In the laboratory, a separate receiving and disinfecting area
should be established to reduce contamination in the production area. Bringing untreated items into the laboratory increases
chances for cross infection (260). If no communication has
been received regarding prior cleaning and disinfection of a
material, the dental laboratory staff should perform cleaning
and disinfection procedures before handling. If during
manipulation of a material or appliance a previously undetected area of blood or bioburden becomes apparent, cleaning
and disinfection procedures should be repeated. Transfer of
oral microorganisms into and onto impressions has been documented (417–419). Movement of these organisms onto dental casts has also been demonstrated (420). Certain microbes
have been demonstrated to remain viable within gypsum cast
materials for <7 days (421). Incorrect handling of contaminated impressions, prostheses, or appliances, therefore, offers
an opportunity for transmission of microorganisms (260).
Whether in the office or laboratory, PPE should be worn until
disinfection is completed (1,2,7,10,13).
If laboratory items (e.g., burs, polishing points, rag wheels, or
laboratory knives) are used on contaminated or potentially contaminated appliances, prostheses, or other material, they should
be heat-sterilized, disinfected between patients, or discarded (i.e.,
disposable items should be used) (260,407). Heat-tolerant items
used in the mouth (e.g., metal impression tray or face bow fork)
should be heat-sterilized before being used on another patient
(2,407). Items that do not normally contact the patient, prosthetic device, or appliance but frequently become contaminated
and cannot withstand heat-sterilization (e.g., articulators, case
December 19, 2003
pans, or lathes) should be cleaned and disinfected between
patients and according to the manufacturer’s instructions. Pressure pots and water baths are particularly susceptible to contamination with microorganisms and should be cleaned and
disinfected between patients (422). In the majority of instances,
these items can be cleaned and disinfected with an EPAregistered hospital disinfectant. Environmental surfaces should
be barrier-protected or cleaned and disinfected in the same manner as in the dental treatment area.
Unless waste generated in the dental laboratory (e.g., disposable trays or impression materials) falls under the category
of regulated medical waste, it can be discarded with general
waste. Personnel should dispose of sharp items (e.g., burs, disposable blades, and orthodontic wires) in puncture-resistant
containers.
Laser/Electrosurgery Plumes
or Surgical Smoke
During surgical procedures that use a laser or electrosurgical
unit, the thermal destruction of tissue creates a smoke
byproduct. Laser plumes or surgical smoke represent another
potential risk for DHCP (423–425). Lasers transfer electromagnetic energy into tissues, resulting in the release of a heated
plume that includes particles, gases (e.g., hydrogen cyanide,
benzene, and formaldehyde), tissue debris, viruses, and offensive odors. One concern is that aerosolized infectious material
in the laser plume might reach the nasal mucosa of the laser
operator and adjacent DHCP. Although certain viruses (e.g.,
varicella-zoster virus and herpes simplex virus) appear not to
aerosolize efficiently (426,427), other viruses and various bacteria (e.g., human papilloma virus, HIV, coagulase-negative
Staphylococcus, Corynebacterium species, and Neisseria species)
have been detected in laser plumes (428–434). However, the
presence of an infectious agent in a laser plume might not be
sufficient to cause disease from airborne exposure, especially if
the agent’s normal mode of transmission is not airborne. No
evidence indicates that HIV or HBV have been transmitted
through aerosolization and inhalation (435). Although continuing studies are needed to evaluate the risk for DHCP of
laser plumes and electrosurgery smoke, following NIOSH recommendations (425) and practices developed by the Association of periOperative Registered Nurses (AORN) might be
practical (436). These practices include using 1) standard precautions (e.g., high-filtration surgical masks and possibly full
face shields) (437); 2) central room suction units with in-line
filters to collect particulate matter from minimal plumes; and
3) dedicated mechanical smoke exhaust systems with a highefficiency filter to remove substantial amounts of laser plume
particles. Local smoke evacuation systems have been recom-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
mended by consensus organizations, and these systems can
improve the quality of the operating field. Employers should
be aware of this emerging problem and advise employees of
the potential hazards of laser smoke (438). However, this concern remains unresolved in dental practice and no recommendation is provided here.
M. tuberculosis
Patients infected with M. tuberculosis occasionally seek
urgent dental treatment at outpatient dental settings. Understanding the pathogenesis of the development of TB will help
DHCP determine how to manage such patients.
M. tuberculosis is a bacterium carried in airborne infective
droplet nuclei that can be generated when persons with pulmonary or laryngeal TB sneeze, cough, speak, or sing (439).
These small particles (1–5 µm) can stay suspended in the air
for hours (440). Infection occurs when a susceptible person
inhales droplet nuclei containing M. tuberculosis, which then
travel to the alveoli of the lungs. Usually within 2–12 weeks
after initial infection with M. tuberculosis, immune response
prevents further spread of the TB bacteria, although they can
remain alive in the lungs for years, a condition termed latent
TB infection. Persons with latent TB infection usually exhibit
a reactive tuberculin skin test (TST), have no symptoms of
active disease, and are not infectious. However, they can
develop active disease later in life if they do not receive treatment for their latent infection.
Approximately 5% of persons who have been recently
infected and not treated for latent TB infection will progress
from infection to active disease during the first 1–2 years after
infection; another 5% will develop active disease later in life.
Thus, approximately 90% of U.S. persons with latent TB
infection do not progress to active TB disease. Although both
latent TB infection and active TB disease are described as TB,
only the person with active disease is contagious and presents
a risk of transmission. Symptoms of active TB disease include
a productive cough, night sweats, fatigue, malaise, fever, and
unexplained weight loss. Certain immunocompromising medical conditions (e.g., HIV) increase the risk that TB infection
will progress to active disease at a faster rate (441).
Overall, the risk borne by DHCP for exposure to a patient
with active TB disease is probably low (20,21). Only one report
exists of TB transmission in a dental office (442), and TST conversions among DHCP are also low (443,444). However, in
certain cases, DHCP or the community served by the dental
facility might be at relatively high risk for exposure to TB.
Surgical masks do not prevent inhalation of M. tuberculosis
droplet nuclei, and therefore, standard precautions are not
sufficient to prevent transmission of this organism. Recom-
35
mendations for expanded precautions to prevent transmission
of M. tuberculosis and other organisms that can be spread by
airborne, droplet, or contact routes have been detailed in other
guidelines (5,11,20).
TB transmission is controlled through a hierarchy of measures, including administrative controls, environmental controls, and personal respiratory protection. The main
administrative goals of a TB infection-control program are early
detection of a person with active TB disease and prompt isolation from susceptible persons to reduce the risk of transmission. Although DHCP are not responsible for diagnosis and
treatment of TB, they should be trained to recognize signs and
symptoms to help with prompt detection. Because potential
for transmission of M. tuberculosis exists in outpatient settings,
dental practices should develop a TB control program appropriate for their level of risk (20,21).
• A community risk assessment should be conducted periodically, and TB infection-control policies for each dental
setting should be based on the risk assessment. The policies should include provisions for detection and referral
of patients who might have undiagnosed active TB; management of patients with active TB who require urgent
dental care; and DHCP education, counseling, and TST
screening.
• DHCP who have contact with patients should have a
baseline TST, preferably by using a two-step test at the
beginning of employment. The facility’s level of TB risk
will determine the need for routine follow-up TST.
• While taking patients’ initial medical histories and at
periodic updates, dental DHCP should routinely ask all
patients whether they have a history of TB disease or symptoms indicative of TB.
• Patients with a medical history or symptoms indicative of
undiagnosed active TB should be referred promptly for
medical evaluation to determine possible infectiousness.
Such patients should not remain in the dental-care facility any longer than required to evaluate their dental condition and arrange a referral. While in the dental
health-care facility, the patient should be isolated from
other patients and DHCP, wear a surgical mask when not
being evaluated, or be instructed to cover their mouth and
nose when coughing or sneezing.
• Elective dental treatment should be deferred until a physician confirms that a patient does not have infectious TB,
or if the patient is diagnosed with active TB disease, until
confirmed the patient is no longer infectious.
• If urgent dental care is provided for a patient who has, or
is suspected of having active TB disease, the care should
be provided in a facility (e.g., hospital) that provides airborne infection isolation (i.e., using such engineering con-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
36
MMWR
trols as TB isolation rooms, negatively pressured relative
to the corridors, with air either exhausted to the outside
or HEPA-filtered if recirculation is necessary). Standard
surgical face masks do not protect against TB transmission; DHCP should use respiratory protection (e.g., fittested, disposable N-95 respirators).
• Settings that do not require use of respiratory protection
because they do not treat active TB patients and do not
perform cough-inducing procedures on potential active
TB patients do not need to develop a written respiratory
protection program.
• Any DHCP with a persistent cough (i.e., lasting >3 weeks),
especially in the presence of other signs or symptoms compatible with active TB (e.g., weight loss, night sweats,
fatigue, bloody sputum, anorexia, or fever), should be
evaluated promptly. The DHCP should not return to the
workplace until a diagnosis of TB has been excluded or
the DHCP is on therapy and a physician has determined
that the DHCP is noninfectious.
Creutzfeldt-Jakob Disease and Other
Prion Diseases
Creutzfeldt-Jakob disease (CJD) belongs to a group of rapidly progressive, invariably fatal, degenerative neurological disorders, transmissible spongiform encephalopathies (TSEs) that
affect both humans and animals and are thought to be caused
by infection with an unusual pathogen called a prion. Prions
are isoforms of a normal protein, capable of self-propagation
although they lack nucleic acid. Prion diseases have an incubation period of years and are usually fatal within 1 year of
diagnosis.
Among humans, TSEs include CJD, Gerstmann-StrausslerScheinker syndrome, fatal familial insomnia, kuru, and variant CJD (vCJD). Occurring in sporadic, familial, and acquired
(i.e., iatrogenic) forms, CJD has an annual incidence in the
United States and other countries of approximately 1 case/
million population (445–448). In approximately 85% of
affected patients, CJD occurs as a sporadic disease with no
recognizable pattern of transmission. A smaller proportion of
patients (5%–15%) experience familial CJD because of inherited mutations of the prion protein gene (448).
vCJD is distinguishable clinically and neuropathologically
from classic CJD, and strong epidemiologic and laboratory
evidence indicates a causal relationship with bovine spongiform
encephalopathy (BSE), a progressive neurological disorder of
cattle commonly known as mad cow disease (449–451). vCJD,
was reported first in the United Kingdom in 1996 (449) and
subsequently in other European countries (452). Only one
case of vCJD has been reported in the United States, in an
December 19, 2003
immigrant from the United Kingdom (453). Compared with
CJD patients, those with vCJD are younger (28 years versus
68 years median age at death), and have a longer duration of
illness (13 months versus 4.5 months). Also, vCJD patients
characteristically exhibit sensory and psychiatric symptoms that
are uncommon with CJD. Another difference includes the ease
with which the presence of prions is consistently demonstrated
in lymphoreticular tissues (e.g., tonsil) in vCJD patients by
immunohistochemistry (454).
CJD and vCJD are transmissible diseases, but not through
the air or casual contact. All known cases of iatrogenic CJD
have resulted from exposure to infected central nervous tissue
(e.g., brain and dura mater), pituitary, or eye tissue. Studies in
experimental animals have determined that other tissues have
low or no detectable infectivity (243,455,456). Limited
experimental studies have demonstrated that scrapie (a TSE in
sheep) can be transmitted to healthy hamsters and mice by
exposing oral tissues to infectious homogenate (457,458).
These animal models and experimental designs might not be
directly applicable to human transmission and clinical dentistry, but they indicate a theoretical risk of transmitting prion
diseases through perioral exposures.
According to published reports, iatrogenic transmission of
CJD has occurred in humans under three circumstances: after
use of contaminated electroencephalography depth electrodes
and neurosurgical equipment (459); after use of extracted
pituitary hormones (460,461); and after implant of contaminated corneal (462) and dura mater grafts (463,464) from
humans. The equipment-related cases occurred before the routine implementation of sterilization procedures used in healthcare facilities.
Case-control studies have found no evidence that dental
procedures increase the risk of iatrogenic transmission of TSEs
among humans. In these studies, CJD transmission was not
associated with dental procedures (e.g., root canals or extractions), with convincing evidence of prion detection in human
blood, saliva, or oral tissues, or with DHCP becoming occupationally infected with CJD (465–467). In 2000, prions were
not found in the dental pulps of eight patients with
neuropathologically confirmed sporadic CJD by using electrophoresis and a Western blot technique (468).
Prions exhibit unusual resistance to conventional chemical
and physical decontamination procedures. Considering this
resistance and the invariably fatal outcome of CJD, procedures
for disinfecting and sterilizing instruments potentially contaminated with the CJD prion have been controversial for years.
Scientific data indicate the risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is low to
nil. Until additional information exists regarding the transmissibility of CJD or vCJD, special precautions in addition to
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
standard precautions might be indicated when treating known
CJD or vCJD patients; the following list of precautions is provided for consideration without recommendation
(243,249,277,469):
• Use single-use disposable items and equipment whenever
possible.
• Consider items difficult to clean (e.g., endodontic files,
broaches, and carbide and diamond burs) as single-use
disposables and discard after one use.
• To minimize drying of tissues and body fluids on a device,
keep the instrument moist until cleaned and decontaminated.
• Clean instruments thoroughly and steam-autoclave at 134ºC
for 18 minutes. This is the least stringent of sterilization
methods offered by the World Health Organization. The
complete list (469) is available at http://www.who.int/emcdocuments/tse/whocdscsraph2003c.html.
• Do not use flash sterilization for processing instruments
or devices.
Potential infectivity of oral tissues in CJD or vCJD patients is
an unresolved concern. CDC maintains an active surveillance
program on CJD. Additional information and resources are
available at http://www.cdc.gov/ncidod/diseases/cjd/cjd.htm.
Program Evaluation
The goal of a dental infection-control program is to provide
a safe working environment that will reduce the risk of health-
37
care–associated infections among patients and occupational
exposures among DHCP. Medical errors are caused by faulty
systems, processes, and conditions that lead persons to make
mistakes or fail to prevent errors being made by others (470).
Effective program evaluation is a systematic way to ensure procedures are useful, feasible, ethical, and accurate. Program evaluation is an essential organizational practice; however, such
evaluation is not practiced consistently across program areas,
nor is it sufficiently well-integrated into the day-to-day management of the majority of programs (471).
A successful infection-control program depends on developing standard operating procedures, evaluating practices, routinely
documenting adverse outcomes (e.g., occupational exposures
to blood) and work-related illnesses in DHCP, and monitoring
health-care–associated infections in patients. Strategies and tools
to evaluate the infection-control program can include periodic
observational assessments, checklists to document procedures,
and routine review of occupational exposures to bloodborne
pathogens. Evaluation offers an opportunity to improve the
effectiveness of both the infection-control program and dentalpractice protocols. If deficiencies or problems in the implementation of infection-control procedures are identified, further
evaluation is needed to eliminate the problems. Examples of
infection-control program evaluation activities are provided
(Table 5).
TABLE 5. Examples of methods for evaluating infection-control programs
Program element
Evaluation activity
Appropriate immunization of dental health-care personnel (DHCP).
Conduct annual review of personnel records to ensure up-to-date immunizations.
Assessment of occupational exposures to infectious agents.
Report occupational exposures to infectious agents. Document the steps that
occurred around the exposure and plan how such exposure can be prevented in
the future.
Comprehensive postexposure management plan and medical follow-up program
after occupational exposures to infectious agents.
Ensure the postexposure management plan is clear, complete, and available at all
times to all DHCP. All staff should understand the plan, which should include tollfree phone numbers for access to additional information.
Adherence to hand hygiene before and after patient care.
Observe and document circumstances of appropriate or inappropriate
handwashing. Review findings in a staff meeting.
Proper use of personal protective equipment to prevent occupational exposures to
infectious agents.
Observe and document the use of barrier precautions and careful handling of
sharps. Review findings in a staff meeting.
Routine and appropriate sterilization of instruments using a biologic monitoring
system.
Monitor paper log of steam cycle and temperature strip with each sterilization load,
and examine results of weekly biologic monitoring. Take appropriate action when
failure of sterilization process is noted.
Evaluation and implementation of safer medical devices.
Conduct an annual review of the exposure control plan and consider new
developments in safer medical devices.
Compliance of water in routine dental procedures with current drinking U.S.
Environmental Protection Agency water standards (fewer than 500 CFU of
heterotrophic water bacteria).
Monitor dental water quality as recommended by the equipment manufacturer,
using commercial self-contained test kits, or commercial water-testing laboratories.
Proper handling and disposal of medical waste.
Observe the safe disposal of regulated and nonregulated medical waste and take
preventive measures if hazardous situations occur.
Health-care–associated infections.
Assess the unscheduled return of patients after procedures and evaluate them for
an infectious process. A trend might require formal evaluation.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
38
MMWR
Infection-Control Research
Considerations
Although the number of published studies concerning dental infection control has increased in recent years, questions
regarding infection-control practices and their effectiveness
remain unanswered. Multiple concerns were identified by the
working group for this report, as well as by others during the
December 19, 2003
public comment period (Box). This list is not exhaustive and
does not represent a CDC research agenda, but rather is an
effort to identify certain concerns, stimulate discussion, and
provide direction for determining future action by clinical,
basic science, and epidemiologic investigators, as well as health
and professional organizations, clinicians, and policy makers.
BOX. Dental infection-control research considerations
Education and promotion
• Design strategies to communicate, to the public and providers, the risk of disease transmission in dentistry.
• Promote use of protocols for recommended postexposure management and follow-up.
• Educate and train dental health-care personnel (DHCP) to screen and evaluate safer dental devices by using tested design
and performance criteria.
Laboratory-based research
• Develop animal models to determine the risk of transmitting organisms through inhalation of contaminated aerosols (e.g.,
influenza) produced from rotary dental instruments.
• Conduct studies to determine the effectiveness of gloves (i.e., material compatibility and duration of use).
• Develop devices with passive safety features to prevent percutaneous injuries.
• Study the effect of alcohol-based hand-hygiene products on retention of latex proteins and other dental allergens (e.g.,
methylmethacrylate, glutaraldehyde, thiurams) on the hands of DHCP after latex glove use.
• Investigate the applicability of other types of sterilization procedures (e.g., hydrogen peroxide gas plasma) in dentistry.
• Encourage manufacturers to determine optimal methods and frequency for testing dental-unit waterlines and maintaining
dental-unit water-quality standards.
• Determine the potential for internal contamination of low-speed handpieces, including the motor, and other devices connected to dental air and water supplies, as well as more efficient ways to clean, lubricate, and sterilize handpieces and other
devices attached to air or waterlines.
• Investigate the infectivity of oral tissues in Creutzfeldt-Jakob disease (CJD) or variant CJD patients.
• Determine the most effective methods to disinfect dental impression materials.
• Investigate the viability of pathogenic organisms on dental materials (e.g., impression materials, acrylic resin, or gypsum
materials) and dental laboratory equipment.
• Determine the most effective methods for sterilization or disinfection of digital radiology equipment.
• Evaluate the effects of repetitive reprocessing cycles on burs and endodontic files.
• Investigate the potential infectivity of vapors generated from the various lasers used for oral procedures.
Clinical and population-based epidemiologic research and development
• Continue to characterize the epidemiology of blood contacts, particularly percutaneous injuries, and the effectiveness of
prevention measures.
• Further assess the effectiveness of double gloving in preventing blood contact during routine and surgical dental procedures.
• Continue to assess the stress placed on gloves during dental procedures and the potential for developing defects during
different procedures.
• Develop methods for evaluating the effectiveness and cost-effectiveness of infection-control interventions.
• Determine how infection-control guidelines affect the knowledge, attitudes, and practices of DHCP.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
Recommendations
Each recommendation is categorized on the basis of existing
scientific data, theoretical rationale, and applicability. Rankings
are based on the system used by CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC)
to categorize recommendations:
Category IA. Strongly recommended for implementation
and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation
and supported by experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required for implementation as mandated
by federal or state regulation or standard. When IC is used, a
second rating can be included to provide the basis of existing
scientific data, theoretical rationale, and applicability. Because
of state differences, the reader should not assume that the
absence of a IC implies the absence of state regulations.
Category II. Suggested for implementation and supported
by suggestive clinical or epidemiologic studies or a theoretical
rationale.
Unresolved issue. No recommendation. Insufficient evidence or no consensus regarding efficacy exists.
I. Personnel Health Elements of an Infection-Control
Program
A. General Recommendations
1. Develop a written health program for DHCP
that includes policies, procedures, and guidelines
for education and training; immunizations;
exposure prevention and postexposure management; medical conditions, work-related illness,
and associated work restrictions; contact dermatitis and latex hypersensitivity; and maintenance
of records, data management, and confidentiality (IB) (5,16–18,22).
2. Establish referral arrangements with qualified
health-care professionals to ensure prompt and
appropriate provision of preventive services,
occupationally related medical services, and
postexposure management with medical followup (IB, IC) (5,13,19,22).
B. Education and Training
1. Provide DHCP 1) on initial employment,
2) when new tasks or procedures affect the
employee’s occupational exposure, and 3) at a
minimum, annually, with education and training regarding occupational exposure to potentially infectious agents and infection-control
procedures/protocols appropriate for and spe-
39
cific to their assigned duties (IB, IC) (5,11,13,
14,16,19,22).
2. Provide educational information appropriate in
content and vocabulary to the educational level,
literacy, and language of DHCP (IB, IC) (5,13).
C. Immunization Programs
1. Develop a written comprehensive policy regarding immunizing DHCP, including a list of all
required and recommended immunizations (IB)
(5,17,18).
2. Refer DHCP to a prearranged qualified healthcare professional or to their own health-care professional to receive all appropriate immunizations
based on the latest recommendations as well as
their medical history and risk for occupational
exposure (IB) (5,17).
D. Exposure Prevention and Postexposure Management
1. Develop a comprehensive postexposure management and medical follow-up program (IB, IC)
(5,13,14,19).
a. Include policies and procedures for prompt
reporting, evaluation, counseling, treatment,
and medical follow-up of occupational
exposures.
b. Establish mechanisms for referral to a qualified health-care professional for medical
evaluation and follow-up.
c. Conduct a baseline TST, preferably by
using a two-step test, for all DHCP who
might have contact with persons with suspected or confirmed infectious TB, regardless of the risk classification of the setting
(IB) (20).
E. Medical Conditions, Work-Related Illness, and
Work Restrictions
1. Develop and have readily available to all DHCP
comprehensive written policies regarding work
restriction and exclusion that include a statement
of authority defining who can implement such
policies (IB) (5,22).
2. Develop policies for work restriction and exclusion that encourage DHCP to seek appropriate
preventive and curative care and report their
illnesses, medical conditions, or treatments that
can render them more susceptible to opportunistic infection or exposures; do not penalize
DHCP with loss of wages, benefits, or job status (IB) (5,22).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
40
MMWR
3. Develop policies and procedures for evaluation,
diagnosis, and management of DHCP with suspected or known occupational contact dermatitis (IB) (32).
4. Seek definitive diagnosis by a qualified healthcare professional for any DHCP with suspected
latex allergy to carefully determine its specific
etiology and appropriate treatment as well as
work restrictions and accommodations (IB) (32).
F. Records Maintenance, Data Management, and
Confidentiality
1. Establish and maintain confidential medical
records (e.g., immunization records and documentation of tests received as a result of occupational exposure) for all DHCP (IB, IC) (5,13).
2. Ensure that the practice complies with all applicable federal, state, and local laws regarding
medical recordkeeping and confidentiality (IC)
(13,34).
II. Preventing Transmission of Bloodborne Pathogens
A. HBV Vaccination
1. Offer the HBV vaccination series to all DHCP
with potential occupational exposure to blood
or other potentially infectious material (IA, IC)
(2,13,14,19).
2. Always follow U.S. Public Health Service/CDC
recommendations for hepatitis B vaccination,
serologic testing, follow-up, and booster dosing
(IA, IC) (13,14,19).
3. Test DHCP for anti-HBs 1–2 months after
completion of the 3-dose vaccination series (IA,
IC) (14,19).
4. DHCP should complete a second 3-dose vaccine series or be evaluated to determine if they
are HBsAg-positive if no antibody response
occurs to the primary vaccine series (IA, IC)
(14,19).
5. Retest for anti-HBs at the completion of the second vaccine series. If no response to the second
3-dose series occurs, nonresponders should be
tested for HBsAg (IC) (14,19).
6. Counsel nonresponders to vaccination who are
HBsAg-negative regarding their susceptibility to
HBV infection and precautions to take (IA, IC)
(14,19).
7. Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline
December 19, 2003
the vaccination should sign a declination form
to be kept on file with the employer (IC) (13).
B. Preventing Exposures to Blood and OPIM
1. General recommendations
a. Use standard precautions (OSHA’s bloodborne pathogen standard retains the term
universal precautions) for all patient encounters (IA, IC) (11,13,19,53).
b. Consider sharp items (e.g., needles, scalers,
burs, lab knives, and wires) that are contaminated with patient blood and saliva as
potentially infective and establish engineering controls and work practices to prevent
injuries (IB, IC) (6,13,113).
c. Implement a written, comprehensive program designed to minimize and manage
DHCP exposures to blood and body fluids
(IB, IC). (13,14,19,97).
2. Engineering and work-practice controls
a. Identify, evaluate, and select devices with
engineered safety features at least annually
and as they become available on the market
(e.g., safer anesthetic syringes, blunt suture
needle, retractable scalpel, or needleless IV
systems) (IC) (13,97,110–112).
b. Place used disposable syringes and needles,
scalpel blades, and other sharp items in
appropriate puncture-resistant containers
located as close as feasible to the area in which
the items are used (IA, IC) (2,7,13,19,113,
115).
c. Do not recap used needles by using both
hands or any other technique that involves
directing the point of a needle toward any
part of the body. Do not bend, break, or
remove needles before disposal (IA, IC)
(2,7,8,13,97,113).
d. Use either a one-handed scoop technique or
a mechanical device designed for holding the
needle cap when recapping needles (e.g.,
between multiple injections and before
removing from a nondisposable aspirating
syringe) (IA, IC) (2,7,8,13,14,113).
3. Postexposure management and prophylaxis
a. Follow CDC recommendations after percutaneous, mucous membrane, or nonintact
skin exposure to blood or other potentially
infectious material (IA, IC) (13,14,19).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
III. Hand Hygiene
A. General Considerations
1. Perform hand hygiene with either a
nonantimicrobial or antimicrobial soap and
water when hands are visibly dirty or contaminated with blood or other potentially infectious
material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the
manufacturer’s instructions (IA) (123).
2. Indications for hand hygiene include
a. when hands are visibly soiled (IA, IC);
b. after barehanded touching of inanimate
objects likely to be contaminated by blood,
saliva, or respiratory secretions (IA, IC);
c. before and after treating each patient (IB);
d. before donning gloves (IB); and
e. immediately after removing gloves (IB, IC)
(7–9,11,13,113,120–123,125,126,138).
3. For oral surgical procedures, perform surgical
hand antisepsis before donning sterile surgeon’s
gloves. Follow the manufacturer’s instructions by
using either an antimicrobial soap and water, or
soap and water followed by drying hands and
application of an alcohol-based surgical handscrub product with persistent activity (IB) (121–
123,127–133,144,145).
4. Store liquid hand-care products in either disposable closed containers or closed containers that
can be washed and dried before refilling. Do not
add soap or lotion to (i.e., top off ) a partially
empty dispenser (IA) (9,120,122,149,150).
B. Special Considerations for Hand Hygiene and
Glove Use
1. Use hand lotions to prevent skin dryness associated with handwashing (IA) (153,154).
2. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or
other oil emollients on the integrity of gloves
during product selection and glove use (IB)
(2,14,122,155).
3. Keep fingernails short with smooth, filed edges
to allow thorough cleaning and prevent glove
tears (II) (122,123,156).
4. Do not wear artificial fingernails or extenders
when having direct contact with patients at high
risk (e.g., those in intensive care units or operating rooms) (IA) (123,157–160).
5. Use of artificial fingernails is usually not recommended (II) (157–160).
41
6. Do not wear hand or nail jewelry if it makes
donning gloves more difficult or compromises
the fit and integrity of the glove (II) (123,142,
143).
IV. PPE
A. Masks, Protective Eyewear, and Face Shields
1. Wear a surgical mask and eye protection with
solid side shields or a face shield to protect
mucous membranes of the eyes, nose, and mouth
during procedures likely to generate splashing
or spattering of blood or other body fluids (IB,
IC) (1,2,7,8,11,13,137).
2. Change masks between patients or during
patient treatment if the mask becomes wet (IB)
(2).
3. Clean with soap and water, or if visibly soiled,
clean and disinfect reusable facial protective
equipment (e.g., clinician and patient protective eyewear or face shields) between patients (II)
(2).
B. Protective Clothing
1. Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or uniform) that
covers personal clothing and skin (e.g., forearms)
likely to be soiled with blood, saliva, or OPIM
(IB, IC) (7,8,11,13,137).
2. Change protective clothing if visibly soiled (134);
change immediately or as soon as feasible if penetrated by blood or other potentially infectious
fluids (IB, IC) (13).
3. Remove barrier protection, including gloves,
mask, eyewear, and gown before departing work
area (e.g., dental patient care, instrument processing, or laboratory areas) (IC) (13).
C. Gloves
1. Wear medical gloves when a potential exists for
contacting blood, saliva, OPIM, or mucous
membranes (IB, IC) (1,2,7,8,13).
2. Wear a new pair of medical gloves for each
patient, remove them promptly after use, and
wash hands immediately to avoid transfer of
microorganisms to other patients or environments (IB) (1,7,8,123).
3. Remove gloves that are torn, cut, or punctured
as soon as feasible and wash hands before
regloving (IB, IC) (13,210,211).
4. Do not wash surgeon’s or patient examination
gloves before use or wash, disinfect, or sterilize
gloves for reuse (IB, IC) (13,138,177,212,213).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
42
MMWR
5. Ensure that appropriate gloves in the correct size
are readily accessible (IC) (13).
6. Use appropriate gloves (e.g., puncture- and
chemical-resistant utility gloves) when cleaning
instruments and performing housekeeping tasks
involving contact with blood or OPIM (IB, IC)
(7,13,15).
7. Consult with glove manufacturers regarding the
chemical compatibility of glove material and
dental materials used (II).
D. Sterile Surgeon’s Gloves and Double Gloving
During Oral Surgical Procedures
1. Wear sterile surgeon’s gloves when performing
oral surgical procedures (IB) (2,8,137).
2. No recommendation is offered regarding the
effectiveness of wearing two pairs of gloves to
prevent disease transmission during oral surgical procedures. The majority of studies among
HCP and DHCP have demonstrated a lower frequency of inner glove perforation and visible
blood on the surgeon’s hands when double gloves
are worn; however, the effectiveness of wearing
two pairs of gloves in preventing disease transmission has not been demonstrated (Unresolved
issue).
V. Contact Dermatitis and Latex Hypersensitivity
A. General Recommendations
1. Educate DHCP regarding the signs, symptoms,
and diagnoses of skin reactions associated with frequent hand hygiene and glove use (IB) (5,31,32).
2. Screen all patients for latex allergy (e.g., take
health history and refer for medical consultation when latex allergy is suspected) (IB) (32).
3. Ensure a latex-safe environment for patients and
DHCP with latex allergy (IB) (32).
4. Have emergency treatment kits with latex-free
products available at all times (II) (32).
VI. Sterilization and Disinfection of Patient-Care Items
A. General Recommendations
1. Use only FDA-cleared medical devices for sterilization and follow the manufacturer’s instructions for correct use (IB) (248).
2. Clean and heat-sterilize critical dental instruments before each use (IA) (2,137,243,244,
246,249,407).
3. Clean and heat-sterilize semicritical items before
each use (IB) (2,249,260,407).
4. Allow packages to dry in the sterilizer before they
are handled to avoid contamination (IB) (247).
December 19, 2003
5. Use of heat-stable semicritical alternatives is
encouraged (IB) (2).
6. Reprocess heat-sensitive critical and semi-critical instruments by using FDA-cleared sterilant/
high-level disinfectants or an FDA-cleared lowtemperature sterilization method (e.g., ethylene
oxide). Follow manufacturer’s instructions for use
of chemical sterilants/high-level disinfectants
(IB) (243).
7. Single-use disposable instruments are acceptable
alternatives if they are used only once and disposed of correctly (IB, IC) (243,383).
8. Do not use liquid chemical sterilants/high-level
disinfectants for environmental surface disinfection or as holding solutions (IB, IC) (243,245).
9. Ensure that noncritical patient-care items are
barrier-protected or cleaned, or if visibly soiled,
cleaned and disinfected after each use with an
EPA-registered hospital disinfectant. If visibly
contaminated with blood, use an EPA-registered
hospital disinfectant with a tuberculocidal claim
(i.e., intermediate level) (IB) (2,243,244).
10. Inform DHCP of all OSHA guidelines for
exposure to chemical agents used for disinfection and sterilization. Using this report, identify
areas and tasks that have potential for exposure
(IC) (15).
B. Instrument Processing Area
1. Designate a central processing area. Divide the
instrument processing area, physically or, at a
minimum, spatially, into distinct areas for
1) receiving, cleaning, and decontamination;
2) preparation and packaging; 3) sterilization;
and 4) storage. Do not store instruments in an
area where contaminated instruments are held
or cleaned (II) (173,247,248).
2. Train DHCP to employ work practices that prevent contamination of clean areas (II).
C. Receiving, Cleaning, and Decontamination Work
Area
1. Minimize handling of loose contaminated
instruments during transport to the instrument
processing area. Use work-practice controls (e.g.,
carry instruments in a covered container) to
minimize exposure potential (II). Clean all visible blood and other contamination from dental instruments and devices before sterilization
or disinfection procedures (IA) (243,249–252).
2. Use automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) to remove
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
debris to improve cleaning effectiveness and
decrease worker exposure to blood (IB) (2,253).
3. Use work-practice controls that minimize contact with sharp instruments if manual cleaning
is necessary (e.g., long-handled brush) (IC) (14).
4. Wear puncture- and chemical-resistant/heavyduty utility gloves for instrument cleaning and
decontamination procedures (IB) (7).
5. Wear appropriate PPE (e.g., mask, protective
eyewear, and gown) when splashing or spraying
is anticipated during cleaning (IC) (13).
D. Preparation and Packaging
1. Use an internal chemical indicator in each package. If the internal indicator cannot be seen from
outside the package, also use an external indicator (II) (243,254,257).
2. Use a container system or wrapping compatible
with the type of sterilization process used and
that has received FDA clearance (IB) (243,247,
256).
3. Before sterilization of critical and semicritical
instruments, inspect instruments for cleanliness,
then wrap or place them in containers designed
to maintain sterility during storage (e.g., cassettes
and organizing trays) (IA) (2,247,255,256).
E. Sterilization of Unwrapped Instruments
1. Clean and dry instruments before the unwrapped
sterilization cycle (IB) (248).
2. Use mechanical and chemical indicators for each
unwrapped sterilization cycle (i.e., place an
internal chemical indicator among the instruments or items to be sterilized) (IB) (243,258).
3. Allow unwrapped instruments to dry and cool
in the sterilizer before they are handled to avoid
contamination and thermal injury (II) (260).
4. Semicritical instruments that will be used
immediately or within a short time can be sterilized unwrapped on a tray or in a container system, provided that the instruments are handled
aseptically during removal from the sterilizer and
transport to the point of use (II).
5. Critical instruments intended for immediate
reuse can be sterilized unwrapped if the instruments are maintained sterile during removal from
the sterilizer and transport to the point of use
(e.g., transported in a sterile covered container)
(IB) (258).
6. Do not sterilize implantable devices unwrapped
(IB) (243,247).
43
7. Do not store critical instruments unwrapped (IB)
(248).
F. Sterilization Monitoring
1. Use mechanical, chemical, and biological monitors according to the manufacturer’s instructions
to ensure the effectiveness of the sterilization
process (IB) (248,278,279).
2. Monitor each load with mechanical (e.g., time,
temperature, and pressure) and chemical indicators (II) (243,248).
3. Place a chemical indicator on the inside of each
package. If the internal indicator is not visible
from the outside, also place an exterior chemical indicator on the package (II) (243,254,257).
4. Place items/packages correctly and loosely into
the sterilizer so as not to impede penetration of
the sterilant (IB) (243).
5. Do not use instrument packs if mechanical or
chemical indicators indicate inadequate processing (IB) (243,247,248).
6. Monitor sterilizers at least weekly by using a biological indicator with a matching control (i.e.,
biological indicator and control from same lot
number) (IB) (2,9,243,247,278,279).
7. Use a biological indicator for every sterilizer load
that contains an implantable device. Verify
results before using the implantable device,
whenever possible (IB) (243,248).
8. The following are recommended in the case of a
positive spore test:
a. Remove the sterilizer from service and
review sterilization procedures (e.g., work
practices and use of mechanical and chemical indicators) to determine whether operator error could be responsible (II) (8).
b. Retest the sterilizer by using biological,
mechanical, and chemical indicators after
correcting any identified procedural problems (II).
c. If the repeat spore test is negative, and
mechanical and chemical indicators are
within normal limits, put the sterilizer back
in service (II) (9,243).
9. The following are recommended if the repeat
spore test is positive:
a. Do not use the sterilizer until it has been
inspected or repaired or the exact reason for
the positive test has been determined (II)
(9,243).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
44
MMWR
b. Recall, to the extent possible, and reprocess
all items processed since the last negative
spore test (II) (9,243,283).
c. Before placing the sterilizer back in service,
rechallenge the sterilizer with biological
indicator tests in three consecutive empty
chamber sterilization cycles after the cause
of the sterilizer failure has been determined
and corrected (II) (9,243,283).
10. Maintain sterilization records (i.e., mechanical,
chemical, and biological) in compliance with
state and local regulations (IB) (243).
G. Storage Area for Sterilized Items and Clean
Dental Supplies
1. Implement practices on the basis of date- or
event-related shelf-life for storage of wrapped,
sterilized instruments and devices (IB) (243,
284).
2. Even for event-related packaging, at a minimum,
place the date of sterilization, and if multiple
sterilizers are used in the facility, the sterilizer
used, on the outside of the packaging material
to facilitate the retrieval of processed items in
the event of a sterilization failure (IB) (243,247).
3. Examine wrapped packages of sterilized instruments before opening them to ensure the barrier wrap has not been compromised during
storage (II) (243,284).
4. Reclean, repack, and resterilize any instrument
package that has been compromised (II).
5. Store sterile items and dental supplies in covered or closed cabinets, if possible (II) (285).
VII. Environmental Infection Control
A. General Recommendations
1. Follow the manufacturers’ instructions for correct use of cleaning and EPA-registered hospital
disinfecting products (IB, IC) (243–245).
2. Do not use liquid chemical sterilants/high-level
disinfectants for disinfection of environmental
surfaces (clinical contact or housekeeping) (IB,
IC) (243–245).
3. Use PPE, as appropriate, when cleaning and disinfecting environmental surfaces. Such equipment might include gloves (e.g., puncture- and
chemical-resistant utility), protective clothing
(e.g., gown, jacket, or lab coat), and protective
eyewear/face shield, and mask (IC) (13,15).
B. Clinical Contact Surfaces
1. Use surface barriers to protect clinical contact
surfaces, particularly those that are difficult to
December 19, 2003
C.
D.
E.
F.
clean (e.g., switches on dental chairs) and change
surface barriers between patients (II) (1,2,260,
288).
2. Clean and disinfect clinical contact surfaces that
are not barrier-protected, by using an EPAregistered hospital disinfectant with a low- (i.e.,
HIV and HBV label claims) to intermediate-level
(i.e., tuberculocidal claim) activity after each
patient. Use an intermediate-level disinfectant
if visibly contaminated with blood (IB)
(2,243,244).
Housekeeping Surfaces
1. Clean housekeeping surfaces (e.g., floors, walls,
and sinks) with a detergent and water or an EPAregistered hospital disinfectant/detergent on a
routine basis, depending on the nature of the
surface and type and degree of contamination,
and as appropriate, based on the location in the
facility, and when visibly soiled (IB) (243,244).
2. Clean mops and cloths after use and allow to
dry before reuse; or use single-use, disposable
mop heads or cloths (II) (243,244).
3. Prepare fresh cleaning or EPA-registered disinfecting solutions daily and as instructed by the
manufacturer. (II) (243,244).
4. Clean walls, blinds, and window curtains in
patient-care areas when they are visibly dusty or
soiled (II) (9,244).
Spills of Blood and Body Substances
1. Clean spills of blood or OPIM and decontaminate surface with an EPA-registered hospital disinfectant with low- (i.e., HBV and HIV label
claims) to intermediate-level (i.e., tuberculocidal
claim) activity, depending on size of spill and
surface porosity (IB, IC) (13,113).
Carpet and Cloth Furnishings
1. Avoid using carpeting and cloth-upholstered
furnishings in dental operatories, laboratories,
and instrument processing areas (II) (9,293–
295).
Regulated Medical Waste
1. General Recommendations
a. Develop a medical waste management program. Disposal of regulated medical waste
must follow federal, state, and local regulations (IC) (13,301).
b. Ensure that DHCP who handle and dispose
of regulated medical waste are trained in
appropriate handling and disposal methods
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
and informed of the possible health and
safety hazards (IC) (13).
2. Management of Regulated Medical Waste in
Dental Health-Care Facilities
a. Use a color-coded or labeled container that
prevents leakage (e.g., biohazard bag) to contain nonsharp regulated medical waste (IC)
(13).
b. Place sharp items (e.g., needles, scalpel
blades, orthodontic bands, broken metal
instruments, and burs) in an appropriate
sharps container (e.g., puncture resistant,
color-coded, and leakproof). Close container
immediately before removal or replacement
to prevent spillage or protrusion of contents
during handling, storage, transport, or shipping (IC) (2,8,13,113,115).
c. Pour blood, suctioned fluids or other liquid
waste carefully into a drain connected to a
sanitary sewer system, if local sewage discharge requirements are met and the state
has declared this an acceptable method of
disposal. Wear appropriate PPE while performing this task (IC) (7,9,13).
VIII. Dental Unit Waterlines, Biofilm, and Water Quality
A. General Recommendations
1. Use water that meets EPA regulatory standards
for drinking water (i.e., <500 CFU/mL of heterotrophic water bacteria) for routine dental
treatment output water (IB, IC) (341,342).
2. Consult with the dental unit manufacturer for
appropriate methods and equipment to maintain the recommended quality of dental water
(II) (339).
3. Follow recommendations for monitoring water
quality provided by the manufacturer of the unit
or waterline treatment product (II).
4. Discharge water and air for a minimum of 20–
30 seconds after each patient, from any device
connected to the dental water system that enters
the patient’s mouth (e.g., handpieces, ultrasonic
scalers, and air/water syringes) (II) (2,311,344).
5. Consult with the dental unit manufacturer on
the need for periodic maintenance of
antiretraction mechanisms (IB) (2,311).
B. Boil-Water Advisories
1. The following apply while a boil-water advisory
is in effect:
a. Do not deliver water from the public water
system to the patient through the dental
45
operative unit, ultrasonic scaler, or other
dental equipment that uses the public water
system (IB, IC) (341,342,346,349,350).
b. Do not use water from the public water system for dental treatment, patient rinsing, or
handwashing (IB, IC) (341,342,346,349,
350).
c. For handwashing, use antimicrobialcontaining products that do not require
water for use (e.g., alcohol-based hand rubs).
If hands are visibly contaminated, use bottled
water, if available, and soap for handwashing
or an antiseptic towelette (IB, IC) (13,122).
2. The following apply when the boil-water
advisory is cancelled:
a. Follow guidance given by the local water
utility regarding adequate flushing of waterlines. If no guidance is provided, flush dental waterlines and faucets for 1–5 minutes
before using for patient care (IC) (244,346,
351,352).
b. Disinfect dental waterlines as recommended
by the dental unit manufacturer (II).
IX. Special Considerations
A. Dental Handpieces and Other Devices Attached
to Air and Waterlines
1. Clean and heat-sterilize handpieces and other
intraoral instruments that can be removed from
the air and waterlines of dental units between
patients (IB, IC) (2,246,275,356,357,360,407).
2. Follow the manufacturer’s instructions for cleaning, lubrication, and sterilization of handpieces
and other intraoral instruments that can be
removed from the air and waterlines of dental
units (IB) (361–363).
3. Do not surface-disinfect, use liquid chemical sterilants, or ethylene oxide on handpieces and
other intraoral instruments that can be removed
from the air and waterlines of dental units (IC)
(2,246,250,275).
4. Do not advise patients to close their lips tightly
around the tip of the saliva ejector to evacuate
oral fluids (II) (364–366).
B. Dental Radiology
1. Wear gloves when exposing radiographs and
handling contaminated film packets. Use other
PPE (e.g., protective eyewear, mask, and gown)
as appropriate if spattering of blood or other
body fluids is likely (IA, IC) (11,13).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
46
MMWR
2. Use heat-tolerant or disposable intraoral devices
whenever possible (e.g., film-holding and positioning devices). Clean and heat-sterilize heattolerant devices between patients. At a
minimum, high-level disinfect semicritical heatsensitive devices, according to manufacturer’s
instructions (IB) (243).
3. Transport and handle exposed radiographs in an
aseptic manner to prevent contamination of
developing equipment (II).
4. The following apply for digital radiography
sensors:
a. Use FDA-cleared barriers (IB) (243).
b. Clean and heat-sterilize, or high-level disinfect, between patients, barrier-protected
semicritical items. If the item cannot tolerate these procedures then, at a minimum,
protect with an FDA-cleared barrier and
clean and disinfect with an EPA-registered
hospital disinfectant with intermediate-level
(i.e., tuberculocidal claim) activity, between
patients. Consult with the manufacturer for
methods of disinfection and sterilization of
digital radiology sensors and for protection
of associated computer hardware (IB) (243).
C. Aseptic Technique for Parenteral Medications
1. Do not administer medication from a syringe to
multiple patients, even if the needle on the
syringe is changed (IA) (378).
2. Use single-dose vials for parenteral medications
when possible (II) (376,377).
3. Do not combine the leftover contents of singleuse vials for later use (IA) (376,377).
4. The following apply if multidose vials are used:
a. Cleanse the access diaphragm with 70%
alcohol before inserting a device into the vial
(IA) (380,381).
b. Use a sterile device to access a multiple-dose
vial and avoid touching the access diaphragm.
Both the needle and syringe used to access
the multidose vial should be sterile. Do not
reuse a syringe even if the needle is changed
(IA) (380,381).
c. Keep multidose vials away from the immediate patient treatment area to prevent inadvertent contamination by spray or spatter
(II).
d. Discard the multidose vial if sterility is compromised (IA) (380,381).
December 19, 2003
D.
E.
F.
G.
5. Use fluid infusion and administration sets (i.e.,
IV bags, tubings and connections) for one
patient only and dispose of appropriately (IB)
(378).
Single-Use (Disposable) Devices
1. Use single-use devices for one patient only and
dispose of them appropriately (IC) (383).
Preprocedural Mouth Rinses
1. No recommendation is offered regarding use of
preprocedural antimicrobial mouth rinses to
prevent clinical infections among DHCP or patients. Although studies have demonstrated that
a preprocedural antimicrobial rinse (e.g.,
chlorhexidine gluconate, essential oils, or povidone-iodine) can reduce the level of oral microorganisms in aerosols and spatter generated
during routine dental procedures and can
decrease the number of microorganisms introduced in the patient’s bloodstream during invasive dental procedures (391–399), the scientific
evidence is inconclusive that using these rinses
prevents clinical infections among DHCP or
patients (see discussion, Preprocedural Mouth
Rinses) (Unresolved issue).
Oral Surgical Procedures
1. The following apply when performing oral surgical procedures:
a. Perform surgical hand antisepsis by using an
antimicrobial product (e.g., antimicrobial
soap and water, or soap and water followed
by alcohol-based hand scrub with persistent
activity) before donning sterile surgeon’s
gloves (IB) (127–132,137).
b. Use sterile surgeon’s gloves (IB) (2,7,121,
123,137).
c. Use sterile saline or sterile water as a coolant/irrigatant when performing oral surgical procedures. Use devices specifically
designed for delivering sterile irrigating fluids (e.g., bulb syringe, single-use disposable
products, and sterilizable tubing) (IB)
(2,121).
Handling of Biopsy Specimens
1. During transport, place biopsy specimens in a
sturdy, leakproof container labeled with the biohazard symbol (IC) (2,13,14).
2. If a biopsy specimen container is visibly contaminated, clean and disinfect the outside of a
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
container or place it in an impervious bag
labeled with the biohazard symbol, (IC) (2,13).
H. Handling of Extracted Teeth
1. Dispose of extracted teeth as regulated medical
waste unless returned to the patient (IC) (13,14).
2. Do not dispose of extracted teeth containing
amalgam in regulated medical waste intended
for incineration (II).
3. Clean and place extracted teeth in a leakproof
container, labeled with a biohazard symbol, and
maintain hydration for transport to educational
institutions or a dental laboratory (IC) (13,14).
4. Heat-sterilize teeth that do not contain amalgam before they are used for educational purposes (IB) (403,405,406).
I. Dental Laboratory
1. Use PPE when handling items received in the
laboratory until they have been decontaminated
(IA, IC) (2,7,11,13,113).
2. Before they are handled in the laboratory, clean,
disinfect, and rinse all dental prostheses and
prosthodontic materials (e.g., impressions, bite
registrations, occlusal rims, and extracted teeth)
by using an EPA-registered hospital disinfectant
having at least an intermediate-level (i.e., tuberculocidal claim) activity (IB) (2,249,252,407).
3. Consult with manufacturers regarding the stability of specific materials (e.g., impression
materials) relative to disinfection procedures (II).
4. Include specific information regarding disinfection techniques used (e.g., solution used and
duration), when laboratory cases are sent offsite and on their return (II) (2,407,409).
5. Clean and heat-sterilize heat-tolerant items used
in the mouth (e.g., metal impression trays and
face-bow forks) (IB) (2,407).
6. Follow manufacturers’ instructions for cleaning
and sterilizing or disinfecting items that become
contaminated but do not normally contact the
patient (e.g., burs, polishing points, rag wheels,
articulators, case pans, and lathes). If manufacturer instructions are unavailable, clean and heatsterilize heat-tolerant items or clean and disinfect
with an EPA-registered hospital disinfectant with
low- (HIV, HBV effectiveness claim) to intermediate-level (tuberculocidal claim) activity,
depending on the degree of contamination (II).
J. Laser/Electrosurgery Plumes/Surgical Smoke
47
1. No recommendation is offered regarding practices to reduce DHCP exposure to laser plumes/
surgical smoke when using lasers in dental practice. Practices to reduce HCP exposure to laser
plumes/surgical smoke have been suggested,
including use of a) standard precautions (e.g.,
high-filtration surgical masks and possibly full
face shields) (437); b) central room suction units
with in-line filters to collect particulate matter
from minimal plumes; and c) dedicated
mechanical smoke exhaust systems with a highefficiency filter to remove substantial amounts
of laser-plume particles. The effect of the exposure (e.g., disease transmission or adverse respiratory effects) on DHCP from dental
applications of lasers has not been adequately
evaluated (see previous discussion, Laser/
Electrosurgery Plumes or Surgical Smoke)
(Unresolved issue).
K. Mycobacterium tuberculosis
1. General Recommendations
a. Educate all DHCP regarding the recognition of signs, symptoms, and transmission
of TB (IB) (20,21).
b. Conduct a baseline TST, preferably by
using a two-step test, for all DHCP who
might have contact with persons with suspected or confirmed active TB, regardless of
the risk classification of the setting (IB) (20).
c. Assess each patient for a history of TB as well
as symptoms indicative of TB and document
on the medical history form (IB) (20,21).
d. Follow CDC recommendations for 1)
developing, maintaining, and implementing
a written TB infection-control plan; 2) managing a patient with suspected or active TB;
3) completing a community risk-assessment
to guide employee TSTs and follow-up; and
4) managing DHCP with TB disease (IB)
(2,21).
2. The following apply for patients known or suspected to have active TB:
a. Evaluate the patient away from other patients
and DHCP. When not being evaluated, the
patient should wear a surgical mask or be
instructed to cover mouth and nose when
coughing or sneezing (IB) (20,21).
b. Defer elective dental treatment until the
patient is noninfectious (IB) (20,21).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
48
MMWR
c. Refer patients requiring urgent dental treatment to a previously identified facility with
TB engineering controls and a respiratory
protection program (IB) (20,21).
L. Creutzfeldt-Jakob Disease (CJD) and Other Prion
Diseases
1. No recommendation is offered regarding use of
special precautions in addition to standard precautions when treating known CJD or vCJD
patients. Potential infectivity of oral tissues in
CJD or vCJD patients is an unresolved issue.
Scientific data indicate the risk, if any, of sporadic CJD transmission during dental and oral
surgical procedures is low to nil. Until additional
information exists regarding the transmissibility
of CJD or vCJD during dental procedures, special precautions in addition to standard precautions might be indicated when treating known
CJD or vCJD patients; a list of such precautions is provided for consideration without recommendation (see Creutzfeldt-Jakob Disease
and Other Prion Diseases) (Unresolved issue).
M. Program Evaluation
1. Establish routine evaluation of the infectioncontrol program, including evaluation of performance indicators, at an established frequency
(II) (470-471).
Infection-Control Internet Resources
Advisory Committee on Immunization Practices
http://www.cdc.gov/nip/ACIP/default.htm
American Dental Association
http://www.ada.org
American Institute of Architects Academy of Architecture for Health
http://www.aahaia.org
American Society of Heating, Refrigeration, Air-conditioning Engineers
http://www.ashrae.org
Association for Professionals in Infection Control and
Epidemiology, Inc.
http://www.apic.org/resc/guidlist.cfm
CDC, Division of Healthcare Quality Promotion
http://www.cdc.gov/ncidod/hip
CDC, Division of Oral Health, Infection Control
http://www.cdc.gov/OralHealth/infectioncontrol/index.htm
CDC, Morbidity and Mortality Weekly Report
http://www.cdc.gov/mmwr
December 19, 2003
CDC, NIOSH
http://www.cdc.gov/niosh/homepage.html
CDC Recommends, Prevention Guidelines System
http://www.phppo.cdc.gov/cdcRecommends/AdvSearchV.asp
EPA, Antimicrobial Chemicals
http://www.epa.gov/oppad001/chemregindex.htm
FDA
http://www.fda.gov
Immunization Action Coalition
http://www.immunize.org/acip
Infectious Diseases Society of America
http://www.idsociety.org/PG/toc.htm
OSHA, Dentistry, Bloodborne Pathogens
http://www.osha.gov/SLTC/dentistry/index.html
http://www.osha.gov/SLTC/bloodbornepathogens/index.html
Organization for Safety and Asepsis Procedures
http://www.osap.org
Society for Healthcare Epidemiology of America, Inc.,
Position Papers
http://www.shea-online.org/PositionPapers.html
Acknowledgement
The Division of Oral Health thanks the working group as well as
CDC and other federal and external reviewers for their efforts in
developing and reviewing drafts of this report and acknowledges that
all opinions of the reviewers might not be reflected in all of the
recommendations.
References
1. CDC. Recommended infection-control practices for dentistry. MMWR
1986;35:237–42.
2. CDC. Recommended infection-control practices for dentistry, 1993.
MMWR 1993;42(No. RR-8).
3. US Census Bureau. Statistical Abstract of the United States: 2001.
Washington, DC: US Census Bureau, 2001. Available at http://www.
census.gov/prod/www/statistical-abstract-02.html.
4. Health Resources and Services Administration, Bureau of Health Professions. United States health workforce personnel factbook. Rockville,
MD: US Department of Health and Human Services, Health Resources
and Services Administration, 2000.
5. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN,
Deitchman SD, Hospital Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel, 1998.
Am J Infect Control 1998;26:289–354.
6. Greene VW. Microbiological contamination control in hospitals.
1. Perspectives. Hospitals 1969;43:78–88.
7. CDC. Perspectives in disease prevention and health promotion
update: universal precautions for prevention of transmission of
human immunodeficiency virus, hepatitis B virus, and other bloodborne
pathogens in health-care settings. MMWR 1988;38:377–382, 387–8.
The list of references for this article is several pages
long. For the complete list, please see the MMWR article
online at www.cdc.gov/mmwr/PDF/RR/RR5217.pdf
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
62
MMWR
December 19, 2003
Appendix A
Regulatory Framework for Disinfectants and Sterilants
When using the guidance provided in this report
regarding use of liquid chemical disinfectants and sterilants,
dental health-care personnel (DHCP) should be aware of federal laws and regulations that govern the sale, distribution,
and use of these products. In particular, DHCPs should know
what requirements pertain to them when such products are
used. Finally, DHCP should understand the relative roles of
the U.S. Environmental Protection Agency (EPA), the U.S.
Food and Drug Administration (FDA), the Occupational
Safety and Health Administration (OSHA) and CDC.
The choice of specific cleaning or disinfecting agents is largely
a matter of judgment, guided by product label claims and
instructions and government regulations. A single liquid chemical germicide might not satisfy all disinfection requirements
in a given dental practice or facility. Realistic use of liquid
chemical germicides depends on consideration of multiple factors, including the degree of microbial killing required; the
nature and composition of the surface, item, or device to be
treated; and the cost, safety, and ease of use of the available
agents. Selecting one appropriate product with a higher degree of potency to cover all situations might be more convenient.
In the United States, liquid chemical germicides (disinfectants) are regulated by EPA and FDA (A-1–A-3). In healthcare settings, EPA regulates disinfectants that are used on
environmental surfaces (housekeeping and clinical contact
surfaces), and FDA regulates liquid chemical sterilants/
high-level disinfectants (e.g., glutaraldehyde, hydrogen peroxide, and peracetic acid) used on critical and semicritical patientcare devices. Disinfectants intended for use on clinical contact
surfaces (e.g., light handles, radiographic-ray heads, or drawer
knobs) or housekeeping surfaces (e.g., floors, walls, or sinks)
are regulated in interstate commerce by the Antimicrobials
Division, Office of Pesticide Programs, EPA, under the
authority of the Federal Insecticide, Fungicide, and
Rodenticide Act (FIFRA) of 1947, as amended in 1996 (A-4).
Under FIFRA, any substance or mixture of substances intended
to prevent, destroy, repel, or mitigate any pest, including
microorganisms but excluding those in or on living man or
animals, must be registered before sale or distribution. To
obtain a registration, a manufacturer must submit specific data
regarding the safety and the effectiveness of each product.
EPA requires manufacturers to test formulations by using
accepted methods for microbicidal activity, stability, and toxicity to animals and humans. Manufacturers submit these data
to EPA with proposed labeling. If EPA concludes a product
may be used without causing unreasonable adverse effects, the
product and its labeling are given an EPA registration number, and the manufacturer may then sell and distribute the
product in the United States. FIFRA requires users of products to follow the labeling directions on each product explicitly.
The following statement appears on all EPA-registered product labels under the Directions for Use heading: “It is a violation of federal law to use this product inconsistent with its
labeling.” This means that DHCP must follow the safety precautions and use directions on the labeling of each registered
product. Not following the specified dilution, contact time,
method of application, or any other condition of use is considered misuse of the product.
FDA, under the authority of the 1976 Medical Devices
Amendment to the Food, Drug, and Cosmetic Act, regulates
chemical germicides if they are advertised and marketed for
use on specific medical devices (e.g., dental unit waterline or
flexible endoscope). A liquid chemical germicide marketed for
use on a specific device is considered, for regulatory purposes,
a medical device itself when used to disinfect that specific medical device. Also, this FDA regulatory authority over a particular instrument or device dictates that the manufacturer is
obligated to provide the user with adequate instructions for
the safe and effective use of that device. These instructions
must include methods to clean and disinfect or sterilize the
item if it is to be marketed as a reusable medical device.
OSHA develops workplace standards to help ensure safe and
healthful working conditions in places of employment. OSHA
is authorized under Pub. L. 95-251, and as amended, to enforce these workplace standards. In 1991, OSHA published
Occupational Exposure to Bloodborne Pathogens; final rule
[29 CFR Part 1910.1030] (A-5). This standard is designed to
help prevent occupational exposures to blood or other potentially infectious substances. Under this standard, OSHA has
interpreted that, to decontaminate contaminated work surfaces, either an EPA-registered hospital tuberculocidal disinfectant or an EPA-registered hospital disinfectant labeled as
effective against human immunodeficiency virus (HIV) and
hepatitis B virus (HBV) is appropriate. Hospital disinfectants
with such HIV and HBV claims can be used, provided surfaces are not contaminated with agents or concentration of
agents for which higher level (i.e., intermediate-level) disinfection is recommended. In addition, as with all disinfectants,
effectiveness is governed by strict adherence to the label
instructions for intended use of the product.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
CDC is not a regulatory agency and does not test, evaluate,
or otherwise recommend specific brand-name products of
chemical germicides. This report is intended to provide overall guidance for providers to select general classifications of
products based on certain infection-control principles. In this
report, CDC provides guidance to practitioners regarding
appropriate application of EPA- and FDA-registered liquid
chemical disinfectants and sterilants in dental health-care settings.
CDC recommends disinfecting environmental surfaces or
sterilizing or disinfecting medical equipment, and DHCP
should use products approved by EPA and FDA unless no
such products are available for use against certain microorganisms or sites. However, if no registered or approved products
are available for a specific pathogen or use situation, DHCP
are advised to follow the specific guidance regarding unregistered or unapproved (e.g., off-label) uses for various chemical
germicides. For example, no antimicrobial products are registered for use specifically against certain emerging pathogens
(e.g., Norwalk virus), potential terrorism agents (e.g., variola
major or Yersinia pestis), or Creutzfeldt-Jakob disease agents.
One point of clarification is the difference in how EPA and
FDA classify disinfectants. FDA adopted the same basic terminology and classification scheme as CDC to categorize
medical devices (i.e., critical, semicritical, and noncritical) and
to define antimicrobial potency for processing surfaces (i.e.,
sterilization, and high-, intermediate- and low-level disinfection) (A-6). EPA registers environmental surface disinfectants
based on the manufacturer’s microbiological activity claims
when registering its disinfectant. This difference has led to confusion on the part of users because the EPA does not use the
terms intermediate- and low-level disinfectants as used in CDC
guidelines.
CDC designates any EPA-registered hospital disinfectant
without a tuberculocidal claim as a low-level disinfectant and
any EPA-registered hospital disinfectant with a tuberculocidal
claim as an intermediate-level disinfectant. To understand this
comparison, one needs to know how EPA registers disinfectants. First, to be labeled as an EPA hospital disinfectant, the
product must pass Association of Official Analytical Chemists
(AOAC) effectiveness tests against three target organisms: Salmonella choleraesuis for effectiveness against gram-negative
bacteria; Staphylococcus aureus for effectiveness against grampositive bacteria; and Pseudomonas aeruginosa for effectiveness
63
against a primarily nosocomial pathogen. Substantiated label
claims of effectiveness of a disinfectant against specific microorganisms other than the test microorganisms are permitted,
but not required, provided that the test microorganisms are
likely to be present in or on the recommended use areas and
surfaces. Therefore, manufacturers might also test specifically
against organisms of known concern in health-care practices
(e.g., HIV, HBV, hepatitis C virus [HCV], and herpes) although it is considered likely that any product satisfying AOAC
tests for hospital disinfectant designation will also be effective
against these relatively fragile organisms when the product is
used as directed by the manufacturer.
Potency against Mycobacterium tuberculosis has been recognized as a substantial benchmark. However, the tuberculocidal
claim is used only as a benchmark to measure germicidal
potency. Tuberculosis is not transmitted via environmental surfaces but rather by the airborne route. Accordingly, use of such
products on environmental surfaces plays no role in preventing the spread of tuberculosis. However, because mycobacteria have among the highest intrinsic levels of resistance among
the vegetative bacteria, viruses, and fungi, any germicide with
a tuberculocidal claim on the label is considered capable of
inactivating a broad spectrum of pathogens, including such
less-resistant organisms as bloodborne pathogens (e.g., HBV,
HCV, and HIV). It is this broad-spectrum capability, rather
than the product’s specific potency against mycobacteria, that
is the basis for protocols and regulations dictating use of
tuberculocidal chemicals for surface disinfection.
EPA also lists disinfectant products according to their
labeled use against these organisms of interest as follows:
• List B. Tuberculocide products effective against Mycobacterium species.
• List C. Products effective against human HIV-1 virus.
• List D. Products effective against human HIV-1 virus and
HBV.
• List E. Products effective against Mycobacterium species,
human HIV-1 virus, and HBV.
• List F. Products effective against HCV.
Microorganisms vary in their resistance to disinfection and
sterilization, enabling CDC’s designation of disinfectants as
high-, intermediate-, and low-level, when compared with EPA’s
designated organism spectrum (Figure). However, exceptions
to this general guide exist, and manufacturer’s label claims and
instructions should always be followed.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
64
MMWR
December 19, 2003
FIGURE. Decreasing order of resistance of microorganisms to germicidal chemicals
Organism
Processing Level Required
Sterilization
Bacterial spores
Geobacillus stearothermophilus
Bacillus atrophaeus
Mycobacteria
Mycobacterium tuberculosis
Nonlipid or small viruses
Polio virus
Coxsackle virus
Rhinovirus
Fungi
Aspergillus
Candida
Vegetative bacteria
Staphylococcus species
Pseudomonus species
Salmonella species
Lipid or medium-sized viruses
Human immunodeficiency virus
Herpes simplex virus
Hepatitis B and hepatitis C
Coronavirus
FDA sterilant/high-level disinfectant
(= CDC sterilant/high-level disinfectant)
EPA hospital disinfectant with
tuberculocidal claim
(= CDC intermediate-level disinfectant)
EPA hospital disinfectant
(= CDC low-level disinfectant)
Source: Adapted from Bond WW, Ott BJ, Franke K, McCracken JE. Effective use of liquid chemical germicides on medical devices; instrument design
problems. In: Block SS, ed. Disinfection, sterilization and preservation. 4 th ed. Philadelphia, PA: Lea & Gebiger, 1991:1100.
References
A-1. Food and Drug Administration (FDA) and US Environmental Protection Agency (EPA). Memorandum of understanding between the
FDA and EPA: notice regarding matters of mutual responsibility—
regulation of liquid chemical germicides intended for use on medical
devices. Rockville, MD: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, US
Environmental Protection Agency, 1993.
A-2. Food and Drug Administration (FDA). Interim measures for registration of antimicrobial products/liquid chemical germicides with medical device use claims under the memorandum of understanding between
EPA and FDA. Rockville, MD: US Department of Health and
Human Services, Food and Drug Administration, 1994.
A-3. Food and Drug Administration. Guidance for industry and FDA
reviewers: content and format of premarket notification [510(k)] submissions for liquid chemical sterilants/high level disinfectants. Rockville,
MD: US Department of Health and Human Services, Food and Drug
Administration, 2000. Available at http://www.fda.gov/cdrh/ode/
397.pdf.
A-4. US Environmental Protection Agency. 40 CFR Parts 152, 156, and
158. Exemption of certain pesticide substances from federal insecticide, fungicide, and rodenticide act requirements. Amended 1996.
Federal Register 1996;61:8876–9.
A-5. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne
pathogens; needlesticks and other sharps injuries; final rule. Federal
Register 2001;66:5317–25. As amended from and includes 29 CFR
Part 1910.1030. Occupational exposure to bloodborne pathogens;
final rule. Federal Register 1991;56:64174–82. Available at http://www.
osha.gov/SLTC/dentistry/index.html.
A-6. Spaulding EH. Role of chemical disinfection in preventing nosocomial infections. In: Proceedings of the International Conference on
Nosocomial Infections, 1970. Brachman PS, Eickhoff TC, eds. Chicago, IL: American Hospital Association, 1971:247–54.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
Vol. 52 / RR-17
Recommendations and Reports
65
Appendix B
Immunizations Strongly Recommended for Health-Care Personnel (HCP)
Vaccine
Dose schedule
Indications
Major precautions
and contraindications
Special considerations
Hepatitis B
recombinant
vaccine*
Three-dose schedule
Health-care personnel (HCP)
administered intramuscularly
at risk for exposure to blood
(IM) in the deltoid; 0,1,6 and body fluids.
second dose administered 1
month after first dose; third dose
administered 4 months after
second. Booster doses are not
necessary for persons who have
developed adequate antibodies
to hepatitis B surface antigen
(anti-HBs).
History of anaphylactic reaction to
common baker’s yeast. Pregnancy
is not a contraindication.
No therapeutic or adverse effects on hepatitis
B virus (HBV)-infected persons; costeffectiveness of prevaccination screening for
susceptibility to HBV depends on costs of
vaccination and antibody testing and
prevalence of immunity in the group of
potential vaccinees; health-care personnel who
have ongoing contact with patients or blood
should be tested 1–2 months after completing
the vaccination series to determine serologic
response. If vaccination does not induce
adequate anti-HBs (>10 mIU/mL), a second
vaccine series should be administered.
Influenza
vaccine
(inactivated)¶
Annual single-dose vaccination
IM with current vaccine.
HCP who have contact with
patients at high risk or who
work in chronic-care facilities;
HCP aged >50 years or who
have high-risk medical
conditions.
History of anaphylactic hypersensitivity to eggs or to other components of the vaccine.
Recommended for women who will be in the
second or third trimesters of pregnancy during
the influenza season and women in any stage
of pregnancy who have chronic medical
conditions that are associated with an
increased risk of influenza.§
Measles livevirus vaccine
One dose administered
subcutaneously (SC); second
dose >4 weeks later.
HCP who were born during or
after 1957 without documentation of 1) receipt of 2 doses of
live vaccine on or after their first
birthday, 2) physician-diagnosed
measles, or 3) laboratory
evidence of immunity. Vaccine
should also be considered for
all HCP who have no proof of
immunity, including those born
before 1957.
Pregnancy; immunocompromised†
state (including human immunodeficiency virus [HIV]-infected
persons with severe immunosuppression); history of anaphylactic
reactions after gelatin ingestion or
receipt of neomycin; or recent
receipt of antibody-containing
blood products.
Measles, mumps, rubella (MMR) is the
recommended vaccine, if recipients are also
likely to be susceptible to rubella or mumps;
persons vaccinated during 1963–1967 with
1) measles killed-virus vaccine alone,
2) killed-virus vaccine followed by live-virus
vaccine, or 3) a vaccine of unknown type,
should be revaccinated with two doses of
live-virus measles vaccine.
Mumps livevirus vaccine
One dose SC; no booster.
HCP believed susceptible can
be vaccinated; adults born
before 1957 can be considered
immune.
Pregnancy; immunocompromised†
state; history of anaphylactic
reaction after gelatin ingestion or
receipt of neomycin.
MMR is the recommended vaccine.
Rubella livevirus vaccine
One dose SC; no booster.
HCP, both male and female,
who lack documentation of
receipt of live vaccine on or
after their first birthday, or lack
of laboratory evidence of
immunity can be vaccinated.
Adults born before 1957 can
be considered immune, except
women of childbearing age.
Pregnancy; immunocompromised†
state; history of anaphylactic
reaction after receipt of neomycin.
Women pregnant when vaccinated or who
become pregnant within 4 weeks of
vaccination should be counseled regarding
theoretic risks to the fetus; however, the risk
of rubella vaccine-associated malformations
among these women is negligible. MMR is the
recommended vaccine.
Varicella-zoster
live-virus
vaccine
Two 0.5 mL doses SC 4–8
weeks apart if aged >13 years.
HCP without reliable history of
varicella or laboratory evidence
of varicella immunity.
Pregnancy; immunocompromised†
state; history of anaphylactic
reaction after receipt of neomycin
or gelatin; recent receipt of
antibody-containing blood products;
salicylate use should be avoided
for 6 weeks after vaccination.
Because 71%–93% of U.S.-born persons
without a history of varicella are immune,
serologic testing before vaccination might be
cost-effective.
Sources: Adapted from Bolyard EA, Hospital Infection Control Practices Advisory Committee. Guidelines for infection control in health care personnel, 1998. Am J Infect Control
1998;26:289–354.
CDC. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices
Advisory Committee (HICPAC). MMWR 1997;46(No. RR-18).
CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2003;52:1-34.
CDC. Using live, attenuated influenza vaccine for prevention and control of influenza: supplemental recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 2003;52(No. RR-13).
* A federal standard issued in December 1991 under the Occupational Safety and Health Act mandates that hepatitis B vaccine be made available at the employer’s expense to
all HCP occupationally exposed to blood or other potentially infectious materials. The Occupational Safety and Health Administration requires that employers make available
hepatitis B vaccinations, evaluations, and follow-up procedures in accordance with current CDC recommendations.
†
Persons immunocompromised because of immune deficiencies, HIV infection, leukemia, lymphoma, generalized malignancy; or persons receiving immunosuppressive therapy
with corticosteroids, alkylating drugs, antimetabolites; or persons receiving radiation.
§
Vaccination of pregnant women after the first trimester might be preferred to avoid coincidental association with spontaneous abortions, which are most common during the first
trimester. However, no adverse fetal effects have been associated with influenza vaccination.
¶
A live attenuated influenza vaccine (LAIV) is FDA-approved for healthy persons aged 5-49 years. Because of the possibility of transmission of vaccine viruses from recipients
of LAIV to other persons and in the absence of data on the risk of illness and among immunocompromised persons infected with LAIV viruses, the inactivated influenza vaccine
is preferred for HCP who have close contact with immunocompromised persons.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
66
MMWR
December 19, 2003
Appendix C
Methods for Sterilizing and Disinfecting Patient-Care Items
and Environmental Surfaces*
Health-care application
Process
Sterilization
Result
Destroys all microorganisms, including bacterial
spores.
Method
Heat-automated
High temperature
Examples
Type of
patient-care item
Environmental
surfaces
Not applicable
Steam, dry heat, unsaturated chemical vapor
Heat-tolerant critical
and semicritical
Ethylene oxide gas, plasma sterilization
Heat-sensitive critical
and semicritical
Liquid immersion†
Chemical sterilants. Glutaraldehyde,
glutaraldehydes with phenol, hydrogen
peroxide, hydrogen peroxide with peracetic acid,
peracetic acid
Heat-sensitive critical
and semicritical
Destroys all microorganisms, but not necessarily
high numbers of bacterial
spores.
Heat-automated
Washer-disinfector
Heat-sensitive
semicritical
Not applicable
Liquid immersion†
Chemical sterilants/high-level disinfectants.
Glutaraldehyde, glutaraldehyde with phenol,
hydrogen peroxide, hydrogen peroxide with
peracetic acid, ortho-phthalaldehyde
Intermediatelevel
disinfection
Destroys vegetative bacteria
and the majority of fungi and
viruses. Inactivates
Mycobacterium bovis.§ Not
necessarily capable of killing
bacterial spores.
Liquid contact
U.S. Environmental Protection Agency (EPA)registered hospital disinfectant with label claim
of tuberculocidal activity (e.g., chlorinecontaining products, quaternary ammonium
compounds with alcohol, phenolics, iodophors,
EPA-registered chlorine-based product¶)
Noncritical with visible
blood
Clinical contact
surfaces; blood
spills on
housekeeping
surfaces
Low-level
disinfection
Destroys the majority of
vegetative bacteria, certain
fungi, and viruses. Does not
inactivate Mycobacterium
bovis .§
Liquid contact
EPA-registered hospital disinfectant with no
label claim regarding tuberculocidal activity.**
The Occupational Safety and Health Administration also requires label claims of human
immunodeficiency virus (HIV) and hepatitis B
virus (HBV) potency for clinical contact surfaces
(e.g., quaternary ammonium compounds, some
phenolics, some iodophors)
Noncritical without
visible blood
Clinical contact
surfaces;
housekeeping
surfaces
Low temperature
High-level
disinfection
* EPA and the Food and Drug Administration (FDA) regulate chemical germicides used in health-care settings. FDA regulates chemical sterilants used on critical and semicritical
medical devices, and the EPA regulates gaseous sterilants and liquid chemical disinfectants used on noncritical surfaces. FDA also regulates medical devices, including
sterilizers. More information is available at 1) http://www.epa.gov/oppad001/chemregindex.htm, 2) http://www.fda.gov/cdrh/index.html, and 3) http://www.fda.gov/cdrh/ode/
germlab.html.
† Contact time is the single critical variable distinguishing the sterilization process from high-level disinfection with FDA-cleared liquid chemical sterilants. FDA defines a high-level
disinfectant as a sterilant used under the same contact conditions as sterilization except for a shorter immersion time (C-1).
§ The tuberculocidal claim is used as a benchmark to measure germicidal potency. Tuberculosis (TB) is transmitted via the airborne route rather than by environmental surfaces
and, accordingly, use of such products on environmental surfaces plays no role in preventing the spread of TB. Because mycobacteria have among the highest intrinsic levels of
resistance among vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e., an intermediate-level disinfectant) is considered capable of
inactivating a broad spectrum of pathogens, including much less resistant organisms, including bloodborne pathogens (e.g., HBV, hepatitis C virus [HCV], and HIV). It is this
broad-spectrum capability, rather than the product’s specific potency against mycobacteria, that is the basis for protocols and regulations dictating use of tuberculocidal
chemicals for surface disinfection.
¶ Chlorine-based products that are EPA-registered as intermediate-level disinfectants are available commercially. In the absence of an EPA-registered chlorine-based product, a
fresh solution of sodium hypochlorite (e.g., household bleach) is an inexpensive and effective intermediate-level germicide. Concentrations ranging from 500 ppm to 800 ppm of
chlorine (1:100 dilution of 5.25% bleach and tap water, or approximately ¼ cup of 5.25% bleach to 1 gallon of water) are effective on environmental surfaces that have been
cleaned of visible contamination. Appropriate personal protective equipment (e.g., gloves and goggles) should be worn when preparing hypochlorite solutions (C-2,C-3). Caution
should be exercised, because chlorine solutions are corrosive to metals, especially aluminum.
** Germicides labeled as “hospital disinfectant” without a tuberculocidal claim pass potency tests for activity against three representative microorganisms: Pseudomonas aeruginosa,
Staphylococcus aureus, and Salmonella choleraesuis.
References
C-1. Food and Drug Administration. Guidance for industry and FDA
reviewers: content and format of premarket notification [510(k)] submissions for liquid chemical sterilants/high level disinfectants. Rockville,
MD: US Department of Health and Human Services, Food and Drug
Administration, 2000. Available at http://www.fda.gov/cdrh/ode/
397.pdf.
C-2. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne
pathogens; needlesticks and other sharps injuries; final rule. Federal
Register 2001;66:5317–25. As amended from and includes 29 CFR
Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64174–82. Available at http://www.
osha.gov/SLTC/dentistry/index.html.
C-3. CDC. Guidelines for environmental infection control in health-care
facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003;52(No.
RR-10).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
MMWR
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge
in electronic format and on a paid subscription basis for paper copy. To receive an electronic copy each week, send an e-mail message to [email protected]. The
body content should read SUBscribe mmwr-toc. Electronic copy also is available from CDC’s World-Wide Web server at http://www.cdc.gov/mmwr or from CDC’s
file transfer protocol server at ftp://ftp.cdc.gov/pub/publications/mmwr. To subscribe for paper copy, contact Superintendent of Documents, U.S. Government
Printing Office, Washington, DC 20402; telephone 202-512-1800.
Data in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on
Friday; compiled data on a national basis are officially released to the public on the following Friday. Address inquiries about the MMWR Series, including material
to be considered for publication, to Editor, MMWR Series, Mailstop C-08, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone 888-232-3228.
All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.
All MMWR references are available on the Internet at http://www.cdc.gov/mmwr. Use the search function to find specific articles.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or
their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in
MMWR were current as of the date of publication.
✩U.S. Government Printing Office: 2004-633-140/4-00056 Region IV
ISSN: 1057-5987
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL['
ADA.org: ADA Statement on Infection Control in Dentistry
Page 1 of 1
Bloodborne Pathogens Appendix E
Licensure |
Catalog |
Member Directory |
Contact Us |
ADA POSITIONS & STATEMENTS
ADA STATEMENT ON INFECTION CONTROL IN DENTISTRY
Twenty-five years ago the ADA Foundation's Health Screening Program helped identify HBV as
an occupational hazard in dentistry. The ADA responded by being the first to recommend that
dentists follow standard infection control procedures. The ADA subsequently worked with the
Centers for Disease Control and Prevention (CDC) to develop CDC's own infection control
recommendations for dentistry, which were issued in 1993. Since then, both the ADA and CDC
have updated and supplemented their recommendations from time to time to reflect new
scientific knowledge and growing understanding of the principles of infection control.
ADA LIBRARY
ADA PUBLICATIONS
DENTAL CAREERS AND
JOB LISTINGS
EVIDENCE BASED DENTISTRY
PODCASTS
ADA POLICIES & POSITIONS
ADA Current Policies
ADA Positions &
Statements
Research Agenda
STANDARDS
In December 2003, the CDC published a major consolidation and update of its infection control
recommendations for dentistry.1 Although the procedures recommended in the 2003 document
are for the most part unchanged, the new document does incorporate relevant
recommendations that were previously scattered throughout several other CDC publications
and contains an extensive review of the science related to dental infection control.
The 2003 CDC Guidelines are a comprehensive and evidence-based source for infection
control practices relevant to the dental office that have been developed for the protection of
dental care workers and their patients. The ADA urges all practicing dentists, dental auxiliaries
and dental laboratories to employ appropriate infection control procedures as described in the
2003 CDC Guidelines, and to keep up-to-date as scientific information leads to improvements in
infection control, risk assessment and disease management in oral health care.
The ADA has long advocated the use of infection control procedures in dental practice and
provided dentists with resources to help them understand and implement them. In addition to
the online resources available at ADA.org, the Association has a number of publications that
provide detailed information about infection control and treatment of patients with infectious
diseases. These include Dental Management of the HIV-Infected Patient and ADA Catalog
products, including the Effective Infection Control training DVD (P692), the ADA Regulatory
Compliance Manual and the OSHA Training for Dental Professionals DVD (P889).
Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental HealthCare Settings – 2003. MMWR 2003;52(No. RR-17)
Adopted March 2004
Return to Top
For more topics related to the needs of patients, see:
Oral Health Topics A-Z
Copyright 1995-2008 American Dental Association.
Reproduction or republication strictly prohibited without prior written permission.
See Privacy Policy (Updated 03/14/05) and Terms of Use for further legal information.
Link opens in separate window.
Pop-up Blocker may need to be disabled.
Member only content.
from http://www.ada.org/prof/resources/positions/statements/infectionconrol.asp
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[(
http://www.ada.org/prof/resources/positions/statements/infectionconrol.asp
1/7/2008
Bloodborne Pathogens Appendix F
___________________________________________
Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human
Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis
8SGDWHG863XEOLF+HDOWK6HUYLFH*XLGHOLQHVIRUWKH0DQDJHPHQWRI2FFXSDWLRQDO([SRVXUHV
WR+XPDQ,PPXQRGHILFLHQF\9LUXVDQG5HFRPPHQGDWLRQVIRU3RVWH[SRVXUH3URSK\OD[LV
$XWKRUV'DYLG7.XKDU0''DYLG.+HQGHUVRQ0'.LPEHUO\$6WUXEOH3KDUP':DOLG
+HQHLQH3K'9DVDYL7KRPDV53K03+/DXUD:&KHHYHU0'6F0$KPHG*RPDD0'
6F'063+$GHOLVD/3DQOLOLR0'DQGIRUWKH863XEOLF+HDOWK6HUYLFH:RUNLQJ*URXS
6RXUFH,QIHFWLRQ&RQWURODQG+RVSLWDO(SLGHPLRORJ\9RO1R6HSWHPEHUSS
3XEOLVKHGE\7KH8QLYHUVLW\RI&KLFDJR3UHVVRQEHKDOIRI7KH6RFLHW\IRU+HDOWKFDUH(SLGHPLRORJ\
RI$PHULFD
6WDEOH85/http://www.jstor.org/stable/10.1086/672271 .
$FFHVVHG
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .
http://www.jstor.org/page/info/about/policies/terms.jsp
.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of
content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms
of scholarship. For more information about JSTOR, please contact [email protected].
.
The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaborating
with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.
http://www.jstor.org
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
u s p u b l i c h e a l t h s e rv i c e g u i d e l i n e
Updated US Public Health Service Guidelines for the Management
of Occupational Exposures to Human Immunodeficiency Virus
and Recommendations for Postexposure Prophylaxis
David T. Kuhar, MD;1 David K. Henderson, MD;2 Kimberly A. Struble, PharmD;3
Walid Heneine, PhD;4 Vasavi Thomas, RPh, MPH;4 Laura W. Cheever, MD, ScM;5
Ahmed Gomaa, MD, ScD, MSPH;6 Adelisa L. Panlilio, MD;1
for the US Public Health Service Working Group
This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience
occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles
of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV followup testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt
reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure,
expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for
adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure
management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions
should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and
seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures
to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP
medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week
duration; (4) new recommendation—PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A) for
all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for
situations described in Box 1; (6) close follow-up for exposed personnel (Box 2) should be provided that includes counseling, baseline and
follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and
(7) new recommendation—if a newer fourth-generation combination HIV p24 antigen–HIV antibody test is utilized for follow-up HIV
testing of exposed HCP, HIV testing may be concluded 4 months after exposure (Box 2); if a newer testing platform is not available,
follow-up HIV testing is typically concluded 6 months after an HIV exposure.
Infect Control Hosp Epidemiol 2013;34(9):875-892
Preventing exposures to blood and body fluids (ie, primary
prevention) is the most important strategy for preventing
occupationally acquired human immunodeficiency virus
(HIV) infection. Both individual healthcare providers and the
institutions that employ them should work to ensure adherence to the principles of Standard Precautions,1 including
ensuring access to and consistent use of appropriate work
practices, work practice controls, and personal protective
equipment. For instances in which an occupational exposure
has occurred, appropriate postexposure management is an
important element of workplace safety. This document provides updated recommendations concerning the management
of occupational exposures to HIV.
The use of antiretrovirals as postexposure prophylaxis
(PEP) for occupational exposures to HIV was first considered
in guidelines issued by the Centers for Disease Control and
Prevention (CDC) in 1990.2 In 1996, the first US Public
Health Service (PHS) recommendations advocating the use
of PEP after occupational exposure to HIV were published;
these recommendations have been updated 3 times.3-6 Since
Affiliations: 1. Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control
and Prevention, Atlanta, Georgia; 2. Office of the Deputy Director for Clinical Care, Clinical Center, National Institutes of Health, Bethesda, Maryland;
3. Division of Antiviral Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland; 4. Division of HIV/
AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia;
5. HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland; 6. Division of Surveillance, Hazard Evaluation, and Health
Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio.
Received June 27, 2013; accepted June 27, 2013; electronically published August 6, 2013.
This article is in the public domain, and no copyright is claimed. 0899-823X/2013/3409-0001. DOI: 10.1086/672271
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
876
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
publication of the most recent guidelines in 2005, several new
antiretroviral agents have been approved by the Food and
Drug Administration (FDA), and additional information has
become available regarding both the use and the safety of
agents previously recommended for administration for HIV
PEP.
As a direct result of 7 years’ experience with the 2005
guidelines, several challenges in the interpretation and implementation of those guidelines have been identified. These
challenges include difficulties in determining levels of risk of
HIV transmission for individual exposure incidents, problems
determining the appropriate use of 2 versus 3 (or more) drugs
in PEP regimens, the high frequency of side effects and toxicities associated with administration of previously recommended drugs, and the initial management of healthcare personnel (HCP) with exposures to a source patient whose HIV
infection status was unknown. The PHS working group has
attempted to address both the new information that has been
developed and the challenges associated with the practical
implementation of the 2005 guidelines in this update.
This report encourages using HIV PEP regimens that are
optimally tolerated, eliminates the recommendation to assess
the level of risk associated with individual exposures to determine the number of drugs recommended for PEP, modifies
and expands the list of antiretroviral medications that can be
considered for use as PEP, and offers an option for concluding
HIV follow-up testing of exposed personnel earlier than 6
months after exposure. This report also continues to emphasize the following: (1) primary prevention of occupational
exposures; (2) prompt management of occupational exposures and, if indicated, initiation of PEP as soon as possible
after exposure; (3) selection of PEP regimens that have the
fewest side effects and that are best tolerated by prophylaxis
recipients; (4) anticipating and preemptively treating side effects commonly associated with taking antiretroviral drugs;
(5) attention to potential interactions involving both drugs
that could be included in HIV PEP regimens and other medications that PEP recipients might be taking; (6) consultation
with experts on postexposure management strategies (especially determining whether an exposure has actually occurred
and selecting HIV PEP regimens, particularly when the source
patient is antiretroviral treatment experienced); (7) HIV testing of source patients (without delaying PEP initiation in the
exposed provider) using methods that produce rapid results;
and (8) counseling and follow-up of exposed HCP.
Recommendations concerning the management of occupational exposures to hepatitis B virus and/or hepatitis C virus
(HCV) have been published previously 5,7 and are not included
in this report. Recommendations for nonoccupational (eg,
sexual, pediatric, and perinatal) HIV exposures also have been
published previously.8-10
methods
In 2011, the CDC reconvened the interagency PHS working
group to plan and prepare an update to the 2005 Updated
U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis.6 The PHS working group was comprised
of members from the CDC, the FDA, the Health Resources
and Services Administration, and the National Institutes of
Health. Names, credentials, and affiliations of the PHS working group members are listed as the byline of this guideline.
The working group met twice a month to monthly to create
a plan for the update as well as draft the guideline.
A systematic review of new literature that may have become
available since 2005 was not conducted; however, an initial
informal literature search did not reveal human randomized
trials demonstrating superiority of 2-drug antiretroviral medication regimens versus those with 3 (or more) drugs as PEP
or an optimal PEP regimen for occupational exposures to
HIV. Because of the low risk of transmission associated with
occupational exposures (ie, approximately 0.3% per exposure
when all parenteral exposures are considered together),11 neither the conduct of a randomized trial assessing efficacy nor
the conduct of trials assessing the comparative efficacy of 2versus 3-drug regimens for PEP is practical. In light of the
absence of such randomized trials, the CDC convened a meeting of the interagency PHS working group and an expert
panel of consultants in July 2011 to discuss the use of HIV
PEP and develop the recommendations for this update. The
expert panel consisted of professionals in academic medicine
considered to be experts in the treatment of HIV-infected
individuals, the use of antiretroviral medications, and PEP.
Names, credentials, and affiliations of the expert panel of
consultants are listed in “Expert Panel Consultants” at the
end of this guideline.
Prior to the July 2011 meeting, the meeting participants
were provided an electronic copy of the 2005 guidelines and
asked to review them and consider the following topics for
discussion at the upcoming meeting: (1) the challenges associated with the implementation of the 2005 guidelines, (2)
the role of ongoing risk stratification in determining the use
of 2-drug PEP regimens versus those with 3 or more drugs,
(3) updated drug choices for PEP, (4) the safety and tolerability of antiretroviral agents for the general population and
for pregnant or lactating HCP, and (5) any other topics in
the 2005 guideline that needed to be updated.
At the July 2011 meeting, a CDC representative presented
a review of the 2005 guideline recommendations, surveillance
data on occupational exposures from the National Surveillance System for Healthcare Workers,12 and data from the
National Clinicians’ Post-Exposure Prophylaxis Hotline
(PEPline) on the number of occupational exposures to HIV
managed annually, PEP regimens recommended, and challenges experienced with implementation of the 2005 guidelines. An FDA representative presented a review of the new
medications that have become available since 2005 for the
treatment of HIV-infected individuals, information about
medication tolerability and toxicity, and the use of these medications during pregnancy. These presentations were followed
by a discussion of the topics listed above.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
Among the challenges discussed regarding implementation
of the 2005 guidelines were the difficulties in determining
level of risk of HIV transmission for individual exposure
incidents, which in turn determined the number of drugs
recommended for HIV PEP. The consensus of the meeting
participants was to no longer recommend exposure risk stratification (discussed in detail in “Recommendations for the
Selection of Drugs for HIV PEP” below). To update the drug
choices for PEP, all drugs available for the treatment of HIVinfected individuals were discussed with regard to tolerability,
side effects, toxicity, safety in pregnancy and lactation, pill
burden, and frequency of dosing. A hierarchy of recommended drugs/regimens was developed at the meeting and
utilized in creating the PEP regimen recommendations (Appendixes A and B) in these guidelines. Among other topics
identified as needing an update were the acceptable HIV testing platforms available for source patient and follow-up testing of exposed HCP; the timing of such testing, depending
on the platform used; and the potential utility of source patient drug-resistance information/testing in PEP regimens.
After the expert consultation, the expert panelists received
draft copies of these guidelines as they were updated and
provided insights, information, suggestions, and edits and
participated in subsequent teleconferences with the PHS
working group, to assist in developing these recommendations. Proposed recommendation updates were presented to
the Healthcare Infection Control Practices Advisory Committee in November 201113 and June 201214 during public
meetings. The PHS working group considered all available
information, expert opinion, and feedback in finalizing the
recommendations in this update.
definition of hcp and exposure
The definitions of HCP and occupational exposures are unchanged from those used in 2001 and 2005.5,6 The term HCP
refers to all paid and unpaid persons working in healthcare
settings who have the potential for exposure to infectious
materials, including body substances (eg, blood, tissue, and
specific body fluids), contaminated medical supplies and
equipment, and contaminated environmental surfaces. HCP
might include but are not limited to emergency medical service personnel, dental personnel, laboratory personnel,
autopsy personnel, nurses, nursing assistants, physicians,
technicians, therapists, pharmacists, students and trainees,
contractual staff not employed by the healthcare facility, and
persons not directly involved in patient care but potentially
exposed to blood and body fluids (eg, clerical, dietary, housekeeping, security, maintenance, and volunteer personnel).
The same principles of exposure management could be applied to other workers with potential for occupational exposure to blood and body fluids in other settings.
An exposure that might place HCP at risk for HIV infection
is defined as a percutaneous injury (eg, a needlestick or cut
with a sharp object) or contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or af-
877
flicted with dermatitis) with blood, tissue, or other body fluids
that are potentially infectious. In addition to blood and visibly
bloody body fluids, semen and vaginal secretions are also considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of
HIV, they have not been implicated in occupational transmission from patients to HCP. The following fluids are also considered potentially infectious: cerebrospinal fluid, synovial
fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk for transmission of HIV infection from
these fluids is unknown; the potential risk to HCP from occupational exposures has not been assessed by epidemiologic
studies in healthcare settings. Feces, nasal secretions, saliva,
sputum, sweat, tears, urine, and vomitus are not considered
potentially infectious unless they are visibly bloody.11
Any direct contact (ie, contact without barrier protection)
to concentrated virus in a research laboratory or production
facility requires clinical evaluation. For human bites, clinical
evaluation must include the possibility that both the person
bitten and the person who inflicted the bite were exposed to
bloodborne pathogens. Transmission of HIV infection by this
route has been reported rarely, but not after an occupational
exposure.15-20
risk for occupational
transmission of hiv
Factors associated with risk for occupational transmission of
HIV have been described; risks vary with the type and severity
of exposure.4,5,11 In prospective studies of HCP, the average
risk for HIV transmission after a percutaneous exposure to
HIV-infected blood has been estimated to be approximately
0.3% (95% confidence interval [CI], 0.2%–0.5%)11 and that
after a mucous membrane exposure to be approximately
0.09% (95% CI, 0.006%–0.5%).21 Although episodes of HIV
transmission after nonintact skin exposure have been documented, the average risk for transmission by this route has
not been precisely quantified but is estimated to be less than
the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIVinfected blood also has not been quantified but is probably
considerably lower than that for blood exposures.
Epidemiologic and laboratory studies suggest that multiple
factors might affect the risk of HIV transmission after an
occupational exposure.22 In a retrospective case-control study
of HCP who had percutaneous exposure to HIV, increased
risk for HIV infection was associated with exposure to a larger
quantity of blood from the source person as indicated by (1)
a device (eg, a needle) visibly contaminated with the patient’s
blood, (2) a procedure that involved a needle being placed
directly in a vein or artery, or (3) a deep injury. The risk also
was increased for exposure to blood from source persons with
terminal illness, likely reflecting the higher titer of HIV in
blood late in the course of acquired immunodeficiency syndrome (AIDS). Taken together, these factors suggest a direct
inoculum effect (ie, the larger the viral inoculum, the higher
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
878
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
the risk for infection). One laboratory study that demonstrated that more blood is transferred by deeper injuries and
hollow-bore needles lends further credence to the observed
variation in risk related to inoculum size.23
Exposure to a source patient with an undetectable serum
viral load does not eliminate the possibility of HIV transmission or the need for PEP and follow-up testing. While
the risk of transmission from an occupational exposure to a
source patient with an undetectable serum viral load is
thought to be very low, PEP should still be offered. Plasma
viral load (eg, HIV RNA) reflects only the level of cell-free
virus in the peripheral blood; persistence of HIV in latently
infected cells, despite patient treatment with antiretroviral
drugs, has been demonstrated,24,25 and such cells might transmit infection even in the absence of viremia. HIV transmission from exposure to a source person who had an undetectable viral load has been described in cases of sexual and
mother-to-child transmissions.26,27
antiretroviral agents for pep
Antiretroviral agents from 6 classes of drugs are currently
available to treat HIV infection.28 These include the nucleoside and nucleotide reverse-transcriptase inhibitors (NRTIs),
nonnucleoside reverse-transcriptase inhibitors (NNRTIs),
protease inhibitors (PIs), a fusion inhibitor (FI), an integrase
strand transfer inhibitor (INSTI), and a chemokine (C-C
motif) receptor 5 (CCR5) antagonist. Only antiretroviral
agents approved by the FDA for treatment of HIV infection
are included in these guidelines, although none of these agents
has an FDA-approved indication for administration as PEP.
The rationale for offering antiretroviral medications as HIV
PEP is based on our current understanding of the pathogenesis of HIV infection and the plausibility of pharmacologic
intervention in this process, studies of the efficacy of antiretroviral chemoprophylaxis in animal models,29,30 and epidemiologic data from HIV-exposed HCP.22,31 The recommendations in this report provide guidance for PEP regimens
comprised of 3 (or, when appropriate, more) antiretrovirals,
consonant with currently recommended treatment guidelines
for HIV-infected individuals.28
toxicity and drug interactions
of antiretroviral agents
Persons receiving PEP should complete a full 4-week regimen.5 However, previous results show that a substantial proportion of HCP taking an earlier generation of antiretroviral
agents as PEP frequently reported side effects,12,32-40 and many
were unable to complete a full 4-week course of HIV PEP
due to these effects and toxicities.32-37 Because all antiretroviral
agents have been associated with side effects (Appendix B),28
the toxicity profile of these agents, including the frequency,
severity, duration, and reversibility of side effects, is a critical
consideration in selection of an HIV PEP regimen. The majority of data concerning adverse events has been reported
primarily for persons with established HIV infection receiving
prolonged antiretroviral therapy and therefore might not reflect the experience of uninfected persons who take PEP. In
fact, anecdotal evidence from clinicians knowledgeable about
HIV treatment indicates that antiretroviral agents are tolerated more poorly by HCP taking HIV PEP than by HIVinfected patients on antiretroviral medications. As side effects
have been cited as a major reason for not completing PEP
regimens as prescribed, the selection of regimens should be
heavily influenced toward those that are best tolerated by
HCP receiving PEP. Potential side effects of antiretroviral
agents should be discussed with the PEP recipient, and, when
anticipated, preemptive prescribing of agents for ameliorating
side effects (eg, antiemetics and antispasmodics) may improve
PEP regimen adherence.
In addition, the majority of approved antiretroviral agents
might have potentially serious drug interactions when used
with certain other drugs, thereby requiring careful evaluation
of concomitant medications, including over-the-counter medications and supplements (eg, herbals), used by an exposed
person before prescribing PEP and close monitoring for toxicity
of anyone receiving these drugs.28 PIs and NNRTIs have the
greatest potential for interactions with other drugs. Information regarding potential drug interactions has been published,
and up-to-date information can be found in the Guidelines for
the Use of Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents.28 Additional information is included in manufacturers’ package inserts. Consultation with a pharmacist or physician who is an expert in HIV PEP and antiretroviral medication drug interactions is strongly encouraged.
selection of hiv pep regimens
Guidelines for treating HIV infection, a condition typically
involving a high total body burden of HIV, recommend the
use of 3 or more drugs. Although the applicability of these
recommendations to PEP is unknown, newer antiretroviral
agents are better tolerated and have preferable toxicity profiles
than agents previously used for PEP.28 As less toxic and bettertolerated medications for the treatment of HIV infection are
now available, minimizing the risk of PEP noncompletion,
and the optimal number of medications needed for HIV PEP
remains unknown, the PHS working group recommends prescribing 3 (or more) tolerable drugs as PEP for all occupational exposures to HIV. Medications included in an HIV
PEP regimen should be selected to optimize side effect and
toxicity profiles and a convenient dosing schedule to encourage HCP completion of the PEP regimen.
resistance to antiretroviral agents
Known or suspected resistance of the source virus to antiretroviral agents, particularly to 1 or more of those that might
be included in a PEP regimen, raises concerns about reduced
PEP efficacy.41 Drug resistance to all available antiretroviral
agents has been reported, and cross-resistance within drug
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
classes occurs frequently.42 Occupational transmission of
drug-resistant HIV strains, despite PEP with combination
drug regimens, has been reported.43-45 If a source patient is
known to harbor drug-resistant HIV, expert consultation is
recommended for selection of an optimal PEP regimen. However, awaiting expert consultation should not delay the initiation of HIV PEP. In instances of an occupational exposure
to drug-resistant HIV, administration of antiretroviral agents
to which the source patient’s virus is unlikely to be resistant
is recommended for PEP.
Information on whether a source patient harbors drugresistant HIV may be unclear or unavailable at the time of
an occupational exposure. Resistance should be suspected in
a source patient who experiences clinical progression of disease, a persistently increasing viral load, or a decline in CD4!
T cell count despite therapy and in instances in which a
virologic response to therapy fails to occur. However, resistance testing of the source virus at the time of an exposure
is impractical because the results will not be available in time
to influence the choice of the initial PEP regimen. If source
patient HIV drug resistance is suspected in the management
of an occupational exposure to HIV, consultation with an
expert in HIV management is recommended so that antiretroviral agents to which the source patient’s virus is unlikely
to be resistant may be identified and prescribed. However,
awaiting expert consultation should, again, not delay initiation of HIV PEP. If drug resistance information becomes
available later in a course of PEP, this information should be
discussed with the expert consultant for possible modification
of the PEP regimen.
antiretroviral drugs during
pregnancy and lactation
The decision to offer HIV PEP to a pregnant or breast-feeding
healthcare provider should be based on the same considerations that apply to any provider who sustains an occupational exposure to HIV. The risk of HIV transmission poses
a threat not only to the mother but also to the fetus and
infant, as the risk of mother-to-child HIV transmission is
markedly increased during acute HIV infection during pregnancy and breast-feeding.46 However, unique considerations
are associated with the administration of antiretroviral agents
to pregnant HCP, and the decision to use antiretroviral drugs
during pregnancy should involve both counseling and discussion between the pregnant woman and her healthcare provider(s) regarding the potential risks and benefits of PEP for
both the healthcare provider and her fetus.
The potential risks associated with antiretroviral drug exposure for pregnant women, fetuses, and infants depend on
the duration of exposure as well as the number and type of
drugs. Information about the use of newer antiretroviral
agents, administered as PEP to HIV-uninfected pregnant
women, is limited. For reasons including the complexities
associated with appropriate counseling about the risks and
879
benefits of PEP as well as the selection of antiretroviral drugs
in pregnant women, expert consultation should be sought in
all cases in which antiretroviral medications are prescribed
to pregnant HCP for PEP.
In general, antiretroviral drug toxicity has not been shown
to be increased during pregnancy. Conflicting data have been
published concerning the risk of preterm delivery in pregnant
women receiving antiretroviral drugs, particularly PIs;47 in
studies that have reported a positive association, the increase
in risk was primarily observed in women who were receiving
antiretroviral drug regimens at the time of conception and
continued during pregnancy. Fatal48 and nonfatal49 lactic
acidosis has been reported in pregnant women treated
throughout gestation with a combination of stavudine and
didanosine. Prescribing this drug combination for PEP is not
recommended. Physiologic changes that occur during pregnancy may alter antiretroviral drug metabolism and, therefore, optimal drug dosing. The clinical significance of these
changes is not clear, particularly when used for PEP in HIVuninfected women. For details on antiretroviral drug choice
and dosing in pregnancy, see Recommendations for Use of
Antiretroviral Drugs in Pregnant HIV-1-Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV
Transmission in the United States.10
Prospective data from the Antiretroviral Pregnancy Registry do not demonstrate an increase in overall birth defects
associated with first-trimester antiretroviral drug use. In this
population, the birth defect prevalence is 2.9 per 100 live
births, similar to the prevalence in the general population in
the CDC’s birth defect surveillance system (ie, 2.7 per 100
live births).50 Central nervous system defects were observed
in fetal primates that experienced in utero efavirenz (EFV)
exposure and that had drug levels similar to those representing human therapeutic exposure; however, the relevance
of in vitro laboratory and animal data to humans is unknown.10 While human data are reassuring,51 1 case of meningomyelocele has been reported among the Antiretroviral
Pregnancy Registry prospective cases, and data are insufficient
to conclude that there is no increase in a rare outcome, such
as neural tube defect, with first-trimester EFV exposure.50 For
these reasons, we recommend that pregnant women not use
EFV during the first trimester.10 If EFV-based PEP is used in
women, a pregnancy test should be done to rule out early
pregnancy, and nonpregnant women who are receiving EFVbased PEP should be counseled to avoid pregnancy until after
PEP is completed. HCP who care for women who receive
antiretroviral drugs during pregnancy are strongly advised to
report instances of prenatal exposure to the Antiretroviral
Pregnancy Registry (http://www.APRegistry.com/). The currently available literature contains only limited data describing the long-term effects (eg, neoplasia and mitochondrial
toxicity) of in utero antiretroviral drug exposure. For this
reason, long-term follow-up is recommended for all children
who experience in utero exposures.10,52,53
Antiretroviral drug levels in breast milk vary among drugs,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
880
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
with administration of some drugs resulting in high levels (eg,
lamivudine), while other drugs, such as PIs and tenofovir
(TDF), are associated with only limited penetration into
milk.54,55 Administration of antiretroviral triple-drug regimens
to breast-feeding HIV-infected women has been shown to decrease the risk of transmission to their infants and infant toxicity has been minimal. Prolonged maternal antiretroviral drug
use during breast-feeding may be associated with increased
infant hematologic toxicity,56,57 but limited drug exposure during 4 weeks of PEP may also limit the risk of drug toxicity to
the breast-feeding infant. Breast-feeding should not be a contraindication to use of PEP when needed, given the high risk
of mother-to-infant transmission with acute HIV infection
during breast-feeding.46 The lactating healthcare provider
should be counseled regarding the high risk of HIV transmission through breast milk should acute HIV infection occur (in
a study in Zimbabwe, the risk of breast milk HIV transmission
during the 3 months after seroconversion was 77.6 infections
per 100 child-years).58 To completely eliminate any risk of HIV
transmission to her infant, the provider may want to consider
stopping breast-feeding. Ultimately, lactating women with occupational exposures to HIV who will take antiretroviral medications as PEP must be counseled to weigh the risks and
benefits of continued breast-feeding both while taking PEP and
while being monitored for HIV seroconversion.
management of occupational
exposure by emergency physicians
Many HCP exposures to HIV occur outside of occupational
health clinic hours of operation and at sites at which occupational health services are unavailable, and initial exposure
management is often overseen by emergency physicians or
other providers who are not experts in the treatment of HIV
infection or the use of antiretroviral medications. These providers may not be familiar with either the PHS guidelines for
the management of occupational exposures to HIV or the
available antiretroviral agents and their relative risks and benefits. Previous focus groups conducted among emergency department physicians who had managed occupational exposures to blood and body fluids in 200259 identified 3 challenges
in occupational exposure management: evaluation of an unknown source patient or a source patient who refused testing,
inexperience in managing occupational HIV exposures, and
counseling of exposed workers in busy emergency departments. For these reasons, the PHS working group recommends that institutions develop clear protocols for the management of occupational exposures to HIV, indicating a
formal expert consultation mechanism (eg, the in-house infectious diseases consultant or PEPline), appropriate initial
source patient and exposed provider laboratory testing, procedures for counseling the exposed provider, identifying and
having an initial HIV PEP regimen available, and a mechanism for outpatient HCP follow-up. In addition, these pro-
tocols must be distributed appropriately and must be readily
available (eg, posted on signs in the emergency department,
posted on a website, or disseminated to staff on pocket-sized
cards) to emergency physicians and any other providers who
may be called on to manage these exposure incidents.
recommendations for the
management of hcp potentially
exposed to hiv
Exposure prevention remains the primary strategy for reducing occupational bloodborne pathogen infections. However, when occupational exposures do occur, PEP remains an
important element of exposure management.
HIV PEP
The recommendations provided in this report apply to situations in which a healthcare provider has been exposed to
a source person who has HIV infection or for whom there
is reasonable suspicion of HIV infection. These recommendations reflect expert opinion and are based on limited data
regarding safety, tolerability, efficacy, and toxicity of PEP. If
PEP is offered and taken and the source is later determined
to be HIV negative, PEP should be discontinued, and no
further HIV follow-up testing is indicated for the exposed
provider. Because the great majority of occupational HIV
exposures do not result in transmission of HIV, the potential
benefits and risks of PEP (including the potential for severe
toxicity and drug interactions, such as may occur with oral
contraceptives, H2-receptor antagonists, and proton pump
inhibitors, among many other agents) must be considered
carefully when prescribing PEP. HIV PEP medication regimen
recommendations are listed in Appendix A, and more detailed
information on individual antiretroviral medications is provided in Appendix B. Because of the complexity of selecting
HIV PEP regimens, these recommendations should, whenever
possible, be implemented in consultation with persons who
have expertise in the administration of antiretroviral therapy
and who are knowledgeable about HIV transmission. Reevaluation of exposed HCP is recommended within 72 hours
after exposure, especially as additional information about the
exposure or source person becomes available.
Source Patient HIV Testing
Whenever possible, the HIV status of the exposure source
patient should be determined to guide appropriate use of
HIV PEP. Although concerns have been expressed about HIVnegative sources who might be in the so-called window period
before seroconversion (ie, the period of time between initial
HIV infection and the development of detectable HIV antibodies), no such instances of occupational transmission have
been detected in the United States to date. Hence, investigation of whether a source patient might be in the window
period is unnecessary for determining whether HIV PEP is
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
indicated unless acute retroviral syndrome is clinically suspected. Rapid HIV testing of source patients facilitates timely
decision making regarding the need for administration of HIV
PEP after occupational exposures to sources whose HIV status
is unknown. FDA-approved rapid tests can produce HIV test
results within 30 minutes, with sensitivities and specificities
similar to those of first- and second-generation enzyme immunoassays (EIAs).60 Third-generation chemiluminescent
immunoassays, run on automated platforms, can detect HIVspecific antibodies 2 weeks sooner than conventional EIAs60
and generate test results in an hour or less.61 Fourth-generation combination p24 antigen–HIV antibody (Ag/Ab) tests
produce both rapid and accurate results, and their p24 antigen
detection allows identification of most infections during the
window period.62 Rapid determination of source patient HIV
status provides essential information about the need to initiate and/or continue PEP. Regardless of which type of HIV
testing is employed, all of the above tests are acceptable for
determination of source patient HIV status. Administration
of PEP should not be delayed while waiting for test results.
If the source patient is determined to be HIV negative, PEP
should be discontinued, and no follow-up HIV testing for
the exposed provider is indicated.
Timing and Duration of PEP
Animal studies have suggested that PEP is most effective when
begun as soon as possible after the exposure and that PEP
becomes less effective as time from the exposure increases.29,30
PEP should be initiated as soon as possible, preferably within
hours of exposure. Occupational exposures to HIV should be
considered urgent medical concerns and treated immediately.
For example, a surgeon who sustains an occupational exposure
to HIV while performing a surgical procedure should promptly
scrub out of the surgical case, if possible, and seek immediate
medical evaluation for the injury and PEP. Additionally, if the
HIV status of a source patient for whom the practitioner has
a reasonable suspicion of HIV infection is unknown and the
practitioner anticipates that hours or days may be required to
resolve this issue, antiretroviral medications should be started
immediately rather than delayed.
Although animal studies demonstrate that PEP is likely to
be less effective when started more than 72 hours after exposure,30,63 the interval after which no benefit is gained from
PEP for humans is undefined. If initiation of PEP is delayed,
the likelihood increases that benefits might not outweigh the
risks inherent in taking antiretroviral medications. Initiating
therapy after a longer interval (eg, 1 week) might still be considered for exposures that represent an extremely high risk of
transmission. The optimal duration of PEP is unknown; however, duration of treatment has been shown to influence success
of PEP in animal models.30 Because 4 weeks of PEP appeared
protective in in vitro, animal,29,30,63,64 and occupational22 studies,
PEP should be administered for 4 weeks, if tolerated.
881
Recommendations for the Selection of Drugs for HIV PEP
The PHS no longer recommends that the severity of exposure
be used to determine the number of drugs to be offered in an
HIV PEP regimen, and a regimen containing 3 (or more)
antiretroviral drugs is now recommended routinely for all occupational exposures to HIV. Examples of recommended PEP
regimens include those consisting of a dual NRTI backbone
plus an INSTI, a PI (boosted with ritonavir), or a NNRTI.
Other antiretroviral drug combinations may be indicated for
specific cases (eg, exposure to a source patient harboring drugresistant HIV) but should be prescribed only after consultation
with an expert in the use of antiretroviral agents. No new
definitive data exist to demonstrate increased efficacy of 3-drug
HIV PEP regimens compared with the previously recommended 2-drug HIV PEP regimens for occupational HIV exposures associated with a lower level of transmission risk. The
recommendation for consistent use of 3-drug HIV PEP regimens reflects (1) studies demonstrating superior effectiveness
of 3 drugs in reducing viral burden in HIV-infected persons
compared with 2 agents,28,65,66 (2) concerns about source patient
drug resistance to agents commonly used for PEP,67,68 (3) the
safety and tolerability of new HIV drugs, and (4) the potential
for improved PEP regimen adherence due to newer medications that are likely to have fewer side effects. Clinicians facing
challenges such as antiretroviral medication availability, potential adherence and toxicity issues, and others associated with
a 3-drug PEP regimen might still consider a 2-drug PEP regimen in consultation with an expert.
The drug regimen selected for HIV PEP should have a
favorable side effect profile as well as a convenient dosing
schedule to facilitate both adherence to the regimen and completion of 4 weeks of PEP. Because the agents administered
for PEP still can be associated with severe side effects, PEP
is not justified for exposures that pose a negligible risk for
transmission. Expert consultation could be helpful in determining whether an exposure constitutes a risk that would
warrant PEP. The preferred HIV PEP regimen recommended
in this guideline should be reevaluated and modified whenever additional information is obtained concerning the source
of the occupational exposure (eg, possible treatment history
or antiretroviral drug resistance) or if expert consultants recommend the modification. Given the complexity of choosing
and administering HIV PEP, consultation with an infectious
diseases specialist or another physician who is an expert in
the administration of antiretroviral agents is recommended
whenever possible. Such consultation should not, however,
delay timely initiation of PEP.
The PHS now recommends emtricitabine (FTC) plus TDF
(these 2 agents may be dispensed as Truvada, a fixed-dose
combination tablet) plus raltegravir (RAL) as HIV PEP for
occupational exposures to HIV. This regimen is tolerable,
potent, and conveniently administered, and it has been associated with minimal drug interactions. Additionally, al-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
882
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
Box 1: Situations for Which Expert Consultation for Human Immunodeficiency Virus (HIV)
Postexposure Prophylaxis (PEP) Is Recommended
Delayed (ie, later than 72 hours) exposure report
• Interval after which benefits from PEP are undefined
Unknown source (eg, needle in sharps disposal container or laundry)
• Use of PEP to be decided on a case-by-case basis
• Consider severity of exposure and epidemiologic likelihood of HIV exposure
• Do not test needles or other sharp instruments for HIV
Known or suspected pregnancy in the exposed person
• Provision of PEP should not be delayed while awaiting expert consultation
Breast-feeding in the exposed person
• Provision of PEP should not be delayed while awaiting expert consultation
Known or suspected resistance of the source virus to antiretroviral agents
• If source person’s virus is known or suspected to be resistant to 1 or more of the drugs considered for PEP, selection of drugs to which the source
person’s virus is unlikely to be resistant is recommended
• Do not delay initiation of PEP while awaiting any results of resistance testing of the source person’s virus
Toxicity of the initial PEP regimen
• Symptoms (eg, gastrointestinal symptoms and others) are often manageable without changing PEP regimen by prescribing antimotility or antiemetic
agents
• Counseling and support for management of side effects is very important, as symptoms are often exacerbated by anxiety
Serious medical illness in the exposed person
• Significant underlying illness (eg, renal disease) or an exposed provider already taking multiple medications may increase the risk of drug toxicity
and drug-drug interactions
Expert consultation can be made with local experts or by calling the National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) at 888-448-4911.
though we have only limited data on the safety of RAL during
pregnancy, this regimen could be administered to pregnant
HCP as PEP (see the discussion above). Preparation of this
PEP regimen in single-dose “starter packets,” which are kept
on hand at sites expected to manage occupational exposures
to HIV, may facilitate timely initiation of PEP.
Several drugs may be used as alternatives to FTC plus TDF
plus RAL. TDF has been associated with renal toxicity,69 and
an alternative should be sought for HCP who have underlying
renal disease. Zidovudine could be used as an alternative to
TDF and could be conveniently prescribed in combination with
lamivudine, to replace both TDF and FTC, as Combivir. Alternatives to RAL include darunavir plus ritonavir (RTV), etravirine, rilpivirine, atazanavir plus RTV, and lopinivir plus RTV.
When a more cost-efficient alternative to RAL is required,
saquinivir plus RTV could be considered. A list of preferred
alternative PEP regimens is provided in Appendix A.
Some antiretroviral drugs are contraindicated as HIV PEP
or should be used for PEP only under the guidance of expert
consultants (Appendixes A and B). Among these drugs are
nevirapine, which should not be used and is contraindicated
as PEP because of serious reported toxicities, including hepatotoxicity (with 1 instance of fulminant liver failure requiring
liver transplantation), rhabdomyolysis, and hypersensitivity
syndrome.70-72 Antiretroviral drugs not routinely recommended for use as PEP because of the higher risk for potentially serious or life-threatening adverse events include di-
danosine and tipranavir. The combination of didanosine and
stavudine should not be prescribed as PEP due to increased
risk of toxicity (eg, peripheral neuropathy, pancreatitis, and
lactic acidosis). Additionally, abacavir should be used as HIV
PEP only in the setting of expert consultation, due to the
need for prior HLA B57-01 testing to identify individuals at
higher risk for a potentially fatal hypersensitivity reaction.28
The FI enfuvirtide (Fuzeon, T20) is also not generally recommended as PEP, unless its use is deemed necessary during
expert consultation, due to its subcutaneous route of administration, significant side effects, and potential for development of anti-T20 antibodies that may cause false-positive
HIV antibody tests among uninfected patients.
When the source patient’s virus is known or suspected to
be resistant to 1 or more of the drugs considered for the PEP
regimen, the selection of drugs to which the source person’s
virus is unlikely to be resistant is recommended; again, expert
consultation is strongly advised. If this information is not
immediately available, the initiation of PEP, if indicated,
should not be delayed; the regimen can be modified after
PEP has been initiated whenever such modifications are
deemed appropriate. For HCP who initiate PEP, reevaluation
of the exposed person should occur within 72 hours after
exposure, especially if additional information about the exposure or source person becomes available.
Regular consultation with experts in antiretroviral therapy
and HIV transmission is strongly recommended. Preferably,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
883
Box 2: Follow-Up of Healthcare Personnel (HCP) Exposed to Known or Suspected
Human Immunodeficiency Virus (HIV)–Positive Sources
Counseling (at the time of exposure and at follow-up appointments). Exposed HCP should be advised to use precautions (eg, use of barrier
contraception and avoidance of blood or tissue donations, pregnancy, and, if possible, breast-feeding) to prevent secondary transmission, especially
during the first 6–12 weeks after exposure.
For exposures for which postexposure prophylaxis (PEP) is prescribed, HCP should be informed regarding the following:
• Possible drug toxicities (eg, rash and hypersensitivity reactions that could imitate acute HIV seroconversion and the need for monitoring)
• Possible drug interactions
• The need for adherence to PEP regimens
Early reevaluation after exposure. Regardless of whether a healthcare provider is taking PEP, reevaluation of exposed HCP within 72 hours after
exposure is strongly recommended, as additional information about the exposure or source person may be available.
Follow-up testing and appointments. Follow-up testing at a minimum should include the following:
• HIV testing at baseline and at 6 weeks, 12 weeks, and 6 months after exposure; alternatively, if the clinician is certain that a fourth-generation
combination HIV p24 antigen–HIV antibody test is being utilized, then HIV testing could be performed at baseline, 6 weeks after exposure, and 4
months after exposure
• Complete blood counts and renal and hepatic function tests (at baseline and 2 weeks after exposure; further testing may be indicated if abnormalities
are detected)
HIV testing results should preferably be given to the exposed healthcare provider at face-to-face appointments.
a process for involvement of an expert consultant should be
formalized in advance of an exposure incident. Certain institutions have required consultation with a hospital epidemiologist or infectious diseases consultant when HIV PEP
use is under consideration. At a minimum, expert consultation is recommended for the situations described in Box 1.
Resources for consultation are available from the following
sources:
• PEPline at http://www.nccc.ucsf.edu/about_nccc/pepline/;
telephone: 888-448-4911.
• Antiretroviral Pregnancy Registry at http://www
.apregistry.com/index.htm; address: Research Park, 1011
Ashes Drive, Wilmington, NC 28405; telephone: 800-2584263; fax: 800-800-1052; e-mail: [email protected].
• FDA (for reporting unusual or severe toxicity to antiretroviral
agents) at http://www.fda.gov/medwatch/; telephone: 800332-1088; address: MedWatch, The FDA Safety Information
and Adverse Event Reporting Program, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20852.
• The CDC’s Cases of Public Health Importance (COPHI)
coordinator (for reporting HIV infections in HCP and failures of PEP) at telephone number 404-639-2050.
• HIV/AIDS Treatment Information Service at http://
aidsinfo.nih.gov/.
follow-up of exposed hcp
Importance of Follow-Up Appointments
HCP who have experienced occupational exposure to HIV
should receive follow-up counseling, postexposure testing,
and medical evaluation regardless of whether they take PEP.
Greater emphasis is placed on the importance of follow-up
of HCP on HIV PEP within 72 hours of exposure and im-
proving follow-up care provided to exposed HCP (Box 2).
Careful attention to follow-up evaluation within 72 hours of
exposure can (1) provide another (and perhaps less anxietyridden) opportunity to allow the exposed HCP to ask questions and for the counselor to make certain that the exposed
HCP has a clear understanding of the risks for infection and
the risks and benefits of PEP, (2) ensure that continued treatment with PEP is indicated, (3) increase adherence to HIV
PEP regimens, (4) manage associated symptoms and side effects more effectively, (5) provide an early opportunity for
ancillary medications or regimen changes, (6) improve detection of serious adverse effects, and (7) improve the likelihood of follow-up serologic testing for a larger proportion
of exposed personnel to detect infection. Closer follow-up
should in turn reassure HCP who become anxious after these
events.73,74 The psychological impact of needlesticks or exposure to blood or body fluid should not be underestimated
for HCP. Exposed personnel should be advised to use precautions (eg, use of barrier contraception and avoidance of
blood or tissue donations, pregnancy, and, if possible, breastfeeding) to prevent secondary transmission, especially during
the first 6–12 weeks after exposure. Providing HCP with psychological counseling should be an essential component of
the management and care of exposed HCP.
Postexposure Testing
HIV testing should be used to monitor HCP for seroconversion after occupational HIV exposure. After baseline testing at the time of exposure, follow-up testing should be performed at 6 weeks, 12 weeks, and 6 months after exposure.
Use of fourth-generation HIV Ag/Ab combination immunoassays allow for earlier detection of HIV infection.60,62,75 If
a provider is certain that a fourth-generation combination
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
884
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
HIV Ag/Ab test is used, HIV follow-up testing could be concluded earlier than 6 months after exposure. In this instance,
an alternative follow-up testing schedule could be used (eg,
testing at baseline and 6 weeks after exposure, then concluding testing at 4 months after exposure). Extended HIV followup (eg, for 12 months) is recommended for HCP who become
infected with HCV after exposure to a source who is coinfected with HIV and HCV. Whether extended follow-up is
indicated in other circumstances (eg, for exposure to a source
coinfected with HIV and HCV in the absence of HCV seroconversion or for exposed persons with a medical history
suggesting an impaired ability to mount an antibody response
to acute infection) is unknown. Although rare instances of
delayed HIV seroconversion have been reported,76,77 adding
to an exposed person’s anxiety by routinely extending the
duration of postexposure follow-up is not warranted. However, decisions to extend follow-up in a particular situation
should be based on the clinical judgment of the exposed
person’s healthcare provider and should not be precluded
because of HCP anxiety. HIV tests should also be performed
for any exposed person who has an illness compatible with
an acute retroviral syndrome, regardless of the interval since
exposure. A person in whom HIV infection is identified
should be referred to a specialist who has expertise in HIV
treatment and counseling for medical management. Healthcare providers caring for persons who have occupationally
acquired HIV infection should report these cases to their state
health departments and to the CDC’s COPHI coordinator at
telephone number 404-639-2050.
Monitoring and Management of PEP Toxicity
If PEP is used, HCP should be monitored for drug toxicity
by testing at baseline and again 2 weeks after starting PEP.
In addition, HCP taking antiretrovirals should be evaluated
if any acute symptoms develop while receiving therapy. The
scope of testing should be based on medical conditions in
the exposed person and the known and anticipated toxicities
of the drugs included in the PEP regimen. Minimally, laboratory monitoring for toxicity should include a complete
blood count and renal and hepatic function tests. If toxicities
are identified, modification of the regimen should be considered after expert consultation. In addition, depending on
the clinical situation, further diagnostic studies may be indicated (eg, monitoring for hyperglycemia in a diabetic whose
regimen includes a PI).
Exposed HCP who choose to take PEP should be advised
of the importance of completing the prescribed regimen. Information should be provided about potential drug interactions and prescription/nonprescription drugs and nutritional supplements that should not be taken with PEP or
require dose or administration adjustments, side effects of
prescribed drugs, measures (including pharmacologic interventions) that may assist in minimizing side effects, and
methods of clinical monitoring for toxicity during the follow-
up period. HCP should be advised that evaluation of certain
symptoms (eg, rash, fever, back or abdominal pain, pain on
urination or blood in the urine, dark urine, yellowing of the
skin or whites of the eyes, or symptoms of hyperglycemia
[eg, increased thirst or frequent urination]) should not be
delayed. Serious adverse events should be reported to the
FDA’s MedWatch program.
reevaluation and updating
of hiv pep guidelines
As new antiretroviral agents for treatment of HIV infection
and additional information concerning early HIV infection
and prevention of HIV transmission become available, the
interagency PHS working group will assess the need to update
these guidelines. Updates will be published periodically as
appropriate.
expert panel consultants
Judith Aberg, MD, FIDSA, FACP, New York University; Joseph Eron, MD, University of North Carolina, Chapel Hill;
Ronald Goldschmidt, MD, University of California, San Francisco; Mark Russi, MD, MPH, Yale University; Michael S.
Saag, MD, University of Alabama, Birmingham; and Michael
L. Tapper, MD, Lennox Hill Hospital.
acknowledgments
We thank Lynne M. Mofenson, MD (National Institutes of Health), for
providing expert assistance with drafting the section of the guideline titled
“Antiretroviral Drugs during Pregnancy and Lactation” as well as S. Michele
Owen, PhD (Centers for Disease Control and Prevention [CDC]), and Bernard M. Branson, MD (CDC), for providing expert assistance with drafting
the sections titled “Source Patient HIV Testing” and “Postexposure Testing.”
We also acknowledge contributions from John T. Brooks, MD (CDC), Kenneth Dominguez, MD, MPH (CDC), and David Kim, MD (CDC).
Potential conflicts of interest. The expert panel consultants report the following competing interests: J.A. has a board membership with and has received
funding from Bristol-Myers Squibb, Janssen, Merck, and ViiV; J.E. has consulted
for Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Janssen, Merck, and ViiV
and has received grant funding from Bristol-Myers Squibb, GlaxoSmithKline,
Merck, and ViiV; M.S.S. has consulted for Bristol-Myers Squibb, Gilead, Janssen,
Merck, and ViiV and has received grant funding from Bristol-Myers Squibb,
Gilead, Merck, and ViiV; M.L.T. owns Merck stock. All other authors report
no conflicts of interest relevant to this article.
Address correspondence to David T. Kuhar, MD, Division of Healthcare
Quality Promotion, National Center for Emerging and Zoonotic Infectious
Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road,
NE, MS A-31, Atlanta, GA 30333 ([email protected]).
The material in this report originated in the Division of Healthcare Quality
Promotion (Denise M. Cardo, MD, director), National Center for Emerging
and Zoonotic Infectious Diseases (Beth Bell, MD, director).
Information included in these recommendations might not represent US
Food and Drug Administration (FDA) approval or approved labeling for the
particular product or indications in question. Specifically, the terms “safe”
and “effective” might not be synonymous with the FDA-defined legal standard for product approval.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
885
appendix a
table a1. Human Immunodeficiency Virus (HIV) Postexposure Prophylaxis (PEP) Regimens
Preferred HIV PEP Regimen
Raltegravir (Isentress; RAL) 400 mg PO twice daily
Plus
Truvada, 1 PO once daily
(Tenofovir DF [Viread; TDF] 300 mg ! emtricitabine [Emtriva; FTC] 200 mg)
Alternative Regimens
(May combine 1 drug or drug pair from the left column with 1 pair of nucleoside/nucleotide reverse-transcriptase
inhibitors from the right column; prescribers unfamiliar with these agents/regimens should
consult physicians familiar with the agents and their toxicities) a,b
Tenofovir DF (Viread; TDF) ! emtricitabine (Emtriva; FTC);
Raltegravir (Isentress; RAL)
available as Truvada
Darunavir (Prezista; DRV) ! ritonavir (Norvir; RTV)
Tenofovir DF (Viread; TDF) ! lamivudine (Epivir; 3TC)
Etravirine (Intelence; ETR)
Zidovudine (Retrovir; ZDV; AZT) ! lamivudine (Epivir; 3TC);
Rilpivirine (Edurant; RPV)
available as Combivir
Atazanavir (Reyataz; ATV) ! ritonavir (Norvir; RTV)
Zidovudine (Retrovir; ZDV; AZT) ! emtricitabine (Emtriva; FTC)
Lopinavir/ritonavir (Kaletra; LPV/RTV)
The following alternative is a complete fixed-dose combination regimen, and no additional
antiretrovirals are needed: Stribild (elvitegravir, cobicistat, tenofovir DF, emtricitabine)
Alternative Antiretroviral Agents for Use as PEP Only with Expert Consultationb
Abacavir (Ziagen; ABC)
Efavirenz (Sustiva; EFV)
Enfuvirtide (Fuzeon; T20)
Fosamprenavir (Lexiva; FOSAPV)
Maraviroc (Selzentry; MVC)
Saquinavir (Invirase; SQV)
Stavudine (Zerit; d4T)
Antiretroviral Agents Generally Not Recommended for Use as PEP
Didanosine (Videx EC; ddI)
Nelfinavir (Viracept; NFV)
Tipranavir (Aptivus; TPV)
Antiretroviral Agents Contraindicated as PEP
Nevirapine (Viramune; NVP)
note. For consultation or assistance with HIV PEP, contact the National Clinicians’ Post-Exposure Prophylaxis Hotline at telephone
number 888-448-4911 or visit its website at http://www.nccc.ucsf.edu/about_nccc/pepline/. DF, disoproxil fumarate; PO, per os.
a
The alternatives regimens are listed in order of preference; however, other alternatives may be reasonable based on patient and clinician
preference.
b
For drug dosing information, see Appendix B.
appendix b
table b1. Information on Human Immunodeficiency Virus (HIV) Postexposure Prophylaxis (PEP) Medications
Drug name
Abacavir
(Ziagen; ABC)
Drug class
Dosing (dosage form)
Nucleoside reversetranscriptase inhibitor (NRTI)
ABC: 300 mg daily; available as
300-mg tablet
Also available as component of
fixed-dose combination Epzicom, dosed daily (300 mg of
3TC ! 600 mg of ABC)
Trizivir, dosed twice daily (150
mg of 3TC ! 300 mg of ABC !
300 mg of AZT)
Advantages
Take without regard for
food
Disadvantages
Potential for life-threatening ABC
hypersensitivity reaction (rash, fever, nausea, vomiting, diarrhea,
abdominal pain, malaise, respiratory symptoms) in patients with
HLA-B*5701; requires patient testing prior to use, which may not
be available or practical prior to
initiating PEP
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
886
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
table b1 (Continued)
Drug name
Drug class
Dosing (dosage form)
Atazanavir
(Reyataz; ATV)
Protease inhibitor (PI)
ATV: 300 mg ! RTV: 100 mg
once daily (preferred dosing
for PEPa)
ATV: 400 mg once daily without
RTV (alternative dosing—may
not be used in combination
with TDF)
Available as 100-, 150-, 200-, and
300-mg capsules
Well tolerated
Darunavir
(Prezista; DRV)
PI
Well tolerated
Efavirenz
(Sustiva; EFV)
Nonnucleoside reverse-transcriptase
inhibitor (NNRTI)
DRV: 800 mg once daily ! RTV:
100 mg once daily (preferred
dosing for PEPa)
DRV: 600 mg twice daily ! RTV:
100 mg twice daily (alternative
dosing)
Available as 75-, 150-, 400-, and
600-mg tablets
EFV: 600 mg daily; available as
50- and 200-mg capsules and
600-mg tablets
Also available as component of
fixed-dose combination
Atripla, dosed daily (200 mg of
FTC ! 300 mg of TDF ! 600
mg of EFV)
Elvitegravir (EVG)
Integrase strand transfer inhibitor
(INSTI)
Available as a component of
fixed-dose combination Stribild, dosed daily (150 mg of
EVG ! 150 mg of cobicistat !
300 mg of TDF ! 200 mg of
FTC)
Advantages
Available as a complete regimen dosed once per day
Well tolerated
Available as a complete regimen dosed once per day
Disadvantages
Indirect hyperbilirubinemia and
jaundice common
Rash
Nephrolithiasis
Potential for serious or life-threatening drug interactions that may affect dosing
Absorption depends on low pH; caution when coadministered with H2
antagonists, antacids, and proton
pump inhibitors
PR interval prolongation
Caution in patients with underlying
conduction defects or on concomitant medications that can cause
PR prolongation
Must be given with food
Rash (DRV has sulfonamide moiety)
Diarrhea, nausea, headache
Hepatotoxicity
Potential for serious or life-threatening drug interactions that may affect dosing
Must be given with food and with
RTV
Rash
Neuropsychiatric side effects (eg, dizziness, somnolence, insomnia, abnormal dreaming) common; severe psychiatric symptoms possible
(dosing before bedtime might
minimize these side effects); use
with caution in shift workers
Do not use during pregnancy; teratogen in nonhuman primates
Potential for serious or life-threatening drug interactions that may affect dosing
May cause false-positive results with
some cannabinoid and benzodiazepine screening assays
Take on an empty stomach
Diarrhea, nausea, headache
Nephrotoxicity; should not be administered to individuals with
acute or chronic kidney injury or
those with eGFR !70
Cobicistat is a pharmacokinetic enhancer to increase EVG exposures
and has no antiviral activity but is
a potent CYP3A inhibitor
Potential for serious or life-threatening drug interactions
Must be given with food
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
887
table b1 (Continued)
Drug name
Drug class
Emtricitabine
(Emtriva; FTC)
NRTI
Enfuvirtide
(Fuzeon; T20)
Fusion inhibitor (FI)
Etravirine
(Intelence; ETR)
Dosing (dosage form)
Advantages
200 mg once daily; available as
200-mg capsule
Also available as component of
fixed-dose combination
Atripla, dosed daily (200 mg of
FTC ! 300 mg of TDF ! 600
mg of EFV)
Complera, dosed daily (25 mg of
RPV ! 300 mg of TDF ! 200
mg of FTC)
Stribild, dosed daily (150 mg of
EVG ! 150 mg of cobicistat !
300 mg of TDF ! 200 mg of
FTC)
Truvada, dosed daily (200 mg of
FTC ! 300 mg of TDF)
T20: 90 mg (1 mL) twice daily
by subcutaneous injection;
available as single-dose vial,
reconstituted to 90 mg/mL
Well tolerated
Minimal toxicity
Minimal drug interactions
Take without regard for
food
NNRTI
200 mg twice daily; available as
100- and 200-mg tablets
Well tolerated and has not
had the same frequency
of CNS side effects reported as EFV
Fosamprenavir
(Lexiva; FOSAPV)
PI
FOSAPV: 1,400 mg daily ! RTV:
100 mg once daily (preferred
dosing for PEP)
FOSAPV: 1,400 mg twice daily
without RTV (alternative
dosing)
Available as 700-mg tablet
Well tolerated
Lamivudine
(Epivir; 3TC)
NRTI
3TC: 300 mg once daily (preferred dosing for PEP)
3TC: 150 mg twice daily (alternative dosing)
Available as 150- and 300-mg
tablets
Also available as component of
fixed-dose combination generic
lamivudine/zidovudine, dosed
twice daily (150 mg of 3TC !
300 mg of AZT)
Combivir, dosed twice daily (150
mg of 3TC ! 300 mg of AZT)
Epzicom, dosed daily (300 mg of
3TC ! 600 mg of ABC)
Trizivir, dosed twice daily (150
mg of 3TC ! 300 mg of ABC !
300 mg of AZT)
Well tolerated
Minimal toxicity
Minimal drug interactions
Take without regard for
food
...
Disadvantages
Rash perhaps more frequent than
with 3TC
Hyperpigmentation/skin
discoloration
If the PEP recipient has chronic hepatitis B, withdrawal of this drug
may cause an acute hepatitis
exacerbation
Local injection-site reactions occur in
almost 100% of patients
Never studied among antiretroviralnaive or HIV-negative patients
False-positive EIA HIV antibody tests
might result from formation of
anti-T20 antibodies that crossreact with anti-gp41 antibodies
Twice-daily injection
Rash (including SJS) and hypersensitivity (sometimes with organ dysfunction, including hepatic failure)
Nausea
Potential for serious or life-threatening drug interactions that may affect dosing
Must be given with food
Diarrhea, nausea, vomiting, headache, rash (FOSAPV has sulfonamide moiety)
Potential for serious or life-threatening drug interactions that may affect dosing
Oral contraceptives decrease
FOSAPV concentrations
Take with food if given with RTV
If the PEP recipient has chronic hepatitis B, withdrawal of this drug
may cause an acute hepatitis
exacerbation
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
888
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
table b1 (Continued)
Drug name
Drug class
Dosing (dosage form)
Advantages
Lopinavir/ritonavir
(Kaletra; LPV/RTV)
PI
Kaletra: 400/100 mg p 2 tablets
twice daily (preferred dosing
for PEP)
Kaletra: 800/200 mg p 4 tablets
once daily (alternative dosing)
Available as 200/50-mg tablets
Take without regard for
food
Maraviroc
(Selzentry; MVC)
CCR5 coreceptor
antagonist
MVC: 300 mg twice daily (if on
concomitant CYP3A inducers,
dose may need adjustment by
expert consultant); available as
150- and 300-mg tablets
Well tolerated
Raltegravir
(Isentress; RAL)
INSTI
400 mg twice daily; available as
400-mg tablet
Rilpivirine
(Edurant; RPV)
NNRTI
25 mg once daily; available as 25mg tablet
Also available as component of
fixed-dose combination Complera, dosed daily (25 mg of
RPV ! 300 mg of TDF ! 300
mg of FTC)
Well tolerated
Minimal drug interactions
Take without regard for
food
Well tolerated and fewer
rashes and discontinuations for CNS adverse effects compared with EFV
Available as a complete regimen dosed once per day
Saquinavir
(Invirase; SQV)
PI
SQV: 1,000 mg ! RTV: 100 mg
twice daily (preferred dosing
for PEP); available as 500 mg
tablet
Well tolerated, although GI
events common
Disadvantages
GI intolerance, nausea, vomiting, diarrhea are common
PR and QT interval prolongation
have been reported; use with caution in patients at risk of cardiac
conduction abnormalities or receiving other drugs with similar
effect
Potential for serious or life-threatening drug interactions that may affect dosing
Abdominal pain, cough, dizziness,
musculoskeletal symptoms, pyrexia, rash, orthostatic hypotension
Hepatotoxicity that may present with
an allergic reaction, including rash
Requires HIV tropism testing of
source virus before treatment to
ensure CCR5-tropic virus and efficacy, which may not be available
or practical prior to initiating PEP
Potential for serious or life-threatening drug interactions that may affect dosing
Dose adjustments for MVC required
when given with potent CYP3A
inhibitors or inducers
Insomnia, nausea, fatigue, headache,
and severe skin and hypersensitivity reactions have been reported
Depression, insomnia, rash, hypersensitivity, headache
Potential for serious or life-threatening drug interactions that may affect dosing
Caution when coadministered with
H2 antagonists and antacids
Coadministration with proton pump
inhibitors is contraindicated
Use RPV with caution when coadministered with a drug having a
known risk of torsades de pointes
Must be given with food
GI intolerance, nausea, diarrhea,
headache
Pretreatment ECG recommended
SQV/r is not recommended for patients with any of the following:
(1) congenital or acquired QT
prolongation, (2) pretreatment
ECG 1450 msec, (3) receiving
concomitant therapy with other
drugs that prolong QT interval,
(4) complete AV block without
implanted pacemakers, and (5)
risk of complete AV block
PR and QT interval prolongations,
torsades de pointes has been
reported
Potential for serious or life-threatening drug interactions that may affect dosing
Must be given with food
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
889
table b1 (Continued)
Drug name
Drug class
Stavudine
(Zerit; d4T)
NRTI
Tenofovir DF
(Viread; TDF)
NRTI
Zidovudine
(Retrovir;
ZDV; AZT)
NRTI
Dosing (dosage form)
Advantages
d4T: 40 mg twice daily if body
weight is 160 kg
d4T: 30 mg twice daily if body
weight is !60 kg
Available as 15-, 20-, 30-, and
40-mg tablets
300 mg once daily; available as
300-mg tablet
Also available as component of
fixed-dose combination
Atripla, dosed daily (200 mg of
FTC ! 300 mg of TDF ! 600
mg of EFV)
Complera, dosed daily (25 mg of
RPV ! 300 mg of TDF ! 200
mg of FTC)
Stribild, dosed daily (150 mg of
EVG ! 150 mg of cobicistat !
300 mg of TDF ! 200 mg of
FTC)
Truvada, dosed daily (200 mg of
FTC ! 300 mg of TDF)
AZT: 300 mg twice daily; available as 100-mg capsule or 300mg tablet
Also available as component of
fixed-dose combination generic
lamivudine/zidovudine, dosed
twice daily (150 mg of 3TC !
300 mg of AZT)
Combivir, dosed twice daily (150
mg of 3TC ! 300 mg of AZT)
Trizivir, dosed twice daily (150
mg of 3TC ! 300 mg of ABC !
300 mg of AZT)
Disadvantages
Take without regard for
food
GI side effects include diarrhea and
nausea
Hepatotoxicity, neurologic symptoms
(eg, peripheral neuropathy),
pancreatitis
Well tolerated
Take without regard for
food
Asthenia, headache, diarrhea, nausea,
vomiting
Nephrotoxicity; should not be administered to individuals with
acute or chronic kidney injury or
those with eGFR !60
If the PEP recipient has chronic hepatitis B, withdrawal of this drug
may cause an acute hepatitis
exacerbation
Drug interactions
Take without regard for
food
Side effects (especially nausea, vomiting, headache, insomnia, and fatigue) common and might result
in low adherence
Anemia and neutropenia
note. This appendix does not provide comprehensive information on each individual drug. For detailed information, please refer to individual drug
package inserts. AV, atrioventricular; CNS, central nervous system; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; EIA, enzyme immunoassay; GI, gastrointestinal; SJS, Stevens-Johnson syndrome.
a
Certain antiretroviral agents, such as PIs, have the option of once- or twice-daily dosing depending on treatment history and use with ritonavir. For PEP,
the selection of dosing and schedule is to optimize adherence while minimizing side effects where possible. This table includes the preferred dosing schedule
for each agent, and in all cases with the exception of Kaletra the once-daily regimen option is preferred for PEP. Twice-daily administration of Kaletra is
better tolerated with respect to GI toxicities compared with the once-daily regimen. Alternative dosing and schedules may be appropriate for PEP in certain
circumstances and should preferably be prescribed by individuals experienced in the use of antiretroviral medications.
references
1. Siegel JD, Rhinehart E, Jackson M, et al. 2007 Guideline for
isolation precautions: preventing transmission of infectious
agents in health care settings. Am J Infect Control 2007;35(10
suppl 2):S65–S164.
2. Centers for Disease Control and Prevention. Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR Recomm Rep 1990;
39(RR-1):1–14.
3. Centers for Disease Control and Prevention. Update: provisional
Public Health Service recommendations for chemoprophylaxis
after occupational exposure to HIV. MMWR Morb Mortal Wkly
Rep 1996;45(22):468–480.
4. Centers for Disease Control and Prevention. Public Health Service guidelines for the management of health-care worker ex-
posures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 1998;47(RR-7):1–33.
5. Centers for Disease Control and Prevention. Updated U.S. Public
Health Service guidelines for the management of occupational
exposures to HBV, HCV, and HIV and recommendations for
postexposure prophylaxis. MMWR Recomm Rep 2001;50(RR-11):
1–52.
6. Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; US
Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and
recommendations for postexposure prophylaxis. MMWR Recomm
Rep 2005;54(RR-9):1–17.
7. Advisory Committee on Immunization Practices, Centers for
Disease Control and Prevention. Immunization of health-care
personnel: recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep 2011;
60(RR-7):1–45.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
890
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
8. Smith DK, Grohskopf LA, Black RJ, et al; US Department of
Health and Human Services. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations
from the U.S. Department of Health and Human Services.
MMWR Recomm Rep 2005;54(RR-2):1–20.
9. Havens PL; American Academy of Pediatrics Committee on
Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics 2003;111(6 pt 1):1475–1489.
10. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of
Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. http://aidsinfo.nih.gov/contentfiles
/lvguidelines/PerinatalGL.pdf. Published 2012. Accessed August
23, 2012.
11. Bell DM. Occupational risk of human immunodeficiency virus
infection in healthcare workers: an overview. Am J Med 1997;
102(5B):9–15.
12. Centers for Disease Control and Prevention. The National Surveillance System for Healthcare Workers (NaSH): Summary Report
for Blood and Body Fluid Exposure Data Collected from Participating Healthcare Facilities (June 1995 through December 2007).
Washington, DC: US Department of Health and Human Services, 2011.
13. Division of Healthcare Quality Promotion, National Center for
Emerging and Zoonotic Infectious Diseases, Centers for Disease
Control and Prevention. Healthcare Infection Control Practices
Advisory Committee (HICPAC): Meeting Summary Report, November 3–4, 2011, Washington, DC. http://www.cdc.gov/maso
/FACM/pdfs/HICPAC/2011110304_HICPAC_MINUTES.pdf.
Washington, DC: US Department of Health and Human Services, 2011. Accessed March 2013.
14. Division of Healthcare Quality Promotion, National Center for
Emerging and Zoonotic Infectious Diseases, Centers for Disease
Control and Prevention. Healthcare Infection Control Practices
Advisory Committee (HICPAC): Meeting Summary Report, June
14–15, 2012, Atlanta, GA. http://www.cdc.gov/maso/FACM
/pdfs/HICPAC/2012061415_HICPAC_MINUTES.pdf. Washington, DC: Department of Health and Human Services, 2012.
Accessed March 2013.
15. Wahn V, Kramer HH, Voit T, Brüster HT, Scrampical B, Scheid
A. Horizontal transmission of HIV infection between two siblings. Lancet 1986;2(8508):694.
16. Transmission of HIV by human bite. Lancet 1987;2(8557):522.
17. Richman KM, Rickman LS. The potential for transmission of
human immunodeficiency virus through human bites. J Acquir
Immune Defic Syndr 1993;6(4):402–406.
18. Vidmar L, Poljak M, Tomazic J, Seme K, Klavs I. Transmission
of HIV-1 by human bite. Lancet 1996;347(9017):1762.
19. Deshpande AK, Jadhav SK, Bandivdekar AH. Possible transmission of HIV infection due to human bite. AIDS Res Ther
2011;8:16.
20. Andreo SM, Barra LA, Costa LJ, Sucupira MC, Souza IE, Diaz
RS. HIV type 1 transmission by human bite. AIDS Res Hum
Retroviruses 2004;20(4):349–350.
21. Ippolito G, Puro V, De Carli G; Italian Study Group on Occupational Risk of HIV infection. The risk of occupational human immunodeficiency virus infection in health care workers:
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Italian multicenter study. Arch Intern Med 1993;153(12):1451–
1458.
Cardo DM, Culver DH, Ciesielski CA, et al; Centers for Disease
Control and Prevention Needlestick Surveillance Group. A casecontrol study of HIV seroconversion in health care workers after
percutaneous exposure. N Engl J Med 1997;337(21):1485–1490.
Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in
reducing blood volumes transferred during simulated needlestick injury. J Infect Dis 1993;168(6):1589–1592.
Furtado MR, Callaway DS, Phair JP, et al. Persistence of HIV1 transcription in peripheral-blood mononuclear cells in patients receiving potent antiretroviral therapy. N Engl J Med 1999;
340(21):1614–1622.
Ibáñez A, Puig T, Elias J, Clotet B, Ruiz L, Martı́nez MA. Quantification of integrated and total HIV-1 DNA after long-term
highly active antiretroviral therapy in HIV-1-infected patients.
AIDS 1999;13(9):1045–1049.
Stürmer M, Doerr HW, Berger A, Gute P. Is transmission of
HIV-1 in non-viraemic serodiscordant couples possible? Antivir
Ther 2008;13(5):729–732.
Tubiana R, Le Chenadec J, Rouzioux C, et al. Factors associated
with mother-to-child transmission of HIV-1 despite a maternal
viral load !500 copies/ml at delivery: a case-control study nested
in the French perinatal cohort (EPF-ANRS CO1). Clin Infect
Dis 2010;50(4):585–596.
Panel on Antiretroviral Guidelines for Adults and Adolescents.
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents. http://aidsinfo.nih.gov/contentfiles
/lvguidelines/adultandadolescentgl.pdf. Published 2012. Accessed September 17, 2012.
Shih CC, Kaneshima H, Rabin L, et al. Postexposure prophylaxis
with zidovudine suppresses human immunodeficiency virus
type 1 infection in SCID-hu mice in a time-dependent manner.
J Infect Dis 1991;163(3):625–627.
Tsai CC, Emau P, Follis KE, et al. Effectiveness of postinoculation
(R)-9-(2-phosphonylmethoxypropyl)adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration
of treatment. J Virol 1998;72(5):4265–4273.
Henderson DK. Human immunodeficiency virus in health care
settings. In: GL Mandell, JE Bennett, R Dolin, eds. Principles
and Practice of Infectious Diseases. New York: Elsevier, 2009:
3753–3770.
Wang SA, Panlilio AL, Doi PA, White AD, Stek M Jr, Saah A.
Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV
Postexposure Prophylaxis Registry. Infect Control Hosp Epidemiol
2000;21(12):780–785.
Swotinsky RB, Steger KA, Sulis C, Snyder S, Craven DE. Occupational exposure to HIV: experience at a tertiary care center.
J Occup Environ Med 1998;40(12):1102–1109.
Parkin JM, Murphy M, Anderson J, El-Gadi S, Forster G, Pinching AJ. Tolerability and side-effects of post-exposure prophylaxis
for HIV infection. Lancet 2000;355(9205):722–723.
Puro V. Post-exposure prophylaxis for HIV infection: Italian
Registry of Post-Exposure Prophylaxis. Lancet 2000;355(9214):
1556–1557.
Lee LM, Henderson DK. Tolerability of postexposure antiretroviral prophylaxis for occupational exposures to HIV. Drug Saf
2001;24(8):587–597.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
phs guidelines for occupational exposures to hiv
37. Russi M, Buitrago M, Goulet J, et al. Antiretroviral prophylaxis
of health care workers at two urban medical centers. J Occup
Environ Med 2000;42(11):1092–1100.
38. Garb JR. One-year study of occupational human immunodeficiency virus postexposure prophylaxis. J Occup Environ Med
2002;44(3):265–270.
39. Grime PR, Ris L, Binns C, Carruthers JR, Williams S. PanThames survey of occupational exposure to HIV and the use
of post-exposure prophylaxis in 71 NHS trusts. J Infect 2001;
42(1):27–32.
40. Puro V, DeCarli G, Soldani F, et al. Adverse drug reactions
associated with PEP. Presented at: 10th Conference on Retroviruses and Opportunistic Infections, 2003, Boston. Poster 711.
41. Beltrami EM, Cheingsong R, Heneine WM, et al; Occupational
HIV Exposure Study Group. Antiretroviral drug resistance in
human immunodeficiency virus–infected source patients for occupational exposures to healthcare workers. Infect Control Hosp
Epidemiol 2003;24(10):724–730.
42. Johnson VA, Calvez V, Günthard HF, et al. 2011 Update of the
drug resistance mutations in HIV-1. Top Antivir Med 2011;19(4):
156–164.
43. Hawkins DA, Asboe D, Barlow K, Evans B. Seroconversion to
HIV-1 following a needlestick injury despite combination postexposure prophylaxis. J Infect 2001;43(1):12–15.
44. Beltrami EM, Luo CC, de la Torre N, Cardo DM. Transmission
of drug-resistant HIV after an occupational exposure despite
postexposure prophylaxis with a combination drug regimen.
Infect Control Hosp Epidemiol 2002;23(6):345–348.
45. Perdue B, Wolfe Rufael D, Mellors J, Quinn T, Margolick J.
HIV-1 transmission by a needle-stick injury despite rapid initiation of four-drug postexposure prophylaxis. Presented at: 6th
Conference on Retroviruses and Opportunistic Infections, 1999,
Chicago.
46. Lockman S, Creek T. Acute maternal HIV infection during pregnancy and breast-feeding: substantial risk to infants. J Infect Dis
2009;200(5):667–669.
47. Kourtis AP. Antiretroviral drug use during pregnancy and risk
of premature delivery: is there a connection? J Infect Dis 2010;
201(7):978–980.
48. Sarner L, Fakoya A. Acute onset lactic acidosis and pancreatitis
in the third trimester of pregnancy in HIV-1 positive women
taking antiretroviral medication. Sex Transm Infect 2002;78(1):
58–59.
49. Mandelbrot L, Kermarrec N, Marcollet A. Case report: nucleoside analogue–induced lactic acidosis in the third trimester of
pregnancy. AIDS 2003;17(2):272–273.
50. Antiretroviral Pregnancy Registry Steering Committee. Antiretroviral Pregnancy Registry International Interim Report for 1 January 1989 through 31 July 2011. Wilmington, NC: Registry Coordinating Center, 2011.
51. Ford N, Calmy A, Mofenson L. Safety of efavirenz in the first
trimester of pregnancy: an updated systematic review and metaanalysis. AIDS 2011;25(18):2301–2304.
52. Blanche S, Tardieu M, Benhammou V, Warszawski J, Rustin P.
Mitochondrial dysfunction following perinatal exposure to nucleoside analogues. AIDS 2006;20(13):1685–1690.
53. Thorne C, Newell ML. Safety of agents used to prevent motherto-child transmission of HIV: is there any cause for concern?
Drug Saf 2007;30(3):203–213.
54. Mirochnick M, Thomas T, Capparelli E, et al. Antiretroviral
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
891
concentrations in breast-feeding infants of mothers receiving
highly active antiretroviral therapy. Antimicrob Agents Chemother
2009;53(3):1170–1176.
Benaboud S, Pruvost A, Coffie PA, et al. Concentrations of
tenofovir and emtricitabine in breast milk of HIV-1-infected
women in Abidjan, Cote d’Ivoire, in the ANRS 12109 TEmAA
study, step 2. Antimicrob Agents Chemother 2011;55(3):1315–
1317.
Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens
in pregnancy and breast-feeding in Botswana. N Engl J Med
2010;362(24):2282–2294.
Dryden-Peterson S, Shapiro RL, Hughes MD, et al. Increased
risk of severe infant anemia after exposure to maternal HAART,
Botswana. J Acquir Immune Defic Syndr 2011;56(5):428–436.
Humphrey JH, Marinda E, Mutasa K, et al; ZVITAMBO Study
Group. Mother to child transmission of HIV among Zimbabwean women who seroconverted postnatally: prospective cohort
study. BMJ 2010;341:c6580.
Panlilio AL, Sinkowitz-Cochran R, Grady MA, Cardo DM, et
al. Barriers to and facilitators of implementing U.S. Public
Health Service (PHS) guidelines on occupational exposure management by emergency physicians. Presented at: 13th Annual
Meeting of the Society for Healthcare Epidemiology of America,
2003, Arlington, VA. Abstract 240.
Masciotra S, McDougal JS, Feldman J, Sprinkle P, Wesolowski
L, Owen SM. Evaluation of an alternative HIV diagnostic algorithm using specimens from seroconversion panels and persons with established HIV infections. J Clin Virol 2011;52(suppl
1):S17–S22.
Branson BM. The future of HIV testing. J Acquir Immune Defic
Syndr 2010;55(suppl 2):S102–S105.
Chavez P, Wesolowski L, Patel P, Delaney K, Owen SM. Evaluation of the performance of the Abbott ARCHITECT HIV
Ag/Ab combo assay. J Clin Virol 2011;52(suppl 1):S51–S55.
Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure
prophylaxis after intravaginal exposure of pig-tailed macaques
to a human-derived retrovirus (human immunodeficiency virus
type 2). J Virol 2000;74(20):9771–9775.
Tsai CC, Follis KE, Sabo A, et al. Prevention of SIV infection
in macaques by (R)-9-(2-phosphonylmethoxypropyl)adenine.
Science 1995;270(5239):1197–1199.
Gulick RM, Mellors JW, Havlir D, et al. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretroviral therapy.
N Engl J Med 1997;337(11):734–739.
Hirsch M, Steigbigel R, Staszewski S, et al. A randomized, controlled trial of indinavir, zidovudine, and lamivudine in adults
with advanced human immunodeficiency virus type 1 infection
and prior antiretroviral therapy. J Infect Dis 1999;180(3):659–
665.
Wheeler WH, Ziebell RA, Zabina H, et al; Variant, Atypical, and
Resistant HIV Surveillance Group. Prevalence of transmitted
drug resistance associated mutations and HIV-1 subtypes in new
HIV-1 diagnoses, U.S.—2006. AIDS 2010;24(8):1203–1212.
Kim D, Wheeler W, Ziebell R, et al. Prevalence of transmitted
antiretroviral drug resistance among newly-diagnosed HIV-1infected persons, US, 2007. Presented at: CROI 2010: 17th Conference on Retroviruses and Opportunistic Infections, 2010, San
Francisco.
Scherzer R, Estrella M, Li Y, et al. Association of tenofovir ex-
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
892
70.
71.
72.
73.
74.
infection control and hospital epidemiology
september 2013, vol. 34, no. 9
posure with kidney disease risk in HIV infection. AIDS 2012;
26(7):867–875.
Cattelan AM, Erne E, Salatino A, et al. Severe hepatic failure
related to nevirapine treatment. Clin Infect Dis 1999;29(2):455–
456.
Johnson S, Baraboutis JG. Adverse effects associated with use
of nevirapine in HIV postexposure prophylaxis for 2 health care
workers. JAMA 2000;284(21):2722–2723.
Centers for Disease Control and Prevention. Serious adverse
events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures—worldwide, 1997–2000. MMWR
Morb Mortal Wkly Rep 2001;49(51–52):1153–1156.
Armstrong K, Gorden R, Santorella G. Occupational exposure
of health care workers (HCWs) to human immunodeficiency
virus (HIV): stress reactions and counseling interventions. Soc
Work Health Care 1995;21(3):61–80.
Meienberg F, Bucher HC, Sponagel L, Zinkernagel C, Gyr N,
Battegay M. Anxiety in health care workers after exposure to
potentially HIV-contaminated blood or body fluids. Swiss Med
Wkly 2002;132(23–24):321–324.
75. Bentsen C, McLaughlin L, Mitchell E, et al. Performance evaluation of the Bio-Rad Laboratories GS HIV Combo Ag/Ab EIA,
a 4th generation HIV assay for the simultaneous detection of
HIV p24 antigen and antibodies to HIV-1 (groups M and O)
and HIV-2 in human serum or plasma. J Clin Virol 2011;
52(suppl 1):S57–S61.
76. Ridzon R, Gallagher K, Ciesielski C, et al. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus
from a needle-stick injury. N Engl J Med 1997;336(13):919–922.
77. Ciesielski CA, Metler RP. Duration of time between exposure
and seroconversion in healthcare workers with occupationally
acquired infection with human immunodeficiency virus. Am J
Med 1997;102(5B):115–116.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
infection control and hospital epidemiology
november 2013, vol. 34, no. 11
erratum
In the September 2013 issue of the journal, in the article by
Kuhar et al (Kuhar DT, Henderson DK, Struble KA, Heneine
W, Thomas V, Cheever LW, Gomaa A, Panlilio AL, US Public
Health Service Working Group. Updated US Public Health
Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34(9):875–892), there are 3 errors. In Appendix
Table B1, row 1 (“Abacavir”), column 3 (“Dosing (dosage
form)”), “300 mg daily” is incorrect; the correct dosing is
600 mg daily. Also in Appendix Table B1, row 17 (“Tenofovir
DF”), column 5 (“Disadvantages”), the text immediately following “Nephrotoxicity” (“should not be administered to individuals with acute or chronic kidney injury or those with
eGFR !60”) should be deleted. Finally, the correct affiliation
for author Ahmed Gomaa is Division of Surveillance, Hazard
Evaluation, and Field [not “Health”] Studies, National Institute for Occupational Safety and Health, Centers for Disease
Control and Prevention, Cincinnati, Ohio. The authors regret
these errors.
! 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3411-0023$15.00. DOI: 10.1086/673726
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[)
Bloodborne Pathogens Appendix G
U.S. Department of Labor
Occupational Safety & Health Administration
www.osha.gov
[skip navigational links]
Search
Advanced Search | A-Z Inde
Frequently Asked Questions
1. What is the Needlestick Safety and Prevention Act?
The Needlestick Safety and Prevention Act (the Act) (Pub. L. 106-430) was signed into law on November
6, 2000. Because occupational exposure to bloodborne pathogens from accidental sharps injuries in
healthcare and other occupational settings continues to be a serious problem, Congress felt that a
modification to OSHA's Bloodborne Pathogens Standard was appropriate (29 CFR 1910.1030) to set
forth in greater detail (and make more specific) OSHA's requirement for employers to identify, evaluate,
and implement safer medical devices. The Act also mandated additional requirements for maintaining a
sharps injury log and for the involvement of non-managerial healthcare workers in evaluating and
choosing devices.
2. How does the "Needlestick Act" apply to OSHA's Bloodborne Pathogens Standard?
The Act directed OSHA to revise its Bloodborne Pathogens Standard (29 CFR 1910.1030). OSHA
published the revised standard in the Federal Register on January 18, 2001; it took effect on April 18,
2001. The agency implemented a 90-day outreach and education effort for both OSHA staff and the
regulated public before beginning enforcement of the new requirements. Accordingly, OSHA will not
enforce the new provisions of the standard (requiring employers to maintain a sharps injury log and to
involve non-managerial employees in selecting safer needle devices) until July 17, 2001. (The
requirement to implement the use of engineering controls, which includes safer medical devices, has
been in effect since 1992).
3. How does the revision affect states that operate their own federally-approved occupational
safety and health programs?
States and territories that operate their own OSHA-approved state programs must adopt the revisions to
the bloodborne pathogens standard, or adopt a more stringent amendment to their existing standard, by
Oct. 18, 2001. (NOTE: The original adoption date for state plan states was July 18, 2001 (or six months
from the date the standard was published in the Federal Register). However, an additional three months
was added which coincides with the Federal 90-day education campaign).
4. Does the standard apply to public sector (State and local government) employees?
Federal OSHA standards do not apply to public sector employees, but the 24 states and two territories
that operate OSHA-approved state plans are required to enforce an "at least as effective" standard in
the public sector.
5. Does the "Needlestick Act" apply to me?
OSHA's Bloodborne Pathogens Standard, including its 2001 revisions, applies to all employers who have
employees with reasonably anticipated occupational exposure to blood or other potentially infectious
materials (OPIM). These employers must implement the applicable requirements set forth in the
standard. Some of the new and clarified provisions in the standard apply only to healthcare activities,
but some of the provisions, particularly the requirements to update the Exposure Control Plan and to
keep a sharps injury log, will apply to non-healthcare as well as healthcare activities.
6. By what date do we have to implement safer medical devices?
The requirement to implement safer medical devices is not new. However, the revised standard further
clarifies what is meant by "engineering controls" in the original 1991 Bloodborne Pathogens standard by
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[*
f
adding language to the definition section of the standard that reflects the development and availability o
new safer medical devices over the last decade. The 1991 standard states, "engineering and work
practice controls shall be used to eliminate or minimize employee exposure." The revision
defines Engineering Controls as "controls (e.g., sharps disposal containers, self-sheathing
needles, safer medical devices, such as sharps with engineered sharps injury protections and
needleless systems) that isolate or remove the bloodborne pathogens hazard from the
workplace." Consequently, you should already have safer devices in place. If you have not already
evaluated and implemented appropriate and available engineering controls, you must do so now. Also,
employees with occupational exposure to blood and OPIM must be trained regarding the proper use of
all engineering and work practice controls.
7. What if I've never had an employee experience a needlestick, do I still need to use safer
devices?
Yes. OSHA standards are intended to be implemented as a means to prevent occupational injuries and
illnesses. In order to most effectively avoid percutaneous injuries from contaminated sharps, employees
must use engineering controls, including safer medical devices.
8. How many non-managerial employees do I need to include in the process of choosing safer
medical devices?
Small medical offices may want to seek input from all employees when making their decisions. Larger
facilities are not required to request input from all exposed employees; however, the employees selected
should represent the range of exposure situations encountered in the workplace (e.g., pediatrics,
emergency department, etc.). The solicitation of employees who have been involved in the input and
evaluation process must be documented in the Exposure Control Plan.
9. Does OSHA have a list of available safer medical devices?
No. OSHA does not approve or endorse any product. It is your responsibility as an employer to
determine which engineering controls are appropriate for specific hazards, based on what is appropriate
to the specific medical procedures being conducted, what is feasible, and what is commercially available.
10. What if a safer option is not available for the medical device that I use?
A key element in choosing a safer medical device, other than its appropriateness to the procedure and
effectiveness, is its availability on the market. If there is no safer option for a particular medical device
used where there is exposure to blood or OPIM, you are not required to use something other than the
device that is normally used. During your annual review of devices, you must inquire about new or
prospective safer options and document this fact in your written Exposure Control Plan. With increasing
medical technology, more devices are becoming available for different procedures. If no engineering
control is available, work practice controls shall be used and, if occupational exposure still remains,
personal protective equipment must also be used.
11. What if the safer device that I choose is on back order?
Safety equipment must be available at all times. If for some reason an engineering control is not
available (due to supply shortages, back orders, shipping delays, etc.), this must be documented in your
Exposure Control Plan. You would then be responsible to implement the chosen control(s) as soon as it
becomes available and adjust your exposure control plan to illustrate such. In the meantime, work
practice controls must be used and, if occupational exposure still remains, personal protective
equipment must also be used.
12. Do I have to keep a sharps injury log? Does it have to be confidential?
If, as an employer, you are required to maintain a log of occupational injuries and illnesses under 29
CFR 1904, you must also establish and maintain a sharps injury log for recording percutaneous injuries
from contaminated sharps. The Sharps Log must contain, at a minimum, information about the injury,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[*
the type and brand of device involved in the injury (if known), the department or work area where the
exposure occurred, and an explanation of how the incident occurred. The log must be recorded and
maintained in such a manner so as to protect the confidentiality of the injured employee (e.g., removal
of personal identifiers).
13. Does the revised Bloodborne Pathogens Standard apply to medical or dental offices that have
fewer than 10 employees?
OSHA's Bloodborne Pathogens Standard applies to all employers with employees who have occupational
exposure to blood or other potentially infectious materials (OPIM), regardless of how many workers are
employed. However, workplaces with 10 or fewer employees are exempt from OSHA recordkeeping
requirements and are also exempt from recording and maintaining a Sharps Injury Log. (See 29 CFR
1904 for applicability of recordkeeping requirements). All other applicable provisions of the Bloodborne
Pathogens Standard still apply.
14. What new information do I need to include in my written Exposure Control Plan? How often to
I need to update it?
In addition to what is already required by the 1991 standard, the revised standard requires the
documentation of (1) annual consideration and implementation of appropriate engineering controls, and
(2) solicitation of non-managerial healthcare workers in evaluating and choosing devices. The plan must
be reviewed and updated at least annually.
15. Where can I get information about what is expected of me?
There are several resources available for employers and employees with regard to occupational
exposures to blood and OPIM. First, of course, is the OSHA Bloodborne Pathogens Standard (29 CFR
1910.1030). Also available are "CPL 2-2.69 (November 2001). Enforcement Procedures for the
Occupational Exposure to Bloodborne Pathogens, and many other related documents. You may
access this information, as well as information from OSHA's Consultation and State Plan State Offices,
via OSHA's website at http://www.osha.gov or by phone at 1-800-321-OSHA. The National Institute for
Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) also
have several documents related to the prevention of occupational exposure to blood and OPIM.
###
Back to Top
www.osha.gov
www
Contact Us | Freedom of Information Act | Customer Survey
Privacy and Security Statement | Disclaimers
Occupational Safety & Health Administration
200 Constitution Avenue, NW
Washington, DC 20210
Page
last updated:
08/0
Page last
updated:
08/05/2005
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[*
Bloodborne Pathogens Appendix H
U.S. Department of Labor
Occupational Safety & Health Administration
www.osha.gov
[skip navigational links]
Search
Advanced Sea
Regulations (Standards - 29 CFR)
Access to employee exposure and medical records. - 1910.1020
Regulations (Standards - 29 CFR) - Table of Contents
•
•
•
•
•
•
•
Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:
Appendix:
1910
Occupational Safety and Health Standards
Z
Toxic and Hazardous Substances
1910.1020
Access to employee exposure and medical records.
A, B
1910.1020(a)
"Purpose." The purpose of this section is to provide employees and their
designated representatives a right of access to relevant exposure and medical
records; and to provide representatives of the Assistant Secretary a right of
access to these records in order to fulfill responsibilities under the Occupational
Safety and Health Act. Access by employees, their representatives, and the
Assistant Secretary is necessary to yield both direct and indirect improvements
in the detection, treatment, and prevention of occupational disease. Each
employer is responsible for assuring compliance with this section, but the
activities involved in complying with the access to medical records provisions
can be carried out, on behalf of the employer, by the physician or other health
care personnel in charge of employee medical records. Except as expressly
provided, nothing in this section is intended to affect existing legal and ethical
obligations concerning the maintenance and confidentiality of employee medical
information, the duty to disclose information to a patient/employee or any other
aspect of the medical-care relationship, or affect existing legal obligations
concerning the protection of trade secret information.
1910.1020(b)
"Scope and application."
1910.1020(b)(1)
This section applies to each general industry, maritime, and construction
employer who makes, maintains, contracts for, or has access to employee
exposure or medical records, or analyses thereof, pertaining to employees
exposed to toxic substances or harmful physical agents.
1910.1020(b)(2)
This section applies to all employee exposure and medical records, and analyses
thereof, of such employees, whether or not the records are mandated by
specific occupational safety and health standards.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(b)(3)
This section applies to all employee exposure and medical records, and analyses
thereof, made or maintained in any manner, including on an in-house or
contractual (e.g., fee-for-service) basis. Each employer shall assure that the
preservation and access requirements of this section are complied with
regardless of the manner in which records are made or maintained.
1910.1020(c)
"Definitions."
1910.1020(c)(1)
"Access" means the right and opportunity to examine and copy.
1910.1020(c)(2)
"Analysis using exposure or medical records" means any compilation of data or
any statistical study based at least in part on information collected from
individual employee exposure or medical records or information collected from
health insurance claims records, provided that either the analysis has been
reported to the employer or no further work is currently being done by the
person responsible for preparing the analysis.
1910.1020(c)(3)
"Designated representative" means any individual or organization to whom an
employee gives written authorization to exercise a right of access. For the
purposes of access to employee exposure records and analyses using exposure
or medical records, a recognized or certified collective bargaining agent shall be
treated automatically as a designated representative without regard to written
employee authorization.
1910.1020(c)(4)
"Employee" means a current employee, a former employee, or an employee
being assigned or transferred to work where there will be exposure to toxic
substances or harmful physical agents. In the case of a deceased or legally
incapacitated employee, the employee's legal representative may directly
exercise all the employee's rights under this section.
1910.1020(c)(5)
"Employee exposure record" means a record containing any of the following
kinds of information:
1910.1020(c)(5)(i)
Environmental (workplace) monitoring or measuring of a toxic substance or
harmful physical agent, including personal, area, grab, wipe, or other form of
sampling, as well as related collection and analytical methodologies,
calculations, and other background data relevant to interpretation of the results
obtained;
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(c)(5)(ii)
Biological monitoring results which directly assess the absorption of a toxic
substance or harmful physical agent by body systems (e.g., the level of a
chemical in the blood, urine, breath, hair, fingernails, etc.) but not including
results which assess the biological effect of a substance or agent or which
assess an employee's use of alcohol or drugs;
1910.1020(c)(5)(iii)
Material safety data sheets indicating that the material may pose a hazard to
human health; or
1910.1020(c)(5)(iv)
In the absence of the above, a chemical inventory or any other record which
reveals where and when used and the identity (e.g., chemical, common, or
trade name) of a toxic substance or harmful physical agent.
1910.1020(c)(6) 1910.1020(c)(6)(i)
"Employee medical record" means a record concerning the health status of an
employee which is made or maintained by a physician, nurse, or other health
care personnel, or technician, including:
1910.1020(c)(6)(i)(A)
Medical and employment questionnaires or histories (including job description
and occupational exposures),
1910.1020(c)(6)(i)(B)
The results of medical examinations (pre-employment, pre-assignment,
periodic, or episodic) and laboratory tests (including chest and other X-ray
examinations taken for the purpose of establishing a base-line or detecting
occupational illnesses and all biological monitoring not defined as an "employee
exposure record"),
1910.1020(c)(6)(i)(C)
Medical opinions, diagnoses, progress notes, and recommendations,
1910.1020(c)(6)(i)(D)
First aid records,
1910.1020(c)(6)(i)(E)
Descriptions of treatments and prescriptions, and
1910.1020(c)(6)(i)(F)
Employee medical complaints.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(c)(6)(ii)
"Employee medical record" does not include medical information in the form of:
1910.1020(c)(6)(ii)(A)
Physical specimens (e.g., blood or urine samples) which are routinely discarded
as a part of normal medical practice, or
1910.1020(c)(6)(ii)(B)
Records concerning health insurance claims if maintained separately from the
employer's medical program and its records, and not accessible to the employer
by employee name or other direct personal identifier (e.g., social security
number, payroll number, etc.), or
1910.1020(c)(6)(ii)(C)
Records created solely in preparation for litigation which are privileged from
discovery under the applicable rules of procedure or evidence; or
1910.1020(c)(6)(ii)(D)
Records concerning voluntary employee assistance programs (alcohol, drug
abuse, or personal counseling programs) if maintained separately from the
employer's medical program and its records.
1910.1020(c)(7)
"Employer" means a current employer, a former employer, or a successor
employer.
1910.1020(c)(8)
"Exposure" or "exposed" means that an employee is subjected to a toxic
substance or harmful physical agent in the course of employment through any
route of entry (inhalation, ingestion, skin contact or absorption, etc.), and
includes past exposure and potential (e.g., accidental or possible) exposure, but
does not include situations where the employer can demonstrate that the toxic
substance or harmful physical agent is not used, handled, stored, generated, or
present in the workplace in any manner different from typical non-occupational
situations.
1910.1020(c)(9)
" Health Professional" means a physician, occupational health nurse, industrial
hygienist, toxicologist, or epidemiologist, providing medical or other
occupational health services to exposed employees.
1910.1020(c)(10)
"Record" means any item, collection, or grouping of information regardless of
the form or process by which it is maintained (e.g., paper document,
microfiche, microfilm, X-ray film, or automated data processing).
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(c)(11)
"Specific chemical identity" means a chemical name, Chemical Abstracts Service
(CAS) Registry Number, or any other information that reveals the precise
chemical designation of the substance.
1910.1020(c)(12) 1910.1020(c)(12)(i)
"Specific written consent" means a written authorization containing the
following:
1910.1020(c)(12)(i)(A)
The name and signature of the employee authorizing the release of medical
information,
1910.1020(c)(12)(i)(B)
The date of the written authorization,
1910.1020(c)(12)(i)(C)
The name of the individual or organization that is authorized to release the
medical information,
1910.1020(c)(12)(i)(D)
The name of the designated representative (individual or organization) that is
authorized to receive the released information,
1910.1020(c)(12)(i)(E)
A general description of the medical information that is authorized to be
released,
1910.1020(c)(12)(i)(F)
A general description of the purpose for the release of the medical information,
and
1910.1020(c)(12)(i)(G)
A date or condition upon which the written authorization will expire (if less than
one year).
1910.1020(c)(12)(ii)
A written authorization does not operate to authorize the release of medical
information not in existence on the date of written authorization, unless the
release of future information is expressly authorized, and does not operate for
more than one year from the date of written authorization.
1910.1020(c)(12)(iii)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
A written authorization may be revoked in writing prospectively at any time.
1910.1020(c)(13)
"Toxic substance or harmful physical agent" means any chemical substance,
biological agent (bacteria, virus, fungus, etc.), or physical stress (noise, heat,
cold, vibration, repetitive motion, ionizing and non-ionizing radiation, hypo - or
hyperbaric pressure, etc.) which:
1910.1020(c)(13)(i)
Is listed in the latest printed edition of the National Institute for Occupational
Safety and Health (NIOSH) Registry of Toxic Effects of Chemical Substances
(RTECS) which is incorporated by reference as specified in Sec. 1910.6; or
1910.1020(c)(13)(ii)
Has yielded positive evidence of an acute or chronic health hazard in testing
conducted by, or known to, the employer; or
1910.1020(c)(13)(iii)
Is the subject of a material safety data sheet kept by or known to the employer
indicating that the material may pose a hazard to human health.
1910.1020(c)(14)
"Trade secret" means any confidential formula, pattern, process, device, or
information or compilation of information that is used in an employer's business
and that gives the employer an opportunity to obtain an advantage over
competitors who do not know or use it.
1910.1020(d)
"Preservation of records."
1910.1020(d)(1)
Unless a specific occupational safety and health standard provides a different
period of time, each employer shall assure the preservation and retention of
records as follows:
1910.1020(d)(1)(i)
"Employee medical records." The medical record for each employee shall be
preserved and maintained for at least the duration of employment plus thirty
(30) years, except that the following types of records need not be retained for
any specified period:
1910.1020(d)(1)(i)(A)
Health insurance claims records maintained separately from the employer's
medical program and its records,
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(d)(1)(i)(B)
First aid records (not including medical histories) of one-time treatment and
subsequent observation of minor scratches, cuts, burns, splinters, and the like
which do not involve medical treatment, loss of consciousness, restriction of
work or motion, or transfer to another job, if made on-site by a non-physician
and if maintained separately from the employer's medical program and its
records, and
1910.1020(d)(1)(i)(C)
The medical records of employees who have worked for less than (1) year for
the employer need not be retained beyond the term of employment if they are
provided to the employee upon the termination of employment.
1910.1020(d)(1)(ii)
"Employee exposure records." Each employee exposure record shall be
preserved and maintained for at least thirty (30) years, except that:
1910.1020(d)(1)(ii)(A)
Background data to environmental (workplace) monitoring or measuring, such
as laboratory reports and worksheets, need only be retained for one (1) year so
long as the sampling results, the collection methodology (sampling plan), a
description of the analytical and mathematical methods used, and a summary of
other background data relevant to interpretation of the results obtained, are
retained for at least thirty (30) years; and
1910.1020(d)(1)(ii)(B)
Material safety data sheets and paragraph (c)(5)(iv) records concerning the
identity of a substance or agent need not be retained for any specified period as
long as some record of the identity (chemical name if known) of the substance
or agent, where it was used, and when it was used is retained for at least thirty
(30) years(1); and
__________
Footnote(1) Material safety data sheets must be kept for those chemicals
currently in use that are effected by the Hazard Communication Standard in
accordance with 29 CFR 1910.1200(g).
1910.1020(d)(1)(ii)(C)
Biological monitoring results designated as exposure records by specific
occupational safety and health standards shall be preserved and maintained as
required by the specific standard.
1910.1020(d)(1)(iii)
"Analyses using exposure or medical records." Each analysis using exposure or
medical records shall be preserved and maintained for at least thirty (30) years.
1910.1020(d)(2)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
Nothing in this section is intended to mandate the form, manner, or process by
which an employer preserves a record so long as the information contained in
the record is preserved and retrievable, except that chest X-ray films shall be
preserved in their original state.
1910.1020(e)
"Access to records" 1910.1020(e)(1)
"General."
1910.1020(e)(1)(i)
Whenever an employee or designated representative requests access to a
record, the employer shall assure that access is provided in a reasonable time,
place, and manner. If the employer cannot reasonably provide access to the
record within fifteen (15) working days, the employer shall within the fifteen
(15) working days apprise the employee or designated representative
requesting the record of the reason for the delay and the earliest date when the
record can be made available.
1910.1020(e)(1)(ii)
The employer may require of the requester only such information as should be
readily known to the requester and which may be necessary to locate or identify
the records being requested (e.g. dates and locations where the employee
worked during the time period in question).
1910.1020(e)(1)(iii)
Whenever an employee or designated representative requests a copy of a
record, the employer shall assure that either:
1910.1020(e)(1)(iii)(A)
A copy of the record is provided without cost to the employee or representative,
1910.1020(e)(1)(iii)(B)
The necessary mechanical copying facilities (e.g., photocopying) are made
available without cost to the employee or representative for copying the record,
or
1910.1020(e)(1)(iii)(C)
The record is loaned to the employee or representative for a reasonable time to
enable a copy to be made.
1910.1020(e)(1)(iv)
In the case of an original X-ray, the employer may restrict access to on-site
examination or make other suitable arrangements for the temporary loan of the
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
X-ray.
1910.1020(e)(1)(v)
Whenever a record has been previously provided without cost to an employee
or designated representative, the employer may charge reasonable, nondiscriminatory administrative costs (i.e., search and copying expenses but not
including overhead expenses) for a request by the employee or designated
representative for additional copies of the record, except that
1910.1020(e)(1)(v)(A)
An employer shall not charge for an initial request for a copy of new information
that has been added to a record which was previously provided; and
1910.1020(e)(1)(v)(B)
An employer shall not charge for an initial request by a recognized or certified
collective bargaining agent for a copy of an employee exposure record or an
analysis using exposure or medical records.
1910.1020(e)(1)(vi)
Nothing in this section is intended to preclude employees and collective
bargaining agents from collectively bargaining to obtain access to information in
addition to that available under this section.
1910.1020(e)(2)
"Employee and designated representative access" 1910.1020(e)(2)(i)
"Employee exposure records."
1910.1020(e)(2)(i)(A)
Except as limited by paragraph (f) of this section, each employer shall, upon
request, assure the access to each employee and designated representative to
employee exposure records relevant to the employee. For the purpose of this
section, an exposure record relevant to the employee consists of:
1910.1020(e)(2)(i)(A)(1)
A record which measures or monitors the amount of a toxic substance or
harmful physical agent to which the employee is or has been exposed;
1910.1020(e)(2)(i)(A)(2)
In the absence of such directly relevant records, such records of other
employees with past or present job duties or working conditions related to or
similar to those of the employee to the extent necessary to reasonably indicate
the amount and nature of the toxic substances or harmful physical agents to
which the employee is or has been subjected, and
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(e)(2)(i)(A)(3)
Exposure records to the extent necessary to reasonably indicate the amount
and nature of the toxic substances or harmful physical agents at workplaces or
under working conditions to which the employee is being assigned or
transferred.
1910.1020(e)(2)(i)(B)
Requests by designated representatives for unconsented access to employee
exposure records shall be in writing and shall specify with reasonable
particularity:
1910.1020(e)(2)(i)(B)(1)
The record requested to be disclosed; and
1910.1020(e)(2)(i)(B)(2)
The occupational health need for gaining access to these records.
1910.1020(e)(2)(ii)
"Employee medical records."
1910.1020(e)(2)(ii)(A)
Each employer shall, upon request, assure the access of each employee to
employee medical records of which the employee is the subject, except as
provided in paragraph (e)(2)(ii)(D) of this section.
1910.1020(e)(2)(ii)(B)
Each employer shall, upon request, assure the access of each designated
representative to the employee medical records of any employee who has given
the designated representative specific written consent. Appendix A to this
section contains a sample form which may be used to establish specific written
consent for access to employee medical records.
1910.1020(e)(2)(ii)(C)
Whenever access to employee medical records is requested, a physician
representing the employer may recommend that the employee or designated
representative:
1910.1020(e)(2)(ii)(C)(1)
Consult with the physician for the purposes of reviewing and discussing the
records requested,
1910.1020(e)(2)(ii)(C)(2)
Accept a summary of material facts and opinions in lieu of the records
requested, or
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(e)(2)(ii)(C)(3)
Accept release of the requested records only to a physician or other designated
representative.
1910.1020(e)(2)(ii)(D)
Whenever an employee requests access to his or her employee medical records,
and a physician representing the employer believes that direct employee access
to information contained in the records regarding a specific diagnosis of a
terminal illness or a psychiatric condition could be detrimental to the
employee's health, the employer may inform the employee that access will only
be provided to a designated representative of the employee having specific
written consent, and deny the employee's request for direct access to this
information only. Where a designated representative with specific written
consent requests access to information so withheld, the employer shall assure
the access of the designated representative to this information, even when it is
known that the designated representative will give the information to the
employee.
1910.1020(e)(2)(ii)(E)
A physician, nurse, or other responsible health care personnel maintaining
employee medical records may delete from requested medical records the
identity of a family member, personal friend, or fellow employee who has
provided confidential information concerning an employee's health status.
1910.1020(e)(2)(iii)
Analyses using exposure or medical records.
1910.1020(e)(2)(iii)(A)
Each employer shall, upon request, assure the access of each employee and
designated representative to each analysis using exposure or medical records
concerning the employee's working conditions or workplace.
1910.1020(e)(2)(iii)(B)
Whenever access is requested to an analysis which reports the contents of
employee medical records by either direct identifier (name, address, social
security number, payroll number, etc.) or by information which could
reasonably be used under the circumstances indirectly to identify specific
employees (exact age, height, weight, race, sex, date of initial employment, job
title, etc.), the employer shall assure that personal identifiers are removed
before access is provided. If the employer can demonstrate that removal of
personal identifiers from an analysis is not feasible, access to the personally
identifiable portions of the analysis need not be provided.
1910.1020(e)(3)
"OSHA access."
1910.1020(e)(3)(i)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
Each employer shall, upon request, and without derogation of any rights under
the Constitution or the Occupational Safety and Health Act of 1970, 29 U.S.C.
651 "et seq.," that the employer chooses to exercise, assure the prompt access
of representatives of the Assistant Secretary of Labor for Occupational Safety
and Health to employee exposure and medical records and to analyses using
exposure or medical records. Rules of agency practice and procedure governing
OSHA access to employee medical records are contained in 29 CFR 1913.10.
1910.1020(e)(3)(ii)
Whenever OSHA seeks access to personally identifiable employee medical
information by presenting to the employer a written access order pursuant to
29 CFR 1913.10(d), the employer shall prominently post a copy of the written
access order and its accompanying cover letter for at least fifteen (15) working
days.
1910.1020(f)
"Trade secrets."
1910.1020(f)(1)
Except as provided in paragraph (f)(2) of this section, nothing in this section
precludes an employer from deleting from records requested by a health
professional, employee, or designated representative any trade secret data
which discloses manufacturing processes, or discloses the percentage of a
chemical substance in mixture, as long as the health professional, employee, or
designated representative is notified that information has been deleted.
Whenever deletion of trade secret information substantially impairs evaluation
of the place where or the time when exposure to a toxic substance or harmful
physical agent occurred, the employer shall provide alternative information
which is sufficient to permit the requesting party to identify where and when
exposure occurred.
1910.1020(f)(2)
The employer may withhold the specific chemical identity, including the
chemical name and other specific identification of a toxic substance from a
disclosable record provided that:
1910.1020(f)(2)(i)
The claim that the information withheld is a trade secret can be supported;
1910.1020(f)(2)(ii)
All other available information on the properties and effects of the toxic
substance is disclosed;
1910.1020(f)(2)(iii)
The employer informs the requesting party that the specific chemical identity is
being withheld as a trade secret; and
1910.1020(f)(2)(iv)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
The specific chemical identity is made available to health professionals,
employees and designated representatives in accordance with the specific
applicable provisions of this paragraph.
1910.1020(f)(3)
Where a treating physician or nurse determines that a medical emergency
exists and the specific chemical identity of a toxic substance is necessary for
emergency or first-aid treatment, the employer shall immediately disclose the
specific chemical identity of a trade secret chemical to the treating physician or
nurse, regardless of the existence of a written statement of need or a
confidentiality agreement. The employer may require a written statement of
need and confidentiality agreement, in accordance with the provisions of
paragraphs (f)(4) and (f)(5), as soon as circumstances permit.
1910.1020(f)(4)
In non-emergency situations, an employer shall, upon request, disclose a
specific chemical identity, otherwise permitted to be withheld under paragraph
(f)(2) of this section, to a health professional, employee, or designated
representative if:
1910.1020(f)(4)(i)
The request is in writing;
1910.1020(f)(4)(ii)
The request describes with reasonable detail one or more of the following
occupational health needs for the information:
1910.1020(f)(4)(ii)(A)
To assess the hazards of the chemicals to which employees will be exposed;
1910.1020(f)(4)(ii)(B)
To conduct or assess sampling of the workplace atmosphere to determine
employee exposure levels;
1910.1020(f)(4)(ii)(C)
To conduct pre-assignment or periodic medical surveillance of exposed
employees;
1910.1020(f)(4)(ii)(D)
To provide medical treatment to exposed employees;
1910.1020(f)(4)(ii)(E)
To select or assess appropriate personal protective equipment for exposed
employees;
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(f)(4)(ii)(F)
To design or assess engineering controls or other protective measures for
exposed employees; and
1910.1020(f)(4)(ii)(G)
To conduct studies to determine the health effects of exposure.
1910.1020(f)(4)(iii)
The request explains in detail why the disclosure of the specific chemical
identity is essential and that, in lieu thereof, the disclosure of the following
information would not enable the health professional, employee or designated
representative to provide the occupational health services described in
paragraph (f)(4)(ii) of this section;
1910.1020(f)(4)(iii)(A)
The properties and effects of the chemical;
1910.1020(f)(4)(iii)(B)
Measures for controlling workers' exposure to the chemical;
1910.1020(f)(4)(iii)(C)
Methods of monitoring and analyzing worker exposure to the chemical; and
1910.1020(f)(4)(iii)(D)
Methods of diagnosing and treating harmful exposures to the chemical;
1910.1020(f)(4)(iv)
The request includes a description of the procedures to be used to maintain the
confidentiality of the disclosed information; and
1910.1020(f)(4)(v)
The health professional, employee, or designated representative and the
employer or contractor of the services of the health professional or designated
representative agree in a written confidentiality agreement that the health
professional, employee or designated representative will not use the trade
secret information for any purpose other than the health need(s) asserted and
agree not to release the information under any circumstances other than to
OSHA, as provided in paragraph (f)(7) of this section, except as authorized by
the terms of the agreement or by the employer.
1910.1020(f)(5)
The confidentiality agreement authorized by paragraph (f)(4)(iv) of this section:
1910.1020(f)(5)(i)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
May restrict the use of the information to the health purposes indicated in the
written statement of need;
1910.1020(f)(5)(ii)
May provide for appropriate legal remedies in the event of a breach of the
agreement, including stipulation of a reasonable pre-estimate of likely
damages; and,
1910.1020(f)(5)(iii)
May not include requirements for the posting of a penalty bond.
1910.1020(f)(6)
Nothing in this section is meant to preclude the parties from pursuing noncontractual remedies to the extent permitted by law.
1910.1020(f)(7)
If the health professional, employee or designated representative receiving the
trade secret information decides that there is a need to disclose it to OSHA, the
employer who provided the information shall be informed by the health
professional prior to, or at the same time as, such disclosure.
1910.1020(f)(8)
If the employer denies a written request for disclosure of a specific chemical
identity, the denial must:
1910.1020(f)(8)(i)
Be provided to the health professional, employee or designated representative
within thirty days of the request;
1910.1020(f)(8)(ii)
Be in writing;
1910.1020(f)(8)(iii)
Include evidence to support the claim that the specific chemical identity is a
trade secret;
1910.1020(f)(8)(iv)
State the specific reasons why the request is being denied; and,
1910.1020(f)(8)(v)
Explain in detail how alternative information may satisfy the specific medical or
occupational health need without revealing the specific chemical identity.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
1910.1020(f)(9)
The health professional, employee, or designated representative whose request
for information is denied under paragraph (f)(4) of this section may refer the
request and the written denial of the request to OSHA for consideration.
1910.1020(f)(10)
When a health professional, employee, or designated representative refers a
denial to OSHA under paragraph (f)(9) of this section, OSHA shall consider the
evidence to determine if:
1910.1020(f)(10)(i)
The employer has supported the claim that the specific chemical identity is a
trade secret;
1910.1020(f)(10)(ii)
The health professional employee, or designated representative has supported
the claim that there is a medical or occupational health need for the
information; and
1910.1020(f)(10)(iii)
The health professional, employee or designated representative has
demonstrated adequate means to protect the confidentiality.
1910.1020(f)(11) 1910.1020(f)(11)(i)
If OSHA determines that the specific chemical identity requested under
paragraph (f)(4) of this section is not a "bona fide" trade secret, or that it is a
trade secret but the requesting health professional, employee or designated
representatives has a legitimate medical or occupational health need for the
information, has executed a written confidentiality agreement, and has shown
adequate means for complying with the terms of such agreement, the employer
will be subject to citation by OSHA.
1910.1020(f)(11)(ii)
If an employer demonstrates to OSHA that the execution of a confidentiality
agreement would not provide sufficient protection against the potential harm
from the unauthorized disclosure of a trade secret specific chemical identity, the
Assistant Secretary may issue such orders or impose such additional limitations
or conditions upon the disclosure of the requested chemical information as may
be appropriate to assure that the occupational health needs are met without an
undue risk of harm to the employer.
1910.1020(f)(12)
Notwithstanding the existence of a trade secret claim, an employer shall, upon
request, disclose to the Assistant Secretary any information which this section
requires the employer to make available. Where there is a trade secret claim,
such claim shall be made no later than at the time the information is provided
to the Assistant Secretary so that suitable determinations of trade secret status
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
can be made and the necessary protections can be implemented.
1910.1020(f)(13)
Nothing in this paragraph shall be construed as requiring the disclosure under
any circumstances of process or percentage of mixture information which is a
trade secret.
1910.1020(g)
"Employee information."
1910.1020(g)(1)
Upon an employee's first entering into employment, and at least annually
thereafter, each employer shall inform current employees covered by this
section of the following:
1910.1020(g)(1)(i)
The existence, location, and availability of any records covered by this section;
1910.1020(g)(1)(ii)
The person responsible for maintaining and providing access to records; and
1910.1020(g)(1)(iii)
Each employee's rights of access to these records.
1910.1020(g)(2)
Each employer shall keep a copy of this section and its appendices, and make
copies readily available, upon request, to employees. The employer shall also
distribute to current employees any informational materials concerning this
section which are made available to the employer by the Assistant Secretary of
Labor for Occupational Safety and Health.
1910.1020(h)
"Transfer of records."
1910.1020(h)(1)
Whenever an employer is ceasing to do business, the employer shall transfer all
records subject to this section to the successor employer. The successor
employer shall receive and maintain these records.
1910.1020(h)(2)
Whenever an employer is ceasing to do business and there is no successor
employer to receive and maintain the records subject to this standard, the
employer shall notify affected current employees of their rights of access to
records at least three (3) months prior to the cessation of the employer's
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
business.
1910.1020(h)(3)
Whenever an employer either is ceasing to do business and there is no
successor employer to receive and maintain the records, or intends to dispose
of any records required to be preserved for at least thirty (30) years, the
employer shall:
1910.1020(h)(3)(i)
Transfer the records to the Director of the National Institute for Occupational
Safety and Health (NIOSH) if so required by a specific occupational safety and
health standard; or
1910.1020(h)(3)(ii)
Notify the Director of NIOSH in writing of the impending disposal of records at
least three (3) months prior to the disposal of the records.
1910.1020(h)(4)
Where an employer regularly disposes of records required to be preserved for at
least thirty (30) years, the employer may, with at least (3) months notice,
notify the Director of NIOSH on an annual basis of the records intended to be
disposed of in the coming year.
1910.1020(i)
"Appendices." The information contained in appendices A and B to this section is
not intended, by itself, to create any additional obligations not otherwise
imposed by this section nor detract from any existing obligation.
[61 FR 5507, Feb. 13, 1996; 61 FR 9227, March 7, 1996; 61 FR 31427, June
20, 1996; 71 FR 16673, April 3, 2006]
Next Standard (1910.1020 App A)
Regulations (Standards - 29 CFR) - Table of Contents
www.osha.gov
Back to Top
Contact Us | Freedom of Information Act | Customer Survey
Privacy and Security Statement | Disclaimers
Occupational Safety & Health Administration
200 Constitution Avenue, NW
Washington, DC 20210
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
%ORRGERUQH3DWKRJHQV$SSHQGL[+
Hazard Communication Program for
Austin Community College, Department of Dental Hygiene (known as ACC-DH)
General Policy
The purpose of this notice is to inform you that the office of:
Austin Community College – Department of Dental Hygiene, located at:
Eastview Campus, Building 8000, 3401 Webberville Road, Austin, TX 78702,
is complying with OSHA Hazard Communication Standard, Title 29 Code of Federal Regulations
1910.1200 by compiling a hazardous chemicals list, by using Safety Data Sheets (SDS), by
ensuring that containers are labeled, and by providing you with training.
The program applies to all work operations in this office where you may be exposed to
hazardous chemicals under normal working conditions or during an emergency situation.
The program coordinator is: Renee Cornett, RDH, MBA – Department Chair.
Renee Cornett, RDH, MBA – Department Chair, has overall responsibility for the program,
which will be reviewed and updated, as necessary, by Kate Goin, BA, RDH – Clinic Manager.
Copies of the written program may be obtained from Kate Goin, BA, RDH – Clinic Manager.
01/2013
1
Hazard Communications
List of Hazardous Chemicals
The program coordinator will make a list of all products that contain hazardous chemicals
(except those that the OSHA Standard excludes. See “Exemptions,” below) used in the facility
and will update the list as necessary. Our list of chemicals contains the names of the chemicals
used in this office. It also indicates examples of materials that may contain these chemicals.
For specific hazardous chemicals in a product, refer to the SDS for that product.
Safety Data Sheets
An SDS is a government-approved form or equivalent that provides specific information
on the chemicals in products you use. It was formerly called a Material Safety Data Sheet
(MSDS). The program coordinator will maintain a file of SDS on products for which the
manufacturers or suppliers consider SDS to be necessary. The program coordinator is
responsible for acquiring, filing, and substituting updated SDS, as well as for contacting
manufacturers, suppliers, or dealers if additional information is needed or if an SDS has
not been provided with the initial shipment of a product and the dental office has reason to
believe that an SDS should have been provided. A master list of SDS is available from the
program coordinator; the file of SDS is accessible to all employees.
Labels and Other Forms of Warning
The program coordinator will ensure that all hazardous chemicals are properly labeled and
that labeling is updated, as necessary. Labels should list, at least, the chemical identity of the
material, appropriate hazard warnings, and the name and address of the manufacturer or
other responsible party. Containers labeled by the manufacturers do not require additional
labels. The manufacturer is responsible for properly labeling the original container. When the
chemicals are transferred to other containers (secondary containers) to be used at a later time
or by employees other than one who is going to use the product immediately, these containers
need to be labeled. Examples are containers of alcohol, bleach, disinfectant, and radiographic
chemicals such as developer and fixer solutions that are transferred from the original
containers. Copies of the original labels can be used to label these containers.
If you transfer chemicals from a labeled container to another container that is intended only
for your immediate use, no labels are required on the second container.
Professional products that are regulated by the Food and Drug Administration (FDA) are
exempt from the labeling requirement of the Hazard Communication Standard (see the list
provided at the end of this section). Examples of such materials are impression materials and
composite resins, the labeling of which is approved by the FDA. These labels must not be
removed from the containers. Drugs that are in solid form for direct administration to the
patient are also exempt from the labeling requirement.
Nonroutine Tasks
When you are required to perform nonroutine tasks that involve hazardous chemicals, a special
training session will be conducted to provide information about the chemicals to which you may
be exposed and the precautions you must take to reduce or avoid exposure.
01/2013
2
Hazard Communications
Exemptions
This regulation does not cover finished articles that do not, under normal use, release a
hazardous chemical (e.g., dental chairs, hand instruments, pencils, and photocopy machines).
Preparing Labels for Secondary Containers
The Hazard Communication Standard requires that hazardous chemicals be labeled if they
are transferred from their original container to an unlabeled secondary container under the
applicable conditions as described above.
List of Hazardous Chemicals
Description
Principal responsibility for determining whether a chemical is hazardous or a product contains
hazardous chemicals lies with the manufacturer or supplier. As a user you should rely on
the information on the label and/or the SDS. If there is any question about whether or not a
chemical or product is potentially hazardous, it should be included in the hazard program.
In order to be in compliance with the Hazard Communication Standard, it is recommended that
you take the following steps:
• Check the products you use in your office against the list of dental products that contain
hazardous chemicals. This list follows and it is titled, “Some Hazardous Chemicals and the
Dental Products in Which They May Be Found.”
• For each product that you have in your office and that is on the list “Some Hazardous
Chemicals and the Dental Products in Which They May Be Found” determine if you have
an SDS. If you do not, request one from the manufacturer without delay.
• OSHA requires that you develop your own list of the hazardous chemicals used in your
office. The information needed for your own list should be taken from the SDS in your files.
A sample of a completed list of hazardous chemicals and a form you may use to make your
list follow. OSHA requires, at a minimum, that the list include the name of the chemical and
that an SDS for that product be on file.
• For products that may contain hazardous chemicals, enter their names on the list of
hazardous chemicals and record the date on which a letter requesting an SDS was sent.
If the manufacturer replies that an SDS is not necessary, indicate that on the form.
• Add additional hazardous chemicals to your list as new SDS are received.
01/2013
3
Hazard Communications
Some Hazardous Chemicals and the Dental Products in Which
They May Be Found
The following is a list of chemical substances identified by OSHA as hazardous that the
American Dental Association believes may be found in the dental office. This list is not all
inclusive. It is based on two sources mentioned in the OSHA regulation: the OSHA Safety
and Health Standards 29 CFR 1910 Subpart Z1 and the Threshold Limit Values for Chemical
Substances and Physical Agents in the Work Environment, American Conference of
Governmental Industrial Hygienists (ACGIH).
Chemical Name
May be found in
Acetic Acid
photographic solutions
Acetone
solvents
Aluminum oxide
polishing disks
Aluminum soluble salts
astringent agents
Asbestos
some cast ring liners
Benzoyl peroxide
resin systems, denture resins
Beryllium
nickel-based casting alloys
Calcium carbonate
polishing agents
Carbon tetrachloride
solvents
Chloroform
solvents
Chromium
casting alloys
Cobalt
casting alloys
Copper
amalgam, casting alloys
Cresol, all isomers
endodontic materials
Cyanide as CN
plating solutions
Dibutylphthalate
impression materials
Ethyl acetate
solvents
Ethyl acrylate
resins
Ethyl alcohol
solvents, sterilizing agents
Ethyl chloride
solvents, topical refrigerants
Ethyl silicate
silicate investments, impression materials
(condensation silicones)
Ethylene oxide
sterilizing agents
Fluorides (as F)
fluoride-containing composites
Formaldehyde
sterilizing agents
Glutaraldehyde
sterilizing agents
Hydrochloric acid
pickling solutions, bleaching agents
Hydrogen fluoride
etching agents for porcelain
Hydroquinone
methacrylate and denture base resins,
photographic solutions
Iodine
iodophor disinfectants and antimicrobial hand
cleansers
Isopropyl alcohol
solvents, wiping agents
Lead/inorganic lead compounds
impression materials (some polysulfides)
01/2013
4
Hazard Communications
LPG (liquid petroleum gas)
burners
Mercury
amalgam
Mercury, organic
topical antiseptics
Methyl acetate
solvents
Methyl alcohol
denatured alcohol
Methyl methacrylate
denture base resins
Methylene chloride
solvents
Molybdenum, insoluble compounds
casting alloys (chromium-cobalt alloys stainless
steel
Nickel, metal and soluble compounds
nickel-based casting alloys, stainless steel
orthodontic appliances
pickling solutions, some bleaching solutions
nitrous oxide
handpiece lubricants
Disinfection devices
solvents, waxes, jellies
disinfectants
etching agents, phosphate cements
resins
pickling agents
impression materials (addition silicones)
casting alloys
burners
polishing agent
composite resins, materials
Nitric acid
Nitrous oxide
Oil mist, mineral
Ozone
Petroleum distillates
Phenol
Phosphoric acid
Phthalic anhydride
Picric acid
Platinum soluble salts
Platinum
Propane
Rouge
Silica, amorphous including Natural
diatomaceous earth
Silica, crystalline (quartz)
Silicon carbide
Silver (metal and soluble Compounds)
composite resins, materials
polishing disks, cutting wheels
amalgam, endodontic points, casting alloys,
photographic solutions
etchant for alloys, copper plating solutions
gloves
nickel-chromium-cobalt alloys
amalgam, polishing pastes
impression materials (condensation silicones)
porcelain, impression materials
solvents
solvents
porcelain
maxillofacial plastics, mouth guard trays
solvents
porcelain, polishing pastes
Sulfuric acid
Talc, nonasbestos form
Tantalum
Tin, inorganic compounds
Tin, inorganic compounds
Titanium dioxide
Toluene
Trichloroethane
Uranium, insoluble compounds
Vinyl chloride
Xylene
Zirconium compounds
01/2013
5
Hazard Communications
Sample List of Hazardous Chemicals for this Office
List of Hazardous Chemicals for this Office
Chemical
Product (Trade
Name)
Company
Generic Area
SDS on File?
(y/n)
Silver
Dispersalloy
Johnson &
Johnson (J&J)
Amalgam
Yes
Tin
Dispersalloy
J&J
Amalgam
Yes
Copper
Dispersalloy
J&J
Amalgam
Yes
Zinc
Dispersalloy
J&J
Amalgam
Yes
Mercury
Dispersalloy
J&J
Amalgam
Yes
Beryllium
Rexillium III
Jeneric
Casting alloy
Yes
Nickel
Rexillium III
Jeneric
Casting alloy
Yes
Chromium
Rexillium III
Jeneric
Casting alloy
Yes
Molybdenum
Rexillium III
Jeneric
Casting alloy
Yes
Nickel
Harmony Line
Extra hard
Williams
Casting alloy
Yes
Copper
Harmony Line
Extra Hard
Williams
Casting alloy
Yes
Platinum
Harmony Line
Extra Hard
Williams
Casting alloy
Yes
Indium
Harmony Line
Extra Hard
Williams
Casting alloy
Yes
Vinyl polysiloxane
Imprint
3M
Impression material
Yes
Quartz silica
Imprint
3M
Impression material
Yes
Cobalt pigment
Imprint
3M
Impression material
Yes
Silane copolymer
Imprint
3M
Impression material
Yes
Hydrophilic agent
Imprint 3M
Impression
Material
Yes
Phosphoric acid
Modern Tenacin
Cement Liquid
L.D. Caulk
Cement Yes
Zinc oxide
Modern Tenacin
Cement Powder
L.D. Caulk
Cement
Yes
Glutaraldehyde
Cidex Plus
Surgikos
Disinfectant/sterilant
Yes
Glass powder
Occlusin
Coe Lab
Composite
Yes
Methacrylate
ether
Occlusin
Coe Lab
Composite
Yes
Methyl
Methacrylate
monomers
Formatray liquid
Kerr
Tray material
Yes
Hydroquinone
Kodax GBX
Developer
Eastman Kodak
Film developer
Yes
01/2013
6
Hazard Communications
List of Hazardous Chemicals for this Dental Setting
The hazardous chemicals can be found in the table on the pages following Hazard
Communication Training Record.
01/2013
7
Hazard Communications
Sample Letter to Request Safety Data Sheets
January, 20XX
Acme Distribution Company
29 Acme Drive
Deerfield, WI 38050
Dear Sir or Madam:
I purchased (amount/size) of (name of product) on (date) from your company. I took
delivery of the product on (date) but I did not receive a Safety Data Sheet (SDS) with
my order.
Please send me the appropriate SDS immediately as required by OSHA.
Thank you for your cooperation,
John L. Smith, D.D.S.
1234 Maple Tree Lane
Scranton, WI 23456
01/2013
8
Hazard Communications
Hazard Communication Training Program
Introduction
OSHA enforces a regulation on the rights of employees to know the potential dangers associated
with chemicals (defined by OSHA as hazardous) that they may encounter in products used on the
job. This regulation preempts existing state and local right-to-know laws, except in those states
that have OSHA-approved right-to-know programs.
OSHA rules require employers, including dentist employers, to inform all employees of the
dangers of hazardous chemicals present in products used in the workplace and to train them
on how to handle these substances safely.
The purpose of the regulation is to help employees understand and deal with chemical
hazards to which they may be exposed during the course of their employment. This hazard
communication training program is for your use in training your employees as required by
OSHA. After the training session, have the employees sign the training record and fill out the
comment forms. Retain the records and forms on file.
Components of the Program
The Hazard Communication Standard requires five basic actions.
1. Labeling
All products that contain hazardous chemicals are to be properly labeled. Ensure that labels
are affixed to all containers of products that contain hazardous chemicals. Containers
properly labeled by the manufacturer or supplier do not need additional labels. Notify the
manufacturer or supplier immediately if it appears that a label is missing or incomplete.
Employees should know the identity of the chemicals in products they are handling. The
information should be on the product labels.
Professional products that are regulated by the Food and Drug Administration (FDA) do not
require additional labels, because the labeling of these products is regulated and approved
by that agency. These labels should not be removed. No additional label needs to be placed
on products regulated by the FDA, assuming the original label is not missing. Drugs that
are in solid final form for direct administration to the patient, (e.g., pills or tablets) are also
exempted from the labeling requirement.
OSHA has recently updated the labeling requirements of hazardous chemicals, which
includes the development of pictograms to warn users of chemical hazards. As of
June 1, 2015, all labels should contain:
•
•
•
•
•
Pictograms
Signal words
Hazard and precautionary statements
The product identifier
Supplier identification
01/2013
9
Hazard Communications
The following two OSHA Quick Cards illustrate:
1. The new system of pictograms
2. The new label requirements
01/2013
10
Hazard Communications
01/2013
Hazard Communications
01/2013
Hazard Communications
Products containing hazardous chemicals that are transferred by an employee to another
container for immediate use need not be labeled in the new container. However, if an employee
transfers the product to a new container for later use by another employee (e.g., a large bottle
of surface disinfecting solution is transferred to a smaller spray bottle for each operatory), the
new container must be properly labeled with hazard information.
This rule can be particularly important for two common areas in the dental office: X-ray tanks
and sterilization/disinfection trays. X-ray tanks should be labeled with the information contained
on the manufacturer’s containers of fixer and developer.
Sterilization/disinfection trays should be labeled similarly if the solution is not immediately used
and discarded.
2. Safety Data Sheet
Obtain SDS from suppliers.
• Manufacturers and dental suppliers are required to provide an SDS for a product if it
contains a hazardous chemical. If an SDS is not supplied, the employer is obligated to
request it from the manufacturer or supplier.
• If the label indicates a hazard, employers may rely on that representation and should
ensure that a current SDS is on file for that product. If you are unsure about any given
product, contact the manufacturer or supplier immediately.
As of June 1, 2015, the Hazard Communication Standard will require new SDS to
be in a uniform format.
The following OSHA Quick Card shows the SDS new format and explains the various
sections of the form:
01/2013
13
Hazard Communications
OSHA
·
Hazard Communication Safety Data Sheets
The Hazard Communication Standard (HCS) requires chemical manufacturers, distributors, or importers
to provide Safety Data Sheets (SDSs) (formerly known as Material Safety Data Sheets or MSDSs) to
communicate the hazards of hazardous chemical products. As of June 1,2015, the HCS will require new
SDSs to be in a uniform format, and include the section numbers, the headings, and associated
information under the headings below:
Section 1,Identification includes product identifier; manufacturer or distributor name, address,
phone number; emergency phone number; recommended use; restrictions on use.
Section 2, Hazard(s) identification includes all hazards regarding the chemical; required label
elements.
Section 3, Composition/information on ingredients includes information on chemical ingredients;
trade secret claims.
Section 4, First-aid measures includes important symptoms/ effects, acute, delayed; required
treatment.
Section S, Fire-fighting measures lists suitable extinguishing techniques, equipment; chemical
hazards from fire.
Section 6, Accidental release measures lists emergency procedures; protective equipment; proper
methods of containment and cleanup.
Section 7, Handling and storage lists precautions for safe handling and storage, including
incompatibilities .
Section 8, Exposure controls/personal protection lists OSHA's Permissible Exposure Limits
(PEL.s); Threshold Limit Values (TLVs); appropriate engineering controls; personal protective equipment
(PPE).
Section 9, Physical and chemical properties lists the chemical's characteristics.
Section 10, Stability and reactivity lists chemical stability and possibility of hazardous reactions.
Section 11, Toxicological information includes routes of exposure; related symptoms, acute and
chronic effects; numerical measures of toxicity.
Section 12, Ecological information*
Section 13, Disposal considerations *
Section 14, Transport information*
Section 15, Regulatory information*
Section 16, Other information, includes the date of preparation or last revision.
*Note: Since other Agencies regulate this information, OSHA will not be enforcing Sections 12 through
15(29 CFR 1910.1200(g)(2)) .
Employers must ensure that SDSs are readily accessible to employees.
See Appendix D of 1910.1200 for a detailed description of SOS contents.
For more information : www .osha .gov
l
01/2013
SHA
(800) 321-0SHA (6742)
U.S. Department of Labor
J
14
Hazard Communications
3. File
Maintain a file of all SDS.
• SDS should be maintained in a file available to all employees. The file should be kept up
to date.
• Employers should maintain a file of requests for SDS to document a good faith attempt to
comply with the OSHA standard.
4. Training
Dentists must provide training for employees at the time of their initial assignment, whenever
a new hazardous material is introduced into the workplace, and whenever procedures for
safe handling and emergencies are modified.
• Giving an employee an SDS to read does not satisfy the intent of this regulation.
The training should make clear to employees the hazards of the chemicals and their
handling, the procedures that involve hazardous chemicals, the location and availability
of the written hazard communication program including the list of chemicals, measures
to prevent exposure, and explanation of the labeling and SDS requirements, and an
explanation of the OSHA rule.
• This can be accomplished through continuing education, staff meetings and discussions,
and/or audiovisual materials. Training sessions should always include an opportunity for
employees to ask questions to ensure that they understand the information presented.
5. Recordkeeping
At the end of each training session, each employee should sign a form indicating
participation. Maintain a record of training sessions.
01/2013
15
Hazard Communications
Employee Notification
The Hazard Communication Program for this office can be found:
on page 1 of this manual
The program coordinator for this dental office is:
Kate Goin, BA, RDH
Your work in this dental office involves one or more products that may contain hazardous
chemicals.
A list of hazardous chemicals in products used in this office is available from the program
coordinator.
It is necessary to know the hazardous chemicals in your workplace.
Information on hazardous chemicals in a specific product can be found in the SDS for
that product.
An SDS file for these products is located in:
the Sterilization Room #8143
It is necessary to know the hazards, methods of controlling exposure, and precautions
on handling of products containing hazardous chemicals.
01/2013
16
Hazard Communications
Dental Office Safety
The following general descriptions deal with several groups of chemicals that may be found
in products handled in the dental office. The hazard potential is dependent on the amount of
exposure and individual variability. In most dental offices the amounts of chemicals are small
and therefore risks should be small as well. The risks can be further minimized if recommended
procedures and precautions are followed.
For information on specific products, always refer to the SDS. If any of the information here
varies from that on an SDS, always rely on the SDS first and foremost.
GENERAL PRECAUTIONS
• Handle chemicals properly in accordance with manufacturer’s or supplier’s instructions.
• Avoid skin contact with chemicals.
• Minimize chemical vapor in the air.
• Do not leave chemical bottles open.
• Do not use a flame near flammable chemicals.
• Do not eat or smoke in areas where chemicals are used.
• When appropriate, wear protective eyewear and masks.
• Know proper cleanup procedures.
• Dispose of all hazardous chemicals in accordance with SDS instructions and applicable
local, state, and federal regulations.
ACID ETCH SOLUTIONS AND GELS
Examples
Solutions and gels for acid etch techniques associated with placement of composites, sealants,
and orthodontic brackets usually contain phosphoric acid
Hazards
Acid burns with possible sloughing of tissue, eye damage
Do:
• Handle acid-soaked material with forceps or gloves.
• Clean spills with a commercial acid spill cleanup kit.
• Avoid skin or soft tissue contact.
• Rinse with a large amount of running water in case of eye or skin contact.
01/2013
17
Hazard Communications
FLAMMABLE GASES
Examples
Nitrous oxide and oxygen, liquefied petroleum gas
Hazards
Fire
Do:
• Test periodically for leaks.
• Avoid contact between compressed oxygen gas and lubricants or grease.
• Avoid having sparks or flames near flammable gases.
FLAMMABLE LIQUIDS
Examples
Solvents such as acetone or alcohol
Hazards
Fire or explosion
Do:
• Store flammable liquids in tightly covered containers.
• Provide adequate ventilation.
• Have fire extinguishers available at locations where these liquids are used.
• Avoid sparks or flames in areas where flammable liquids are used.
BERYLLIUM
Examples
Beryllium dust and fumes arise from the melting, grinding, and milling of some base-metal alloys
Hazards
Contact dermatitis, corneal burns, and inflammation and scarring of respiratory tissues
Do:
• Wear gloves, eye protection, and a NIOSH-approved mask when casting, polishing, or
grinding these alloys.
• Provide adequate local exhaust ventilation for all operations in casting areas.
• Use power suction methods rather than air hoses to remove dust from clothing and to clean
machinery.
• Dispose of wastes, storage materials, or contaminated clothing in sealed bags.
01/2013
18
Hazard Communications
MERCURY
Examples
Bulk mercury, precapsulated alloy, scrap amalgam
Hazards
Nausea, loss of appetite, diarrhea; fine tremors, depression, fatigue, increased irritability,
headache, insomnia; allergic manifestations, contact dermatitis, pneumonitis, nephritis; dark
pigmentation of marginal gingiva, loosening of teeth
Do:
• Work in well-ventilated spaces.
• Avoid direct skin contact with mercury.
• Store mercury in unbreakable, tightly sealed containers away from any source of heat.
• Salvage amalgam scrap; store under photographic fixer solution in a closed container.
• Clean up spilled mercury using appropriate procedures and equipment; do not use a
household vacuum cleaner.
• Place contaminated disposable materials in polyethylene bags and seal.
Please note: The ADA’s Best Management Practices call for use of encapsulated mercury only.
NICKEL
Examples
Nickel-containing dental alloys, gold alloys, solders; particles released during fabrication and
grinding of nickel-containing alloys
Hazards
Allergic manifestations, irritation to eyes and respiratory system
Do:
• Wear protective eyewear and a NIOSH-approved mask when grinding nickel-containing alloys.
• Use high-velocity evacuation systems.
OTHER METALS
Examples
Casting alloys may contain cobalt and chromium; alloys for amalgam contain silver, tin, and
copper
Hazards
Metal dust and fumes may irritate eyes and respiratory systems; contact dermatitis
Do:
• Wear protective eyewear and a NIOSH-approved mask while grinding metal prostheses.
01/2013
19
Hazard Communications
NITROUS OXIDE (N2O)
Hazards
Based on laboratory animal studies and several published reports of N2O abuse, high exposure
may cause adverse health effects, especially neuropathies.
Do:
• Take steps to minimize the concentration of nitrous oxide in the dental suite.
• Use a scavenging system.
• Check nitrous oxide machines, lines, hoses, and masks for leakage.
• Maintain adequate ventilation
ORGANIC CHEMICALS
Examples
Alcohols, ketones, esters, solvents, and monomers such as methyl methacrylate and
dimethacrylates. The halogen-containing organic liquids used in dental offices primarily include
chloroform and carbon tetrachloride and some solvents and cleaners.
Hazards
Fire; allergic manifestations, contact dermatitis; possible mutagenesis; irritation to mucous
membranes; respiratory problems; nausea, liver and kidney damage; central nervous system
depression, headache, drowsiness, loss of consciousness
Do:
• Avoid skin contact.
• Avoid excessive inhalation of vapors.
• Work in well-ventilated areas.
• Use forceps or gloves when handling contaminated gauze or brushes.
• Keep containers tightly closed when not in use.
• Store containers on flat sturdy surfaces.
• Clean outside surfaces of containers after use to prevent residual material from contacting
the next user.
• Use a commercially available flammable solvent cleanup kit in case of spills.
01/2013
20
Hazard Communications
PHOTOGRAPHIC CHEMICALS
Hazards
Contact dermatitis; irritation of eyes, nose, throat, and respiratory system from vapors and fine
particulates of chemicals
Do:
• Use protective eyewear.
• Minimize exposure to dry powder during mixing of solution.
• Avoid skin contact with photographic chemicals and solutions by wearing heavy-duty rubber
gloves.
• Work in well-ventilated areas.
• Clean up spilled chemicals immediately.
• Wash off chemicals with large amounts of water and a pH-balanced soap if contact occurs.
• Regularly launder clothing that comes in contact with photographic solutions.
• Store photographic solutions and chemicals in tightly covered containers.
PICKLING SOLUTIONS
Examples
Strongly acidic solutions containing metal ions after use. The components may be volatile.
Hazards
Burning of skin, irritation of skin and mucous membranes, damage to eyes, irritation to
respiratory system
Do:
• Wear safety goggles for eye protection.
• Use forceps to hold the object being pickled.
• Avoid skin contact by wearing heavy-duty rubber gloves.
• Use pickling solutions in well-ventilated areas.
• Minimize the formation of airborne droplets.
• Avoid splattering of solution and putting hot objects into the solution.
• Store pickling solutions in covered glass containers.
• Keep soda lime or a commercial acid spill cleanup kit available in case of spills.
• Rinse with a large amount of running water in case of eye or skin contact. Seek medical
attention as necessary.
01/2013
21
Hazard Communications
PLASTER AND OTHER GYPSUM PRODUCTS
Examples
Gypsum products contain silica and calcium sulfate
Hazards
Irritation and impairment of respiratory system, silicosis, irritation of the eyes
Do:
• Use plaster and other gypsum products in areas equipped with an exhaust system.
• Wear protective eyewear and a NIOSH-approved mask while handling powders or trimming
models.
• Minimize exposure to powder during handling.
01/2013
22
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/02/15
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Tina Stein
Signature
Attended by Renee Cornett
Signature
Attended by Michelle Landrum
Signature
Attended by Kimberly McDougall
Signature
Attended by Kellie Murphree
Signature
Attended by David Reeves
Signature
01/2015
23
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/02/15
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Deb Segen
Signature
Attended by Rita Snodell
Signature
Attended by Prema Strecker
Signature
Attended by Joe Wright
Signature
Attended by Sima Sohrabi
Signature
Attended by Andrea Kovarik
Signature
01/2015
24
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/12/16
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Veronica Ledesma
Signature
Attended by Teri Frank
Signature
Attended by
Signature
Attended by
Signature
Attended by
Signature
Attended by
Signature
01/2015
25
Hazard Communications
This page intentionally left blank
01/2015
26
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/12/16
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Monique Alarcon
Signature
Attended by Rachel Dickens
Signature
Attended by Sunena Gagneja
Signature
Attended by Lacie Herrin
Signature
Attended by Dylon Hopper
Signature
Attended by Cydnie Johnson
Signature
01/2015
27
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/12/16
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Julia Levitt
Signature
Attended by Stephanie Liu
Signature
Attended by Kristi Madrid
Signature
Attended by Katie Natale
Signature
Attended by Aneesa Patel
Signature
Attended by Lee Pepe
Signature
01/2015
28
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/12/16
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Jennifer Rice
Signature
Attended by Shaunda Talamantez
Signature
Attended by Yulia Voznesenskaya
Signature
Attended by Jeremiah Wallace
Signature
Attended by Allyson Walter
Signature
Attended by
Signature
01/2015
29
Hazard Communications
This page intentionally left blank
01/2015
30
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/02/15
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Jason Blunck
Signature
Attended by Wendy Bushman
Signature
Attended by Josette Chen
Signature
Attended by Amy Deng
Signature
Attended by Becca Eiserer
Signature
Attended by Zainab Jabr
Signature
01/2015
31
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/02/15
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Laura Jaimes
Signature
Attended by Whitney Jones
Signature
Attended by Molly Keith
Signature
Attended by Shari Langerhans
Signature
Attended by Jessica Lee
Signature
Attended by Carrie Nunnally
Signature
01/2015
30
Hazard Communications
Hazard Communication Training Record
This office has conducted a training session for employees incorporating the OSHA Hazard
Communication Standard, including new regulations in 2012 SDS requirements and labeling
requirements.
Date 09/02/15
Conducted by ADA OSHA Training for Dental Professionals video and Kate Goin, BA, RDH
Signature
Attended by Jess Ross
Signature
Attended by Azadeh Samani
Signature
Attended by Elya Singler
Signature
Attended by Allyson Walter
Signature
Attended by Stacy Weiner
Signature
Attended by Jason Whittley
Signature
01/2015
31
Hazard Communications
Hazard Communication Appendix A
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[$
Hazard Communication Appendix A
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[$
Hazard Communication Appendix B
QUICK
CARD
TM
Hazard Communication
Standard Pictogram
As of June 1, 2015, the Hazard Communication Standard
(HCS) will require pictograms on labels to alert users of
the chemical hazards to which they may be exposed. Each
pictogram consists of a symbol on a white background
framed within a red border and represents a distinct
hazard(s). The pictogram on the label is determined by
the chemical hazard classification.
-Ê*ˆV̜}À>“ÃÊ>˜`Ê>â>À`Ã
i>Ì…Ê>â>À`ÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊʏ>“iÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÝV>“>̈œ˜ÊÊ>ÀŽ
UÊ
>ÀVˆ˜œ}i˜
UÊÕÌ>}i˜ˆVˆÌÞ
UÊ,i«Àœ`ÕV̈ÛiÊ/œÝˆVˆÌÞ
UÊ,iëˆÀ>̜ÀÞÊ-i˜ÃˆÌˆâiÀ
UÊ/>À}iÌÊ"À}>˜Ê/œÝˆVˆÌÞ
UÊëˆÀ>̈œ˜Ê/œÝˆVˆÌÞÊ
Uʏ>““>LiÃÊ
UÊ*ÞÀœ«…œÀˆVÃ
UÊ-iv‡i>̈˜}
UʓˆÌÃʏ>““>LiÊ>Ã
UÊ-iv‡,i>V̈ÛiÃ
UÊ"À}>˜ˆVÊ*iÀœÝˆ`iÃ
UÊÀÀˆÌ>˜ÌʭΈ˜Ê>˜`ÊiÞi®
UÊ-Žˆ˜Ê-i˜ÃˆÌˆâiÀ
UÊVÕÌiÊ/œÝˆVˆÌÞÊ­…>À“vՏ®
UÊ >ÀVœÌˆVÊvviVÌÃ
UÊ,iëˆÀ>̜ÀÞÊ/À>VÌÊ
ÊÊÊÀÀˆÌ>˜Ì
UÊ>â>À`œÕÃÊ̜Ê"✘iÊ
ÊÊÊÊ>ÞiÀÊ­ œ˜‡>˜`>̜ÀÞ®
>ÃÊ
ޏˆ˜`iÀÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊ
œÀÀœÃˆœ˜ÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÝ«œ`ˆ˜}ʜ“L
UÊ>ÃiÃÊ1˜`iÀÊ*ÀiÃÃÕÀi
UÊ-Žˆ˜Ê
œÀÀœÃˆœ˜ÉÊ
ÊÊÊÕÀ˜Ã
UÊÞiÊ>“>}i
UÊ
œÀÀœÃˆÛiÊ̜ÊiÌ>Ã
UÊÝ«œÃˆÛiÃ
UÊ-iv‡,i>V̈ÛiÃ
UÊ"À}>˜ˆVÊ*iÀœÝˆ`iÃ
>“iÊ"ÛiÀÊ
ˆÀViÊÊÊÊÊÊÊÊÊʘۈÀœ˜“i˜ÌÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊ-ŽÕÊÊ
ÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊ­ œ˜‡>˜`>̜ÀÞ®ÊÊÊÊÊÊÊÊÊÊÊÊÊÊÊ>˜`Ê
ÀœÃÃLœ˜iÃ
UʵÕ>̈VÊ/œÝˆVˆÌÞ
UÊVÕÌiÊ/œÝˆVˆÌÞÊ
ÊÊÊ­v>Ì>ÊœÀÊ̜݈V®
For more information:
U.S. Department of Labor
www.osha.gov (800) 321-OSHA (6742)
OSHA 3491-02 2012
UÊ"݈`ˆâiÀÃ
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[%
Hazard Communication Appendix C
}
Product
Identifier
SAMPLE LABEL
CODE _______________________________
Product Name________________________
Supplier
Identification
Hazard
Statements
Hazard Pictograms
Signal Word
Danger
}
Fill weight:____________ Lot Number:___________
Gross weight:__________ Fill Date:______________
Expiration Date:________
Directions for Use
__________________________________
__________________________________
__________________________________
Supplemental Information
Highly flammable liquid and vapor.
May cause liver and kidney damage.
Precautionary
Statements
}
Keep container tightly closed. Store in a cool,
well-ventilated place that is locked.
Keep away from heat/sparks/open flame. No smoking.
Only use non-sparking tools.
Use explosion-proof electrical equipment.
Take precautionary measures against static discharge.
Ground and bond container and receiving equipment.
Do not breathe vapors.
Wear protective gloves.
Do not eat, drink or smoke when using this product.
Wash hands thoroughly after handling.
Dispose of in accordance with local, regional, national,
international regulations as specified.
}
Company Name_______________________
Street Address________________________
City_______________________ State_____
Postal Code______________Country_____
Emergency Phone Number_____________
OSHA has updated the requirements for labeling of
hazardous chemicals under its Hazard Communication
Standard (HCS). As of June 1, 2015, all labels will be
required to have pictograms, a signal word, hazard and
precautionary statements, the product identifier, and
supplier identification. A sample revised HCS label,
identifying the required label elements, is shown on the
right. Supplemental information can also be provided
>â>À`Ê
œ““Õ˜ˆV>̈œ˜Ê-Ì>˜`>À`Ê>LiÃ
on the label as needed.
First Aid
If exposed call Poison Center.
If on skin (or hair): Take off immediately any contaminated
clothing. Rinse skin with water.
In Case of Fire: use dry chemical (BC) or Carbon Dioxide (CO2)
fire extinguisher to extinguish.
œÀʓœÀiʈ˜vœÀ“>̈œ˜\
(800) 321-OSHA (6742)
www.osha.gov
OSHA 3492-02 2012
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[&
Hazard Communication Appendix D
QUICK
CARD
TM
Hazard Communication
Safety Data Sheets
The Hazard Communication Standard (HCS) requires
chemical manufacturers, distributors, or importers to
provide Safety Data Sheets (SDSs) (formerly known as
Material Safety Data Sheets or MSDSs) to communicate
the hazards of hazardous chemical products. As of June
1, 2015, the HCS will require new SDSs to be in a uniform
format, and include the section numbers, the headings,
and associated information under the headings below:
Section 1, Identification includes product identifier;
manufacturer or distributor name, address, phone
number; emergency phone number; recommended use;
restrictions on use.
Section 2, Hazard(s) identification includes all hazards
regarding the chemical; required label elements.
Section 3, Composition/information on ingredients
includes information on chemical ingredients; trade secret
claims.
Section 4, First-aid measures includes important symptoms/effects, acute, delayed; required treatment.
Section 5, Fire-fighting measures lists suitable extinguishing
techniques, equipment; chemical hazards from fire.
Section 6, Accidental release measures lists emergency
procedures; protective equipment; proper methods of
containment and cleanup.
Section 7, Handling and storage lists precautions for safe
handling and storage, including incompatibilities.
For more information:
U.S. Department of Labor
OSHA 3493-02 2012
(Continued on other side)
www.osha.gov (800) 321-OSHA (6742)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL['
Hazard Communication Appendix D
QUICK
CARD
TM
Hazard Communication
Safety Data Sheets
Section 8, Exposure controls/personal protection
lists OSHA’s Permissible Exposure Limits (PELs);
Threshold Limit Values (TLVs); appropriate engineering
controls; personal protective equipment (PPE).
Section 9, Physical and chemical properties lists the
chemical’s characteristics.
Section 10, Stability and reactivity lists chemical stability
and possibility of hazardous reactions.
Section 11, Toxicological information includes routes of
exposure; related symptoms, acute and chronic effects;
numerical measures of toxicity.
Section 12, Ecological information*
Section 13, Disposal considerations*
Section 14, Transport information*
Section 15, Regulatory information*
Section 16, Other information, includes the date of
preparation or last revision.
*Note: Since other Agencies regulate this information,
OSHA will not be enforcing Sections 12 through 15
(29 CFR 1910.1200(g)(2)).
For more information:
U.S. Department of Labor
OSHA 3493-02-2012
Employers must ensure that SDSs are readily accessible
to employees.
See Appendix D of 29 CFR 1910.1200 for a detailed
description of SDS contents.
www.osha.gov (800) 321-OSHA (6742)
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL['
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Hazard Communication Appendix E
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
+D]DUG&RPPXQLFDWLRQV$SSHQGL[(
Guidelines/Procedures
SUBJECT: ACC Hazardous Waste Management Program
ACC Management Safety Statement
Guideline/Procedure for
AR#: 3.03.006
Date Effective:
PLACEHOLDER TABLE OF CONTENTS
These Table of Contents divisions will be set up on the EHS web site as hyperlinks to the specific
sections of the
I. Introduction – Value Statement
II. Hazardous Waste Management Regulations
III. Duties and Responsibilities
IV. Hazardous Waste Management Program
A. EHS & Insurance Duties as Administrator of the Hazardous Waste
Management Program
B. Hazardous Waste Training
C. Hazardous Waste Determination
D. Disposal of Non-hazardous Waste
E. Determining Your Generator Status
F. Classification and Segregation of Hazardous Waste
G. Containment and Storage of Hazardous Waste
H. Satellite Accumulation Area and 180-day Accumulation Storage Areas
I. Hazardous Waste Labels and Labeling
J. Hazardous Waste Disposal & Tracking
K. SQG Emergency Preparedness and Contingency Planning
L. Hazardous Waste Management Recordkeeping & Reporting
V. Other Regulated Waste
A.
B.
C.
D.
E.
F.
G.
H.
Used Dry Solid Materials
Used Oil, Used Oil Filters and Used Antifreeze
Gas Cylinders
Photographic Processing Waste
Unknown Chemical Waste
Universal Waste
Biohazard Waste
Contractor Waste
VI. Source Reduction and Hazardous Waste Minimization
VII. Emergency Procedures
Appendix A Definitions
Appendix B Identification of Hazardous Waste (EPA’s “P”, “U”, “F” and “K” listed
hazardous waste)
Appendix C Container Storage Inspection Sheets
Appendix D Spill Prevention and Control Measures – Place Holder
Appendix E Source Reduction and Waste Minimization Plan – Place Holder
2
AUSTIN COMMUNITY COLLEGE
HAZARDOUS WASTE MANAGEMENT PROGRAM
I.
II.
Value
The purpose of this document is to inform faculty, staff, employees, and students at Austin
Community College (ACC), regarding Federal and State hazardous waste disposal regulations
and to define the ACC Hazardous Waste Management Program (Program). The Program
pertains to hazardous waste and does not include procedures for the management of
radioactive, infectious, and biological waste. The ACC Environmental Health Safety and
Insurance Office (herein referred to as EHS & Insurance) administers the Hazardous Waste
Management Program at ACC. Compliance with the program is critical and requires full
cooperation by all College entities.
Hazardous Waste Management Regulations
The U. S. Environmental Protection Agency (EPA) administers the Resource Conservation and
Recovery Act (RCRA). Under this Act, the EPA has the responsibility for regulating hazardous
chemical wastes. RCRA established a "cradle to grave" hazardous waste management
requirement to protect public health and the environment from improper disposal of hazardous
waste. The law went into effect in November 1980. The Texas Commission on Environmental
Quality (TCEQ) administers an equivalent to RCRA for the State of Texas under Industrial Solid
Waste and Municipal Hazardous Waste Regulations of the Texas Administrative Code (TAC)
(Title 30, Part I, Chapter 335). Appendix A provides definitions for commonly used RCRA
words.
Any business or industrial facilities, including academic institutions that generate hazardous waste
are required to comply with EPA and TCEQ hazardous waste regulations. These regulations,
contained in Title 40 Code of Federal Regulations (CFR) Parts 260-279 and Title 30 TAC Chapter
335 respectively, can be very difficult to understand. The intent of the following guidelines are to
provide basic assistance in identifying wastes, in determining if these wastes are considered
hazardous and identifying techniques to safely and correctly manage and dispose of these wastes.
It is vital that generators work closely with EHS and Insurance Office to establish compliant
procedures for the individual areas that generator hazardous waste.
Since Federal and State regulations govern hazardous waste disposal at ACC, failure to comply
with any hazardous waste regulation may result in substantial fines and penalties for the College;
individual generators (e.g., principal investigators, employees) causing the violation may be
3
personally liable. It is ultimately the responsibility of the generator to determine whether their
wastes are considered hazardous or not. EPA and TCEQ regulations stipulate that each individual
who generates hazardous waste is personally liable and is responsible for assuring compliance
with regulations and proper hazardous waste management. A waste generator never totally loses
liability for environmental damage; therefore, the selection of a reliable disposal facility is very
important. Violations may range from failure to properly label a container of hazardous waste to
intentionally disposing of hazardous waste into the air, down the drain, or in the garbage. In
Texas, penalties for non-compliance may be civil, criminal, or administrative violations with
penalties ranging from fines of up to $25,000 per day to a 15-year prison term for
individuals.
ACC has applied for and received an identification number from the EPA and a Texas solid waste
registration number from the TCEQ identifying ACC as a hazardous waste generator, as defined
by RCRA. Some ACC campuses generate between 100 and 1,000 kg of hazardous waste per
month and are subject to regulations applicable to non-industrial Small Quantity Generators,
including hazardous waste storage up to 180 days. ACC has made the decision to internally
manage all campus locations’ hazardous waste in compliance with the regulatory requirements for
a Small Quantity Generator (SQG). This will enable the College to use one consistent set of
guidelines for hazardous waste management.
III.
Duties and Responsibilities
The ACC President is the College Official ultimately responsible for ACC’s compliance with
environmental health and safety regulations. In addition, responsibility and liability for the
Hazardous Waste Management Program extends to the ACC Board of Trustees. The ACC
College President and Board of Trustees shall show visible support for safety as a value at ACC,
through funding and appropriate staffing in support of the Program.
The ACC Executive Team / Administrators are responsible for insuring implementation of the
Hazardous Waste Management Program in their areas of responsibility, showing visible support
for the program and for ensuring the health and safety of the College’s employees and students.
The Dean, Unit Director, Department Chair will have ultimate responsibility for
implementation and compliance with the ACC Hazardous Waste Management Program within
their disciplines / areas / units. Various duties associated with this program may be delegated to
personnel within the department/ unit. This designation of duties does not reduce ultimate
responsibility of Unit Heads or Supervisory Personnel for compliance to the Program.
4
EHS & Insurance Office Duties as Administrator of the Hazardous Waste Management
Program
The EHS & Insurance Office coordinates the Hazardous Waste Management Program for ACC
and designated ACC facilities. Duties of the EHS & Insurance Office include:
1. Assist areas/units with the implementation of and compliance with this Program, including
but not limited to, training, hazardous waste stream determinations and classifications,
oversight of hazardous waste disposal, establishing/coordinating area compliance audits
and assisting with corrective actions.
2. Provide annual and refresher hazardous waste training to all required personnel as defined
by RCRA.
3. Compile and maintain a list of all the College’s hazardous waste generators so that RCRA
training can be documented.
4. Maintain manifest master file. Manifests are required to be maintained for a minimum of
three years however, ACC will maintain them indefinitely.
5. Maintain liaison with the appropriate regulatory authorities (TCEQ, EPA, etc.).
a) Submit required Notice of Registrations to the TCEQ when necessary.
b) Submit annual waste summaries to the TCEQ for all facilities generating more than 220
pounds of hazardous waste in any one calendar month.
6. Ensure that a contract with a qualified, properly licensed hazardous waste disposal
contractor is in place at all times. EHS and I Office will do, at a minimum, annual
inspections of hazardous waste disposal contractors and associated facilities to ensure
compliance with Federal and State regulations.
7. Coordinate a schedule with ACC’s designated hazardous waste disposal contractor for
hazardous waste pick-ups at all facilities and to be present for all pick ups. The EHS &
Insurance Coordinator (or the EHS & Insurance Director as backup) will sign all manifests
for all regulated waste shipments. The Department of Transportation regulates the
transportation of hazardous waste and EHS and I will ensure that EHS and I personnel are
trained and certified as required by D.O.T.
5
8. Coordinate with generators on each campus to prepare for the scheduled hazardous waste
pick-ups.
9. Coordinate with ACC’s designated environmental contractor whenever hazardous waste
testing is needed at a facility.
10. Provide supportive technical consultation to ACC’s hazardous waste generators.
IV.
Hazardous Waste Management Program
A. Introduction
The Hazardous Waste Management Program for Austin Community College shall be administered
by the EHS & Insurance Office, whose line of administrative authority is through the Vice
President of Business Services. Generators are responsible for following the ACC disposal
procedures, for ensuring that their employees are trained in proper disposal procedures, and for
properly identifying the hazardous waste generated.
Each academic, vocational or support department including instructional laboratory facilities
which produces hazardous waste in any way, must, also, ensure that personnel who generate
hazardous waste have received documented training in the use of the ACC hazardous waste
handling system and are complying with ACC procedures in regards to hazardous waste. The
Dean / Director of each group has ultimate responsibility for insuring compliance.
A. Procedures
The following procedures are intended to assure compliance with applicable EPA and TCEQ
regulations for the proper management of hazardous chemical waste and to reduce adverse effects
to human health and the environment.
B. Hazardous Waste Training
RCRA requires that employees of SQGs who manage or handle hazardous waste be trained.
Initial training must be provided prior to an employee participating in any hazardous waste related
activities. Annual refresher training must be completed within 13 months of the previous training.
Training will be approved / provided by the EHS & Insurance Office. This training shall include:
6
1.
2.
3.
4.
5.
6.
Overview of the both EPA and TCEQ regulations
Generators’ responsibilities
Hazardous waste determination
Waste classification, labeling, segregation, and storage
Spill cleanup procedures
Disposal procedures
Although SQGs are not required to maintain training records, ACC has opted to do so. The EHS
& Insurance Office will maintain a master file of all ACC employees’ RCRA training records.
C. Hazardous Chemical Waste Determination
A material becomes "waste" when the individual generator determines that it is no longer useful
and should be discarded. If the material is to be discarded, the EHS & Insurance Office must
make a determination whether the waste is non-hazardous or hazardous for each waste stream
generated by ACC. Because the primary source for waste determination is the generator's process
knowledge, the EHS & Insurance Office utilizes a Chemical Inventory and Waste Stream
Identification spreadsheet that the generator completes and returns to the EHS & Insurance Office
within one day of a material being declared a waste. Certified Laboratories or licensed/certified
waste vendors will perform chemical analyses to be used for the identification/characterization of
unknown or improperly labeled wastes.
ALL WASTE STREAMS MUST BE CLASSIFIED AS HAZARDOUS OR NONHAZARDOUS. CONTACT THE EHS & INSURANCE OFFICE CONCERNING NEW OR
EXISTING WASTE STREAMS THAT ARE UNCLASSIFIED.
Personnel classifying waste streams must be RCRA certified through appropriate and current
RCRA training as specified in 40CFR Parts 260-279. All RCRA training must be approved
through the Director of EHS and I. A material is "non-hazardous waste" if it does not meet the
definition of “hazardous waste". “Hazardous waste” is any waste that is defined as being
hazardous in 40 CFR Section 261.3 and 30 TAC Chapter 335, rule 335.504. A material is
"hazardous waste" if it meets one or more of the following:
1.
It is a chemical listed on one of the Chemical Tables in Appendix B (that provides
EPA’s four hazardous waste lists with respective waste codes: “P”, “U”, “F” and “K”)
By definition, EPA determined that some specific wastes are hazardous. These wastes
7
are incorporated into lists published by the Agency. These lists are organized into
three categories:
2.
3.
•
The F-list (non-specific source wastes). This list identifies wastes from
common manufacturing and industrial processes, such as solvents that have
been used in cleaning or degreasing operations. Because the processes
producing these wastes can occur in different sectors of industry, the F-listed
wastes are known as wastes from non-specific sources. Wastes included on the
F-list can be found in the regulations at 40 CFR §261.31 (click for hyperlink).
•
The K-list (source-specific wastes). This list includes certain wastes from
specific industries, such as petroleum refining or pesticide manufacturing.
Certain sludges and wastewaters from treatment and production processes in
these industries are examples of source-specific wastes. Wastes included on the
K-list can be found in the regulations at 40 CFR §261.32 (click for hyperlink).
•
The P-list and the U-list (discarded commercial chemical products). These
lists include specific commercial chemical products in an unused form. Some
pesticides and some pharmaceutical products become hazardous waste when
discarded. Wastes included on the P- and U-lists can be found in the regulations
at 40 CFR §261.33 (click for hyperlink).
It is a mixture or solution containing a listed chemical) and a non-hazardous chemical.
It meets the definition of one of the following for Characteristic Waste:
Waste that does not meet any of the listings explained above may still be
considered a hazardous waste if exhibits one of the four characteristics defined
in 40 CFR Part 261 Subpart C — ignitability (D001), corrosivity (D002),
reactivity (D003), and toxicity (D004 - D043).
a) Ignitability (flashpoint <60o C (140o F) or supports combustion
1)
8
Ignitability – Ignitable wastes can create fires under certain conditions,
are spontaneously combustible, or have a flash point less than 60 °C
(140 °F). Examples include waste oils and used solvents. For more
details, see 40 CFR §261.21 (click for hyperlink). Test methods that
may be used to determine ignitability include the Pensky-Martens
Closed-Cup Method for Determining Ignitability (Method 1010a) (PDF,
1 pp., 19 KB), the Setaflash Closed-Cup Method for Determining
Ignitability (Method 1020b) (PDF, 1 pp., 17 KB), and the Ignitability of
Solids (Method 1030) (PDF, 13 pp., 116 KB).
(b) Corrosivity (pH ≤2 or≥12.5);
Corrosivity – Corrosive wastes are acids or bases (pH less than or equal to
2, or greater than or equal to 12.5) that are capable of corroding metal
containers, such as storage tanks, drums, and barrels. Battery acid is an
example. For more details, see 40 CFR §261.22 (click for hyperlink). The
test method that may be used to determine corrosivity is the Corrosivity
Towards Steel (Method 1110a) (PDF, 6 pp., 37 KB).
(c) Reactivity (e.g., responds violently to air or water, cyanides, explosives,
unstable chemicals
Reactivity – Reactive wastes are unstable under "normal" conditions. They
can cause explosions, toxic fumes, gases, or vapors when heated,
compressed, or mixed with water. Examples include lithium-sulfur batteries
and explosives. For more details, see 40 CFR §261.23 (click for hyperlink)
There are currently no test methods available.
(d) Toxicity (e.g., pesticides, heavy metals, poisons);
Toxicity – Toxic wastes are harmful or fatal when ingested or absorbed
(e.g., containing mercury, lead, etc.). When toxic wastes are land disposed,
contaminated liquid may leach from the waste and pollute ground water.
Toxicity is defined through a laboratory procedure called the Toxicity
Characteristic Leaching Procedure (TCLP) (Method 1311) (PDF, 35 pp.,
288 KB). The TCLP helps identify wastes likely to leach concentrations of
contaminants that may be harmful to human health or the environment. For
more details, see 40 CFR §261.24. (click for hyperlink)
4.
5.
It is a Universal Waste per 30 TAC 335.261; or
Material is not excluded from the regulations
It is critical that generators classify any waste they generate as either non-hazardous or hazardous
9
so that they will know how the proper disposal method. For example, it is illegal to dispose of
hazardous waste in any of the following ways:
1.
2.
3.
4.
Disposal through the sanitary drain such as sink drain, floor drain or urinal or toilets.
Intentional evaporation in or outside a fume hood.
Disposal in the regular trash.
Disposal through storm drain, on paved surface or on the ground.
However, non-hazardous waste may be disposed using the sanitary sewer or regular trash, with
prior approval of the EHS & Insurance Office. Additional information about non-hazardous waste
disposal can be obtained below or from the EHS & Insurance Office.
D. Disposal of Non-hazardous Waste
An area must have documented approval from the EHS & Insurance Office stating that the waste
is non-hazardous prior to disposal as a non-hazardous waste.
Not all chemical wastes are hazardous and so should not be entered into the ACC Hazardous
Waste Management Program. The following guidelines for determining which non-hazardous
wastes are suitable for disposal through normal waste channels were developed after careful
review of TCEQ regulations.
No waste that is defined as hazardous by the TCEQ or EPA may be placed in the regular trash.
“Regular trash” is referring to placing material into dumpsters outside of a building or any trash
can inside a building. Custodial services will not pick up any type of chemical placed in trashcans
inside a building.
Liquid waste (i.e., bottles of unused or partially used solutions) may never be disposed of in
dumpsters because liquid wastes are not permitted at municipal landfills.
Empty containers of waste commercial products or chemicals are acceptable if:
• No freestanding liquids remain in the container and all disposal requirements noted on the
label are complied with.
• Empty chemical containers should be placed in a dumpster for disposal with other nonhazardous trash when the following requirements are satisfied:
10
o
EPA regulations stipulate that an empty chemical container must:
1. Shall not contain free liquid or solid residue;
2. Pesticide containers or containers which contained acutely hazardous
materials must be triple rinsed and the rinse water collected for disposal as
hazardous waste
3. Have the label removed or defaced;
4. Have the lid or cap removed; and
5. Have a hole punched in the bottom (for metal or plastic containers).
Certain solid, non-hazardous chemicals are suitable for disposal in the sanitary landfills.) Solid,
non-hazardous waste must be placed directly in the dumpsters outside the building and not into the
trashcans inside a building.
The following types of solid waste, which are generally considered non-hazardous or of low
toxicity can be put directly into dumpsters outside the building.
1. Organic chemicals:
a. Sugars and starches
b. Naturally occurring amino acids and salts
c. Citric acid and its Na, K, Mg, Ca, NH4 salts
d. Lactic acid and it’s Na, K, Mg, Ca, NH4 salts
2. Inorganic chemicals:
a. Sulfates: Na, K, Mg, Ca, Sr, NH4
b. Phosphates: Na, K, Mg, Ca, Sr, NH4
c. Carbonates: Na, K, Mg, Ca, Sr, NH4
d. Oxides: B, Na, Ca, Sr, Al, Si, Ti, Mn, Fe, Cu, Zn
e. Chlorides: Na, K, Mg
f. Borates: Na, K, Mg, Ca
g. Fluorides: Ca
Note: As noted above, liquid solutions of such wastes should not be put into the
dumpsters. Contact the EHS & Insurance Office prior to sewer disposal of such
liquid solutions.
11
3. Laboratory materials not contaminated with hazardous chemicals:
a. Chromatographic absorbents
b. Filter papers, filter aids, and glassware
c. Rubber and plastic protective clothing
If there is any question as to whether a waste is acceptable for land filling, please contact the EHS
& Insurance Office.
E. Determining Generator Status
There are three categories of hazardous waste generators:
• Conditionally Exempt Small Quantity Generator (CESQG);
• Small Quantity Generator (SQG); and
• Large Quantity Generator (LQG).
Typically, the more hazardous waste generated, the more stringent the regulations. The EHS &
Insurance Office must know how much hazardous waste each ACC campus generates each month.
This is necessary for three reasons:
1) to know what regulatory requirements apply to the campus;
2) to know the monthly amount when applying for the EPA identification number or when
submitting modifications; and
3) to submit annual waste summary reports to the TCEQ.
In order for the EHS & Insurance Office to determine the generator category for each campus,
each generating area on a campus must count (track) the amount of hazardous waste and acutely
hazardous waste that is generated each calendar month. The total weight of hazardous waste for
the month determines the generator category. One acceptable counting method is to use a
hazardous waste tracking log. The generator may create a log sheet that should have at minimum
the date, type of chemical waste and amount. To facilitate the counting of hazardous waste, the
tracking log can be kept on a clipboard and hung near the Satellite Accumulation Area storage
containers. At the end of each semester, each generating area should provide a copy of their
tracking log to the EHS&I Coordinator (or sooner if requested by the EHS & Insurance Office). If
a campus falls into different generator categories from month to month, the campus should choose
the more stringent requirements to ensure compliance. This last statement should not occur, but if
12
it does, then EHS&I should make determination and ensure compliance.
F. Classification and Segregation of Hazardous Waste
Hazardous chemical waste is categorized into the following hazard classes:
1.
2.
3.
4.
5.
6.
7.
8.
Halogenated solvents
Non-halogenated solvents
Acids (inorganic or organic)
Bases (inorganic or organic)
Heavy metals (silver, cadmium, lead, mercury, etc.)
Poisons (inorganic or organic)
Reactives, water-reactive chemicals
Flammables
Different classes of hazardous chemical waste must not to be commingled in the same waste
container. For example, do not combine inorganic heavy metal compounds with organic acidic waste
solvents. In addition, do not combine non-hazardous waste (e.g., mixture of water, dilute acetic acid,
and sodium bicarbonate) with hazardous chemical waste. Areas should contact EHS and I for
assistance with these determinations.
G. Containment and Storage of Hazardous Waste
An integral part of any hazardous waste management program is the container storage areas.
These areas are used to hold the waste prior to shipment to a permitted Treatment Storage and
Disposal (TSD) facility. Individual hazardous waste generators shall maintain custody and control
of their container storage areas. Generators should do the following regarding hazardous waste
container storage:
1. Ensure the waste containers are accessible to the EHS & Insurance Office.
2. Accumulate their waste in safe, transportable containers that are properly labeled and
stored to prevent human exposure to, or environmental release of, the hazardous waste
materials.
3. Ensure that hazardous waste containers are compatible with the hazardous chemical
waste contents (e.g., do not use metal containers for corrosive waste or plastic
13
containers for organic solvent). Currently, ACC’s hazardous waste disposal vendor
supplies each campus with containers.
4. Use containers that are in good condition and do not leak. All containers must have
suitable screw caps or other means of secure closure. Also true of universal wastes,
e.g., batteries?
5. When waste containers) are required, contact the EHS & Insurance Office for
assistance on selection and placement of appropriate container type and size.
Never overfill hazardous waste containers. Expansion and excess weight can lead to spills,
explosions, and extensive environmental exposure. The following guidelines will help prevent
overfill of containers.
1. Containers of solids must not be filled beyond their weight and volume capacity.
2. Jugs and bottles should not be filled above the shoulder of the container.
3. Closed-head cans (5 gallons or less) should have at least two inches of headspace
between the liquid level and the head of the container.
4. Closed-head drums (larger than 5 gallons) should have at least four inches of
headspace.
Containers must be closed or sealed to prevent leakage. All waste collection containers must be
kept closed except when adding or removing material.
H. Satellite Accumulation Area and 180-Day Accumulation Storage Areas
Hazardous waste that is generated at or near the point of generation is accumulated in a Satellite
Accumulation Area (SAA). Once the waste leaves the SAA, it can be stored in 180-Day
Accumulation Storage Area. As stated above in Section II, ACC has opted to store hazardous
waste in compliance with the SQG regulatory requirements, which allows for 180-Day
Accumulation Storage Area. Each accumulation area has specific requirements set forth in the
regulations.
The following requirements pertain to Satellite Accumulation Areas:
1.
14
The area is secured from “Unauthorized Entry”.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Warning signs (specify) and emergency contacts are posted. These signs are
available from EHS and I.
Hazardous waste is stored in a designated and marked area.
Storage containers are properly labeled with the words “hazardous waste” or with
other words that identify the contents of the containers.
Storage containers are in good condition. If container begins to leak, the generator
must transfer the hazardous waste from the leaking container to a container in good
condition.
Storage containers must be compatible with the hazardous waste being stored (i.e.
made of or lined with materials which will not react with the hazardous waste).
Storage containers must be closed except when adding waste.
Full storage containers are properly labeled as indicated above and marked with an
accumulation start date (reflects the date of the day that the container becomes
full). Once an accumulation start date is assigned, no more materials can be added
to the container.
Areas must be accessible to EHS & Insurance personnel.
Hazardous waste containers are separated from non-waste chemicals.
Less than 55 gallons of any one hazard class of waste or one quart of acutely
hazardous waste is being stored.
Full containers labeled and marked with an accumulation start date are not stored
for more than three days. The generator must transfer full containers to the 180Day Accumulation Storage Area within three days.
Appropriate spill Control Equipment is available.
Weekly inspection of the Satellite Accumulation Area must be completed, using
the form in Appendix C
The following requirements pertain to 180-day Accumulation Storage Areas:
1.
2.
3.
15
The area is secured from “Unauthorized Entry".
Warning signs (specify) and emergency contacts are posted. EHS & Insurance is
the RCRA designated Emergency Coordinator. These signs are available from
EHS and Insurance Office.
Hazardous waste containers and drums stored in the container storage must adhere
to the following guidelines.
a. Containers are properly labeled with the words “hazardous waste” and marked
with an accumulation start date. Once an accumulation start date is assigned, no
more materials can be added to the container.
b. Drums are marked with a completed RCRA sticker. ACC’s hazardous waste
disposal vendor will apply appropriate Department of Transportation (DOT)
labeling prior to shipment.
c. Containers are closed except when adding or removing waste.
d. Containers are in good condition and not leaking.
e. Containers are properly segregated according to hazard class and separated
from non-hazardous waste chemicals.
f. Containers are stored to maintain aisle space to allow the unobstructed
movement of personnel so that they can be inspected.
g. Containers have not been stored for more than 180 days (or 270 days if TSD
facility is greater than 200 miles away.
4. Area is inspected weekly (Appendix C provides a copy of the Container Storage Area
Inspection Sheet). Monthly inspection records are to be submitted to the EHS &
Insurance Office by the 5th day of the following month. Inspection records are to be
maintained for 1 year.
6. Appropriate spill prevention and control measures are established (see Appendix D).
I. Hazardous Waste Labels and Labeling
1.
2.
3.
16
The original chemical label on containers used for waste accumulation must be
destroyed or defaced.
EPA regulations require that hazardous waste containers be labeled with the words
"Hazardous Waste" when the hazardous waste is first added to the container.
Containers at ACC can be labeled in one of two methods:
a. For small containers (less than 5-gallons), attach a completed Hazardous
Waste Disposal Tag (available from the EHS & Insurance Office) with string
to each new waste container when the chemical is first added. Print the
information on the tag legibly. Do not fill in the accumulation start date.
• Alternate means of identifying waste constituents, dates and quantities
may be used with the prior approval of EHS & I Office. These may be
in the form of spreadsheets or tabulation documents that are supplied to
EHS & I Office at the time a chemical waste pickup is requested.
b. For containers larger than 5-gallons, a Hazardous Waste Label (available from the
EHS & Insurance Office) can be used. These labels have an adhesive back and are
placed on the container when the chemical is first added. Hazardous waste labels
for printing out are available through this hyperlink Hazardous Waste Labels.
Identify the hazardous waste on the label but do not fill in the accumulation start
date.
Follow the example below to properly complete your hazardous waste disposal tag:
Fill in the Accumulation Start Date and attach a completed waste disposal tag when the waste
container is full and /or ready for pickup.
HAZARDOUS WASTE
ACCUMULATION
START DATE
CONTENTS
acetone, chloroform, hexane
oil, water
HANDLE WITH CARE!
CONTAINS HAZARDOUS OR TOXIC WASTE
17
(ATTACH TAG TO CONTAINER WITH
STRING)
HAZARDOUS WASTE
DISPOSAL TAG
-----------------------------------------------------------------------2
REQUESTOR :
DEPT/PART:
John Doe
Chemistry
PHONE:
5-3140
CHEMICAL (S)3: Methylene Chloride, Toluene
Attach An Individual Hazardous Waste
Disposal Tag To Each Waste Container
Both upper and lower sections of the tag must
be filled out completely and legibly except
for the accumulation date when chemical is
first added to a waste container. (This
information is essential for record keeping).
1 Fill in the Accumulation Start Date when
the waste container is full and/or ready for
pickup.
HAZARDOUS WASTE
DISPOSAL TAG
ACCUMULATION START DATE1:
5/22/96
Secure the top part of the tag with a string that
encircles the top of the container - rubber
bands, tape, and wire are not acceptable.
2 The "REQUESTOR" is the Principal
Investigator or person in charge of the lab that
generated the waste.
REQUESTOR2: John Doe
DEPT/PART: Chemistry
BLDG.NAME & NO:
Chemistry - 376
ROOM NO. 2002
PHONE: 53140
CHEMICAL (S)3: Methylene Chloride, Toluene
PHYSICAL PROPERTY:
Solid ____ Gas
___Other
18
_____Liquid ____
3 Chemical name/Common name. Chemical
formulas or abbreviations are not
acceptable. List all chemical components in a
waste container (including water). Lists may
be continued on the back of the tag.
Tags for containers of potentially explosive
materials such as picric acid, silanes, nitro
compounds, and ethers must indicate the
percent concentration of these chemicals.
Place any additional Hazard Information
about container contents in REMARKS.
19
J. Hazardous Waste Disposal & Tracking
The EHS & Insurance Office will supply ACC generators a Chemical Waste Request for Disposal form,
coordinate disposal requirements with generators, maintain records of disposal services, and provide
reports as appropriate to Federal or State agencies.
TCEQ and EPA regulations require “cradle to grave” tracking of hazardous waste shipments in order to
ensure proper disposal. Two main forms are required: the Texas Uniform Hazardous Waste Manifest
(Form TNRCC-0311) and land ban documentation. The manifest has four (carbon) copies: green,
yellow, pink, and white. ACC’s hazardous waste disposal vendor prepares all manifests on behalf of the
College prior to pick up. The EHS & Insurance Office is responsible for signing all manifests by hand.
Individuals signing manifests must be certified through appropriate and current training under 49 CFR –
U. S. Department of Transportation (DOT) regulations. At the time of pick up, the initial transporter of
the hazardous waste (ACC’s hazardous waste disposal vendor) and generator (EHS & Insurance Office)
provides a handwritten signature and date of acceptance on the manifest. The EHS & Insurance Office
will retain the green copy and give the transporter the remaining copies of the manifest. The TSD
facility must also sign the manifest upon receipt of the hazardous waste shipment. At this point, the
transporter is given the yellow copy and the TSD facility keeps the pink copy and returns the original
white copy with all signature blocks signed and dated to the EHS & Insurance Office.
The TSD facility must treat listed and characteristic hazardous waste to meet appropriate standards
before land disposal. SQGs must determine whether their waste is restricted from land disposal. This
can be done by testing, process knowledge, or a combination of both. SQGs shipping hazardous waste
must attach a statement to the manifest declaring whether any land disposal restrictions (LDR) apply to
the waste. The LDR includes information on the constituents, categories, and testing data, if available.
ACC’s hazardous waste disposal vendor will handle land ban testing of hazardous waste and will attach
the appropriate information and statement (typically a LDR) to the manifest. However, ACC is still
responsible for their waste and must also maintain land ban documentation for at least three years. ACC
has chosen to maintain land ban documentation indefinitely.
The EHS & Insurance Office arranges vendor-performed routine hazardous waste disposal pickups at
the end of each semester. Approximately one month prior to each pickup, the EHS & Insurance Office
will contact all hazardous waste generators and request they complete a Chemical Waste Request for
Disposal Form, identifying the hazardous wastes each generator has for the upcoming waste shipment.
If a Hazardous Waste Tag is used, the bottom section of the tag must also be sent to the EHS &
Insurance Office at this time. These requests are then compiled into a master list and provided to the
hazardous waste disposal vendor. More frequent vendor pickups for hazardous waste may be scheduled
by the EHS & Insurance Office based on needs at individual Campuses or areas.
The generator requesting hazardous waste disposal service shall ensure that their waste containers meet
the following requirements:
1. The containers are not sitting in the corridors or areas where waste could cause a
health exposure to personnel.
2. The containers are correctly identified by chemical name/common name. Chemical
formulas are not acceptable. When a Hazardous Waste Disposal Tag is completed, fill
20
in the accumulation start date on the disposal tag, separate the bottom part of the
tag, and Inter Office mail it to the EHS & Insurance Office.
3. Labeled containers of liquid/solid chemical waste that are to be stored in the in the
180-Day Accumulation Storage Area. Complete a Chemical Waste Request for
Disposal Form for all containers of hazardous waste materials. Instructions for this
form are available from EHS & Insurance’s Web site.
4.
Containers of liquid and solid waste are in good condition so that handling can be done in a safe
manner and that containers do not leak at a later date. Containers must be suitable for the types of
chemicals they hold and must be suitable for storage for at least 180 days. Containers must be closed
or sealed in such a manner that leakage will not occur. ACC’s hazardous waste disposal vendor will
not pickup containers with improper caps, leaks, outside contamination, or improper labeling.
5. All hazardous waste containers are properly segregated and clearly marked regarding
the contents, hazards and other pertinent information.
6.
Inform the EHS & Insurance Coordinator (ext.3-1021) of any special handling requirements.
7. For lab packs send a Lab Pack Waste Request for Disposal form that includes a list of
all chemicals and quantities to the EHS & Insurance Office.
K. SQG Emergency Preparedness and Contingency Planning
SQGs must designate an Emergency Coordinator to coordinate all emergency response measures. The
emergency coordinator must be on the premises or on call. The EHS & Insurance Director is the
Emergency Coordinator for all ACC campuses. EHS & I Office will provide the required signs for each
generating area at each campus to post next to the telephone or in a visible location on outside waste
storage buildings. These signs will contain the following information:
1. Post the name and telephone number of the emergency coordinator;
2. Location of fire extinguishers and spill control material, and if present, fire alarm; and
3. The telephone number of Campus Police Dispatch and the fire department, unless the campus
has a direct alarm
As part of a facility’s contingency planning, the EHS & Insurance office will attempt to make
arrangements with the appropriate local emergency response authorities regarding the type of waste
handled at the facility and the potential need for these organization’s services. The arrangements should
include the following:
1. Arrangements to familiarize police, fire departments, and emergency response teams with the
layout of the facility, properties of hazardous waste handled at the facility and associated
hazards, places where facility personnel would normally be working, entrances to roads inside
the facility, and possible evacuation routes;
2. Where more than one police and fire department might respond to an emergency, agreements
designating primary emergency authority to a specific police and fire department;
3. Agreements with State emergency response teams, emergency response contractors, and
equipment suppliers; and
4. Arrangements to familiarize local hospitals with the properties of hazardous waste handled at the
facility and the types of injuries or illnesses that could result from fires, explosions or releases at
the facility.
21
L. Hazardous Waste Management Recordkeeping & Reporting
1. Hazardous Waste Manifest – SQGs are required to keep a copy of each signed manifest for three
years from the date the waste was accepted by the initial transporter. However, the EHS &
Insurance Office has opted to maintain manifests indefinitely.
2. Land Ban Documentation - SQGs are required to retain on-site a copy of all notices,
certifications, waste analysis data (including Land Disposal Restrictions for at least three years.
As with the manifest, the EHS & Insurance Office will maintain them indefinitely.
3. Contingency Plans – SQGs are not required to maintain a written contingency plan.
4. Annual Waste Summary – SQGs must submit an annual waste summary to the TCEQ. SQGs
may submit their summary in written format. The TCEQ uses this information to calculate a
generator’s annual waste generation fee.
V. Other Regulated Waste
A. Used Dry Solid Materials
Used dry solid materials (paper, rags, towels, gloves, or Kim Wipes, etc.) contaminated with a listed
hazardous constituent or with extremely toxic chemicals must be double-bagged in heavy-duty plastic
bags and disposed as hazardous waste. Do not use biohazard bags. ACC has also opted to treat dry
solid materials contaminated with a characteristic hazardous constituent (a wipe in contact with a
flammable solvent such as acetone) as hazardous waste. This is due to the potential for these type
materials to also have been in contact with a listed hazardous constituent or extremely toxic chemical.
The EHS & Insurance Office has permitted an alternative to hazardous waste disposal of dirty solvent
rags with use of a commercial laundry service, G & K Services. In this case, G & K Services routinely
picks up dirty solvent rags (that are typically stored in red metal flip top cans) for laundering and
replaces them with clean rags.
B. Used Oil, Used Oil Filters and Used Antifreeze
Used oil is any petroleum-based or synthetic oil that has been used. Used oil that has not been
contaminated with any other hazardous material is considered to be a non-hazardous waste. Used oil
should be stored in storage containers (30 or 55-gallon metal or poly drums if possible) or tanks. Label
all containers and tanks with the words “Used Oil”. Keep containers and tanks in good condition. Do
not allow tanks to rust, leak, or deteriorate. As a good management practice, keep containers and tanks
closed unless adding to or removing used oil. Do not mix any hazardous material or waste with used
oil. To be sure that your used oil does not become contaminated with hazardous waste, store it
separately from all solvents and chemicals and do not mix it with anything. Used oil contaminated with
a listed hazardous waste must be managed and disposed of as a hazardous waste. EPA hazardous waste
code “F002” must be used on used oil that is listed due to halogenated contaminants. Non-contaminated
used oil does not require an EPA hazardous waste code. Used oil is sent out for vendor recycling at
ACC. When a used oil pick up is required, contact the EHS & Insurance Office and a pick up will be
scheduled. Used oil can be accumulated indefinitely provided it is non-contaminated. Please
accumulate at least 55 gallons before calling for a pick up.
22
Used oil filters are also picked up for vendor recycling. Texas law prohibits the dumping of used oil on
land, in sewers, and in waterways. Texas has also banned used oil and used oil filters from being placed
in or accepted for disposal in a landfill.
Currently ACC has one area, Riverside Campus Automotive, which generates used oil and used oil
filters for vendor recycling.
Used antifreeze removed from vehicles may be a hazardous waste. The EPA or TCEQ have not issued
specific regulations for used antifreeze, but general rules for hazardous waste can apply. After antifreeze
goes through a radiator it may be contaminated with gasoline, oils and metals (includes lead, mercury,
cadmium, chromium, copper and zinc). Metals and benzene (from gasoline) are toxic and may cause the
used antifreeze to be a hazardous waste. Antifreeze would also be considered hazardous if it were
mixed with a hazardous material such as a degreasing solvent or gasoline. In addition, antifreeze could
be hazardous if it comes from an old car where the antifreeze has been sitting for years and has picked
up enough metals to be characterized as hazardous for metals content, e.g., >5 parts per million (ppm)
lead, or if the pH is ≥12.5.
ACC’s disposal option for used antifreeze is vendor recycling, if available. If ACC’s used antifreeze
cannot be recycled, it must be disposed of as hazardous waste. Used antifreeze should never be dumped
into a sanitary sewer, storm drain, ditch, dry well or septic system. Many sewage treatment agencies
responsible for wastewater treatment prohibit waste antifreeze disposal into sanitary sewers. Waste
antifreeze disposed of down storm drains or into surface? causes serious water quality problems and
may harm people, pets and wildlife.
C. Gas Cylinders
Gas cylinders should be returned to the manufacturer or distributor whenever possible. Non-returnable
gas cylinders should be labeled and disposed of as hazardous waste.
D. Photographic Processing Waste
Photographic lab waste containing silver must be disposed as hazardous waste. However, silver
recovery units include a filtration system that removes the silver. Photographic lab effluent that does
not contain silver may be discarded through the sanitary sewer system. Please notify the EHS&
Insurance Office if you have this type of equipment.
E. Unknown Chemical Waste
"Unknown" chemical waste will be handled by the EHS & Insurance Office. Place a waste disposal
tag on the container using "unknown" for the chemical waste description. In addition, mark or label the
container as ‘hazardous waste’. ACC will manage the waste as hazardous until testing results indicate
otherwise. Any area generating an unknown chemical waste will be required to supply a documented
23
corrective action provided by the Dean, Director or unit head of the generating area.
F. Universal Waste
Universal waste is any hazardous waste subject to 40 CFR Part 273 (Standards for Universal Waste
Management) and 30 TAC 335.261 (Universal Waste Rule). As part of EPA’s commitment to reinvent
environmental regulations, the Agency issues the “Universal Waste Rule.” This rule was designed to
encourage recycling and proper disposal of certain common hazardous waste wastes while also reducing
the regulatory burden on facilities that generate these wastes. Basically, the TCEQ Universal Waste
Rule offers alternatives to the otherwise applicable regulations for managing five types of hazardous
waste in Texas:
A.
B.
C.
D.
E.
Batteries including lead-acid as described in 40 CFR 273.2;
Pesticides as described in 40 CFR 273.3;
Mercury Thermostats as described in 40 CFR 273.4;
Lamps (mercury, metal halide, etc.) as described in 40 CFR 273.5; and
Paint and paint related waste as described in 30 TAC 335.262(b).
For more information please refer to the EHS & I Office web site Universal Waste Procedures or
contact EHS & I Office for additional information.
G. Biohazardous Waste
Sharps (needles, razor blades, scalpel blades, syringes, glass Pasteur pipettes, etc.) are classified as biohazardous waste even if they are not contaminated. Sharps must be encapsulated (placed in a "puncture
resistant" container or plastic/metal container and filled with paraffin or plaster of paris). Discard the
containers of sharps as bio-hazardous waste. For additional information on disposal of bio hazardous
waste, please refer to the EHS & I Office web site Bio-Hazardous Waste Procedure (link to
procedure) or contact the EHS & Insurance Office for additional information.
H. Contractor Waste
Any hazardous waste that is generated in conjunction with contractor / vendor work performed for ACC
falls under the same regulatory requirements as if ACC is the generator. Project managers, project
coordinators and purchasing are responsible for clearly delineating in the contract that is responsible for
managing the hazardous waste generated by a contracted project. The contract must clearly state that
the vendor assumes responsibility for disposing of hazardous waste generated by a project in adherence
to all applicable state and federal regulations. If it is not clearly stated in the contract that the vendor is
responsible for hazardous waste disposal, ACC is responsible for proper disposal of any hazardous
waste generated from the project being performed for the College. The project manger will be required
to follow procedures outlined in this document. ACC still retains ultimate responsibility as generator of
the hazardous waste. Refer to Contractor Safety Manual.
24
VI. Source Reduction and Hazardous Waste Minimization
Hazardous waste regulations have evolved from emphasis on reduction to the prevention of
environmental pollution. The Pollution Prevention Act of 1990 (Federal Regulation) made the
prevention of pollution and reduction of waste generation, a national priority. The Texas Waste
Reduction Policy Act (Senate Bill 1099 of 1991) requires Large Quantity Generators to prepare and
implement a Source Reduction and Waste Minimization Plan. At this time, ACC is not required to
develop a Plan due to being a Small Quantity Generator. Appendix E has been included in the event a
Plan is required to be developed due to an increase in generator status. The Plan will be developed and
coordinated by the EHS & Insurance Office.
The key to the Plan is "front-end minimization". Front-end minimization means reducing hazardous
waste by reducing the quantities of hazardous chemicals used and by substituting less hazardous
materials. Teaching laboratories and other working groups (Physical Plant, Power Plant, etc.) that
generate hazardous waste should review their purchasing practices and systems, chemical usage
patterns, and workplace activities to identify potential points of their operations where source reduction
and waste minimization can be implemented.
•
Prudent Practices and Special Concerns
1. Minimizing Quantities of Hazardous Waste – It is common practice to order chemicals in larger
quantities than necessary to take advantage of reduced costs of substances. As a result, aging
reagents or solvents are left for disposal. With the current high disposal costs, often disposal is
more than the initial acquisition cost of the chemicals. It is estimated that as much as 40% of
laboratory hazardous waste may be unused chemicals. Besides reducing the disposal cost,
smaller inventories reduce exposure to personnel. Storage of unused chemicals for an extended
period of time tends to increase the risk of an accident.
Another way to reduce quantities of waste is by precipitating out the active chemicals and
drying or filtering the water from the hazardous waste. As waste technology advances, the
removal of non-hazardous materials and separation of chemicals from waste is becoming more
desirable. This is often most easily accomplished at the point of generation.
2.
Substitution - Substitution of non-hazardous or less hazardous chemicals for a hazardous
chemical is a commonly used method of reducing hazards and wastes. Examples include using
hot water and soap for cleaning instead of toxic, flammable organic solvents; "Nochromix"
instead of toxic chromic/sulfuric acids; water-based paints instead of oil-based paints; spiritfilled thermometers instead of mercury-filled thermometers; and non-carcinogenic solvents
instead of carcinogenic solvents. Substitution is not always possible but should be accomplished
when practical.
3.
Surplus Chemical Exchange - The concept of exchanging excess solvents and reagents with
other labs or departments needing these materials reduces purchasing and disposal costs. It has
25
been established that other labs can use about 30% to 40% of excessive or unused materials.
Exchange of materials should be emphasized. EHS and I Office must be contacted to arrange
for transportation of chemicals. Chemicals shall be transported by vendors that are certified /
licensed to transport chemicals.
4. Unknown - Unknowns are a special problem in labs, especially when labs change occupants or
processes. Labs should be cleaned up and old unneeded chemicals disposed of by the occupant
who is terminating the use of the lab. Immediately label all chemicals so that they do not
become unknowns. All chemicals, mixtures and solutions should be clearly labeled at all times.
All unknowns will have to be analyzed by an EPA certified laboratory in order to have
constituents or characteristics identified to allow for proper waste classification. Although
analysis is often expensive and time consuming, there is no alternate solution to proper
identification of unknown hazardous waste or materials. Cost for analysis and identification of
any unknowns, whenever necessary, is the responsibility of the generator of the unknown
hazardous waste and will be accomplished prior to request for disposal.
5. Special Laboratory Disposal Methods - The EPA and the TCEQ provide several regulatory
exclusions that allow generators to treat hazardous waste without a permit. One on-site treatment
method is elementary neutralization. This treatment is used to neutralize corrosive (D002)
wastes. For example, small amounts of common inorganic acids (except hydrofluoric and
chromic acids) can be diluted and neutralized to a pH between 5 and 10 and disposed of via the
sanitary sewer. Hazardous chemicals can be treated to reduce the hazard or the quantity of waste
in the laboratory ONLY if the treatment procedure is included as part of the written
experimental protocol. This must be approved through the EHS & Insurance Office.
Inert, non-toxic salts, sugars and buffers can be diluted and disposed via the sanitary sewer.
Contact the EHS & Insurance Office before any treatment or disposal of chemical waste is
performed in the laboratory.
6. Reactive Materials - Reactive wastes include cyanides, sulfides, air and/or water reactives,
oxidizers, explosives, and flammable solids. Special care must be exercised when handling these
materials to prevent contact with incompatible materials, such as air, water or organic materials.
Reactives should be isolated from other hazardous waste and should be stabilized whenever
possible. For example, water reactives should be stored in a desiccator and picric acid should
always be saturated with water.
7. Disposal Costs - A lab-pack is the most common and most expensive method of packaging nonbulkable solid chemical waste, such as toxics and reactives, for disposal. Chemical waste
materials in various sized containers are packed into metal drums for transportation and final
disposal. An inert packing material (vermiculite) is used to surround and protect the containers.
Lab-packs contain a maximum of 17 gallons of waste chemicals per 55-gallon drum, 8 gallons
per 30-gallon drum, and 1 gallon per 5-gallon pail. The most recent disposal cost of a 55-gallon
lab-pack averages about $550.00. This cost includes preparation, packaging, labeling,
transportation, and ultimate treatment or disposal.
26
8.
VII.
Non-hazardous Waste Disposal - All chemical wastes that do not meet the definition of a RCRA
hazardous waste must still be disposed of properly to protect human health and the environment.
In most cases, disposal via the sanitary sewer or the trash is not permitted; however, there are
exceptions, which will be made by the EHS & Insurance Office on a case-by-case basis.
Emergency Procedures
Chemical-using personnel and students (specify - what about students?) are required to receive training
on the hazards associated with chemicals used and how to respond to emergencies). ACC Hazard
Communication Program requires that ACC employees be informed of hazardous materials that they
might use or be exposed to at work. In addition, the program should include training on handling spills
and other emergencies. Material Safety Data Sheets (MSDSs) are a source of this information and
should be maintained for all chemicals used or stored within a workplace. Special cleanup supplies
should be available and employees should be trained on how to use these supplies. The EHS &
Insurance Office can provide additional information on handling specific chemical spills. Hazardous
waste disposal procedures should be followed for disposal of contaminated clothing, rags, absorbent
materials or other waste generated from clean up of spills or leaks. All chemical-using areas should post
emergency numbers to be used and develop a response scenario for emergencies. All chemical users
should know emergency numbers and develop a response scenario for emergencies. Refer to ACC
Hazardous Material Spill Procedure
APPENDIX A:
DEFINITIONS
Accumulation Start Date The date when a hazardous waste container is full. This is the date from which a Small Quantity Generator
has 180 days to dispose of the waste.
Acutely Hazardous Waste Wastes are considered "acutely hazardous". These are wastes that the EPA has determined to be so
dangerous in small amounts that they are regulated the same way large amounts of other hazardous
wastes are. These include all "P" listed wastes and mixtures under EPA waste codes F020, F021, F022,
27
F023, F026 and F027 from non-specific sources found in the federal regulations (40 CFR Part 261
Subpart D.).
180-Day Accumulation Storage Area –
Site designated by the Environmental Health Safety & Insurance Office to be used for the storage of
hazardous wastes prior to shipment to permitted disposal facilities.
Characteristic Hazardous Waste Waste that exhibit one or more of the four characteristics referenced in the federal regulations (40
CFR Part 261 Subpart C) is considered hazardous.
Disposal The discharge, deposit, injection, dumping, spilling, or placing of any solid waste or hazardous waste
(whether containerized or non-containerized) into or on any land or water so that such solid waste or any
constituent thereof may enter the environment or be emitted into the air or discharged into any water,
including ground waters.
EPA Identification Number –
The number assigned by the Environmental Protection Agency to each generator, transporter, and
processing, storage or disposal facility..
Facility –
Includes all contiguous land, and structures, other appurtenances, and improvements on the land used for
storing, processing, or disposing of municipal hazardous waste or industrial solid waste.
Generator –
Any person, by site, who produces municipal hazardous waste or industrial solid waste; any person who
possesses municipal hazardous waste or industrial solid waste to be shipped to any other person; or any
person whose act first causes the solid waste to become subject to regulation. Person refers to an
individual, trust, firm, corporation, Federal Agency, State, political subdivision of a State, municipality,
or any interstate body.
Hazardous Material –
A substance or material, including a hazardous substance, which has been determined by the Secretary of
Transportation to be capable of posing an unreasonable risk to health, safety, and property when transported
in commerce, and which has been so designated.
Hazardous Waste –
Any solid waste material listed or identified in Title 40 Code of Federal Regulations, Part 261, Subpart C
and D or exhibiting the characteristics of ignitability, corrosivity, reactivity, or E.P.A. toxicity also defined
in Part 261. Tables containing the listing and characteristics of hazardous wastes are shown in Appendix B.
Lab Pack -
28
Method of categorizing unused, obsolete or unknown chemicals, determining the optimum disposal
process, and implementing lab pack disposal. Qualified personnel pack these materials in compliance
with EPA and DOT regulations. For example, the EPA requires that carriers be federally licensed and
insured and that disposal facilities comply with their standards. The DOT mandates that waste materials
be packaged, labeled and shipped according to its regulations.
Listed Hazardous Waste Over 400 commercial chemical products and wastes from specific industrial and manufacturing
processes are listed as hazardous wastes in the Code of Federal Regulations (40 CFR Part 261 Subpart
D.) Listed wastes have a chemical specific or generic mixture identification number assigned by the
EPA. For example; Phenol is U188, a certain chlorinated solvent mixture might be F002 depending of
the mixture. Listed waste consists of four lists defined by the EPA, the K-list, F-list, U-list and P-list.
Manifest –
A legal document containing required information, which must accompany shipments of Municipal
Hazardous Waste or Class I-Industrial Solid Waste transported on public roads or thoroughfares.
Mixed Waste –
A radioactive waste that is also a hazardous waste.
Permit –
A written document issued by EPA or TCEQ that, by its conditions, authorizes the construction,
installation, modification, or operation of a specified municipal hazardous waste or industrial solid
waste storage, processing, or disposal facility in accordance with specified limitations.
Person Any individual, corporation, organization, government or governmental subdivision or agency, business
trusts, partnership, association or any legal entity.
Processing –
The extraction of materials, transfer, volume reduction, conversion to energy, or other separation and
preparation of solid waste for reuse or disposal, including the treatment or neutralization of hazardous
waste, designed to change the physical, chemical, or biological character or composition of any
hazardous waste so as to neutralize such waste, or as to recover energy or material from the waste or so
as to render such waste non-hazardous or less hazardous; safer to transport, store, and dispose; or
amenable for recovery, amenable for storage, or reduced in volume.
Recyclable Materials –
Wastes that are recycled. Recycled material is used, reused, or reclaimed.
Reclaimed material –
Is processed or regenerated to recover a usable product. Examples: Recovery of lead from spent
batteries, or regeneration of spent solvent.
29
Satellite Accumulation Area –
An area, system, or structure used for temporary accumulation of hazardous waste prior to transport to
the central accumulation area.
Solid Waste –
Any garbage, refuse, sludge from a waste treatment plant, water treatment plant, or air pollution control
facility or other discarded material, including solid, liquid, semi-solid, or contained gaseous material
resulting from industrial, municipal, commercial, mining and agricultural operations, and from
community and institutional activities.
Storage –
The holding of solid waste for a temporary period, at the end of which the waste is processed, disposed
of, recycled, or stored elsewhere.
Texas Solid Waste Number –
The number assigned by the TCEQ to each generator, transporter, and processing, storage, or disposal
facility.
TCEQ The Texas Commission on Environmental Quality is the governing agency responsible for regulating
the discharge of pollutants into waters of the state; regulates hazardous and industrial solid waste
generation, storage, transportation, treatment and disposal; and regulates the cleanup of inactive and
abandoned hazardous waste sites in the State of Texas.
Transporter –
Any person who conveys or transports municipal hazardous waste or industrial solid waste by truck,
ship, pipeline or other means.
Universal Waste –
Any hazardous waste subject to 40 CFR Part 273 and 30 TAC 335.261 to include:
F. Batteries including lead-acid as described in 40 CFR 273.2;
G. Pesticides as described in 40 CFR 273.3;
H. Mercury Thermostats as described in 40 CFR 273.4;
I.
Lamps as described in 40 CFR 273.5; and
J.
Paint and paint related waste as described in 30 TAC 335.262(b).
Used Oil Used oil is any petroleum-based or synthetic oil that has been used
Waste –
Any material for which there is no use and is to be discarded as valueless.
30
APPENDIX B: IDENTIFICATION OF HAZARDOUS WASTE
40 CFR
Subpart C—Characteristics of Hazardous Waste
§ 261.20 General.
§ 261.21 Characteristic of ignitability.
§ 261.22 Characteristic of corrosivity.
31
§ 261.23 Characteristic of reactivity.
§ 261.24 Toxicity characteristic.
Subpart D—Lists of Hazardous Wastes
§ 261.30 General.
§ 261.31 Hazardous wastes from non-specific sources.
§ 261.32 Hazardous wastes from specific sources.
§ 261.33 Discarded commercial chemical products, off-specification species, container
residues, and spill residues thereof.
§ 261.35 Deletion of certain hazardous waste codes following equipment cleaning and
replacement.
§ 261.38 Comparable/Syngas Fuel Exclusion.
Appendix I to Part 261—Representative Sampling Methods
Appendix II to Part 261 [Reserved]
Appendix III to Part 261 [Reserved]
Appendix IV to Part 261 [Reserved for Radioactive Waste Test Methods]
Appendix V to Part 261 [Reserved for Infectious Waste Treatment Specifications]
Appendix VI to Part 261 [Reserved for Etiologic Agents]
Appendix VII to Part 261—Basis for Listing Hazardous Waste
Appendix VIII to Part 261—Hazardous Constituents
Appendix IX to Part 261—Wastes Excluded Under §§260.20 and 260.22
Appendix C -
SATELLITE ACCUMULATION AREA WEEKLY INSPECTION FORM
32
Following 2 forms will be posted on web and hyperlinked to program
180 Day Accumulation Area Inspection Sheet
Weekly Inspection
Date: _______________________________
Location:
Department: ______________________________
Contact Person: __________________
Inspected by: _____________________________
33
Accumulation Time
1. Is the beginning date of accumulation clearly indicated
on each container?
□ N/A □ Yes □ No
2. Has accumulation time limitation been exceeded?
□ N/A □ Yes □ No
3. Has accumulation quantity been exceeded?
□ N/A □ Yes □ No
4. Is each container being used to collect waste marked
“Hazardous Waste” and identifiable contents?
□ N/A □ Yes □ No
Comment:
Containers
1.
Are containers in good condition?
□ N/A
□ Yes
□ No
2.
Are all containers kept closed and stored in a safe manner?
□ N/A
□ Yes
□ No
3.
Is waste compatible with container?
□ N/A
□ Yes
□ No
4.
Any noticeable chemical contamination on the containers?
□ N/A
□ Yes
□ No
5.
Are containers inspected weekly for leakage and deterioration?
□ N/A
□ Yes
□ No
Comment:
Storage
1.
Are incompatible wastes appropriately separated?
□ N/A
□ Yes
□ No
2.
Does the storage area have containment protection?
□ N/A
□ Yes
□ No
3.
Are spill cleanup supplies available?
□ N/A
□ Yes
□ No
A. Date and time of inspection?
□ N/A
□ Yes
□ No
B. Name of inspector?
□ N/A
□ Yes
□ No
C. Recorded observation and date of repairs/remedial action?
□ N/A
□ Yes
□ No
Comment:
4.
Does the inspection log include:
Comment:
34
Discharges
1.
Is there any evidence of spills or leaks from the waste?
□ N/A
□ Yes
□ No
2.
Is there any evidence of fires or explosion from the waste?
□ N/A
□ Yes
□ No
Comment:
Security
1.
Is area secured from Unauthorized Entry?
□ N/A
□ Yes
□ No
2.
Is the area have a “Danger - Unauthorized Personnel Keep Out”
sign posted?
□ N/A
□ Yes
□ No
3.
Does the area have a “Danger - No Smoking” sign posted?
□ N/A
□ Yes
□ No
4.
Are emergency contacts and phone numbers posted?
□ N/A
□ Yes
□ No
Comment:
35
WEEKLY 180 DAY ACCUMULATION AREA INSPECTION LOG SUMMARY
Submit to EHS & I by 5th of Following Month
Month ____________________, ___________
Date/Time
Inspector
1
2
3
4
Place a " √ " in the Category that is "Satisfactory"
Place an "X" in the Category that is "Not Satisfactory"
Place "N/A" if it does not apply
36
5
6
7
8
9
10
11
12
13
14
Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
General Order
General Cleanliness
Building Condition
Spill Containments
Equipment
A.
Eye protection
B.
Spill pillows, plastic disposal bags
C.
Gloves, tyvek suits, etc.
D.
Sock / absorbent
E.
Mop, broom, bucket, dustpan
Fire extinguishers
Locks
Ground Wire
Electrical/Lights
Telephone
Ventilation
Emergency Eyewash
Emergency Shower
Drum Storage
A.
Drum Condition
C. Isle Width
B.
RCRA Stickers
D. Non-leaking Drum
President/Executive Vice President:
Date:
Waste Management Appendix A
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[$
(Generators of less than 50 pounds of regulated medical waste per month, who ship less than 50 pounds per shipment)
Waste Management Appendix B
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[%
Waste Management Appendix C
Directory of Dental Waste Recyclers
Notice and Disclaimer
This Directory of Dental Waste Recyclers has been compiled from information supplied by
companies listed in websites and other public information sources. It is provided solely for
general informational purposes and should not be used as a substitute for a dentist's own
evaluation of a prospective recycler.
A listing in this directory does not indicate, and is not to be interpreted as, an endorsement by
the American Dental Association (ADA) of the listed recycler, the accuracy of the
information in a recycler’s listing or the recycler’s services or products. The ADA provides
no guarantees or warranties for the recyclers and/or their services as listed in this directory.
The information in this directory is current as of March 2012. Since information may
change, the directory will be updated periodically. Users who become aware of any updates
can send new information to [email protected] or can fax updates to 312/440-2536.
ADA recommends that dentists contact recyclers before recovering waste, such as amalgam,
and ask about any specific handling instructions the recycler may have. It is important to
select a reputable recycler that complies with applicable federal and state law, and provides
adequate indemnification for its acts and omissions.
Some Questions You May Wish to Ask Your Recycler …
What kind of waste do you accept?
Do your services include pick up of waste from dental offices? If not, can waste
be shipped to you?
Do you provide packaging for storage, pick up or shipping of waste?
If packaging is not provided, how should the waste be packaged?
What types of waste can be packaged together?
Do your procedures comply with ANSI/ADA Specification 109: Procedures for
Storing Dental Amalgam Waste and Requirements for Amalgam Waste
Storage/Shipment Containers?1
Does your company have an EPA or applicable state license?
Does the company use the proper forms required by the EPA and state agencies?
How much do your services cost?
Do you accept whole filters from the vacuum pump for recycling?
Do you pay for clean non-contact amalgam (scrap)?
Do you accept extracted teeth with amalgam restorations?
Is disinfection required for amalgam waste?
1
American National Standard/American Dental Association Specification No. 109 - 2006. Procedures for
storing dental amalgam waste and requirements for amalgam waste storage/shipment containers. Chicago:
American Dental Association.
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
c
Mail-In
√
√
√
√
Pick-Up
√
√
√a
√
Liquid
Mercury
√
√
√
√a
Contact
Amalgam
√
√
√
√
√
Non-Contact
Amalgam
√
√
√
√
√
Extracted
Teeth w/
Amalgam
√
√
√
√
Amalgam
Traps & Filters
√
√
√
√
√
Sludge
√
√
√
√b
√
Fixer Solution
√
√
√
√
Lead Foil
Packages
√
√
√
√
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste
a
b
and requirements for Amalgam Waste Storage/Shipment Containers. Service available in California only. Will accept if already coming to pick up crowns or bridgework.
c
No information supplied to us from the company regarding compliance with Specification No. 109.
Clean Harbors, Inc.
Norwell, MA
(800) 282-0058
www.cleanharbors.com/
c
Carolina Environmental Associates
Burlington NC
(336) 229-0058
Bethlehem Apparatus Company
Hellertown, PA
(610) 838-7034
www.bethlehemapparatus.com/
Barnes HazMat, Inc.
Pacoima, CA
(877) 600-6737
www.barneshazmat.com/
Amalgaway
Indianapolis, IN
(800) 267-1467
www.amalgaway.com/
Company/Contact Information
Lead Aprons,
Collars
Radiograph-Related
Waste
Radiographs
Dental Waste Recyclers Providing Nationwide Services
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
√
√
√
√
√
√
√
√
√
√
√
√e √e
√
√
√
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste and
e
f
d
requirements for Amalgam Waste Storage/Shipment Containers.
No amalgam waste accepted via mail-in. Limitations apply. Call for information. Pick up within 150 miles
of Rogers, MN.
√f
√
√
√
√
√
Enviro-Chem, Inc.
Rogers, MN
(800) 225-8322
(800) 999-1294 (CA)
www.enviro-chem.bz/
√
√e √e √e
√
√e √e √ e √ e √ e √ e √ e √ e √ e √ e √ e √ e √
Mail-In
EcoSolutions/Stericycle
Milpitas, CA
(866) 783-7422
http://www.stericycle.com/
√
√
Liquid
Mercury
√
√e
√
Extracted
Teeth w/
Amalgam
Doral Refining
Freeport, NY
(800) 645-2794
www.doralcorp.com/
Non-Contact
Amalgam
√
Amalgam
Traps & Filters
√d
Contact
Amalgam
√
Sludge
Dental Refiners
Stateline, Nevada
(800) 786-1742
Pick-Up
√
Fixer Solution
√
Radiographs
Dental Recycling North America Inc.
New York, NY
(800) 360-1001
www.drna.com/
Company/Contact Information
Lead Foil
Packages
Radiograph-Related
Waste
Lead Aprons,
Collars
Dental Waste Recyclers Providing Nationwide Services, cont’d.
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
√
Healthcare Compliance Service
Palm Bay, FL
(888)726-8505
www.hcstoday.com
Pick-Up
√g
√
Liquid
Mercury
√
√
√
Contact
Amalgam
√
√
√
√
Non-Contact
Amalgam
√
√
√
√
√
Extracted
Teeth w/
Amalgam
√e
√
√
√
√
Sludge
√
√
√
√
√
√
√
√
√
Radiographs
√
√
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam
c
g
Waste and requirements for Amalgam Waste Storage/Shipment Containers. Available in New York City and surrounding areas. No information supplied to us from
e
the company regarding compliance with Specification No. 109. Limitations apply. Call for information.
√
√
Greymart Metal Co.
Brooklyn, NY
(800) 238-1813
www.greymart.com/
c
√
Green Lights Recycling, Inc.
Blaine, MN
(800) 208-8340
www.greenlightsrecycling.com
Heritage Environmental Services
Indianapolis, IN
(888) 437-4224
www.heritage-enviro.com
√
Mail-In
Garfield Refining Company
Philadelphia, PA
(800) 523-0968
www.garfield-refining.com/
Company/Contact
Information
Amalgam
Traps & Filters
Radiograph-Related
Waste
Fixer Solution
Dental Amalgam-Related Waste
Lead Foil
Packages
Type of
Program
Lead Aprons,
Collars
Dental Waste Recyclers Providing Nationwide Services, cont’d.
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
Pick-Up
√ √e √e √ e
Non-Contact
Amalgam
√e
√
√
√
Extracted
Teeth w/
Amalgam
√e
√
√
√
Amalgam
Traps & Filters
Sludge
√
√
√
√
Fixer Solution
√
√
√
√e √e √e √e
√
√
√
√e √e
√
√
√
Radiographs
√
√i
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste
c
and requirements for Amalgam Waste Storage/Shipment Containers. No information supplied to us from the company regarding compliance with Specification No. 109.
i
e
h
All states except AK, HI, and ME. Sharps program available at www.prepaidrecycling.com Limitations apply. Call for information.
√
Stericycle
Lake Forest, IL
(800) 355-8773
www.stericycle.com/
√
√
√
√
Safety Kleen
Plano, TX
(800) 669-5740
www.safety-kleen.com/
√
√h
√
√
Veolia Environmental Services
Lombard, IL
(800) 556-5267
www.veoliaes.com/
√
Liquid
Mercury
√
c
Mail-In
√
Contact
Amalgam
Mercury Waste Solutions, Inc.
Union Grove WI
(800) 741-3343
www.mwsi.com/
Mercury Refining Co., Inc.
Albany, NY
(800) 833-3505
www.mercuryrefining.com/
Company/Contact
Information
Lead Foil
Packages
Radiograph-Related
Waste
Lead Aprons,
Collars
Dental Waste Recyclers Providing Nationwide Services, cont’d.
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
Mail-In
√
Contact
Amalgam
√
Sludge
√
Amalgam
Traps & Filters
√
Extracted
Teeth w/
Amalgam
√
Non-Contact
Amalgam
√
√
Fixer Solution
Liquid
Mercury
Pick-Up
Radiograph-Related
Waste
√
Lead Foil
Packages
Dental Amalgam-Related Waste
Radiographs
Mail-In
√
Pick-Up
√
Contact
Amalgam
√
Non-Contact
Amalgam
√
Extracted
Teeth w/
Amalgam
√
Sludge
Amalgam
Traps & Filters
√ √
Radiographs
Fixer Solution
Liquid
Mercury
√
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam
Waste and requirements for Amalgam Waste Storage/Shipment Containers.
Metasys
Miami, FL
877-METASYS (638-2797)
www.ecotwo.com/
Company/Contact Information
Lead Foil
Packages
RadiographRelated Waste
Lead Aprons,
Collars
Dental Waste Recyclers Servicing All States Except Hawaii
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste
and requirements for Amalgam Waste Storage/Shipment Containers.
WCM, Inc
Carlsbad, CA
(866) 436-9264
www.wastewise.com
Company/Contact
Information
Type of
Program
Lead Aprons,
Collars
Dental Waste Recyclers Providing Nationwide Services, cont’d.
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
j
Mail-In
√
√
Pick-Up
√M
√
Liquid
Mercury
√k
Contact
Amalgam
√
Non-Contact
Amalgam
√
√
Extracted
Teeth w/
Amalgam
√
√
Sludge
Amalgam
Traps & Filters
Fixer Solution
√
√ √ √ √
√ √
√
√
√
Radiographs
√
Containers.
Pick-up within 150 miles of Minneapolis.
k
Pick-up only.
No information supplied to us from the company regarding compliance with Specification No. 109. Based on the information supplied to us by the company, this
company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste and requirements for Amalgam Waste Storage/Shipment
c
Maguire Refining, Inc.
Minneapolis, MN
(800) 486-2858
www.maguireref.com
Enviro Medical Waste Inc.
Miamisburg, OH
(866) 669-9201
www.enviromedicalwaste.com/
c
Company/Contact Information
Lead Foil
Packages
RadiographRelated Waste
Lead Aprons,
Collars
Dental Waste Recyclers Servicing All States Except Alaska & Hawaii
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
Pick-Up
√
√H
√H
Liquid
Mercury
√
√
Contact
Amalgam
√H √
√
√
Non-Contact
Amalgam
√
√
√
Extracted
Teeth w/
Amalgam
√
√
Amalgam
Traps & Filters
√
√
√
Fixer Solution
Sludge
√
√
√ √e
√ √e
√
√
√
Lead Foil
Packages
√
√
√
√
√e
√e
√
Based on the information supplied to us by the company, this company complies with the ANSI/ADA Specification No. 109: Procedures for Storing Dental Amalgam Waste and
e
requirements for Amalgam Waste Storage/Shipment Containers. Limitations apply. Call for information.
Integrated Waste Control
Hayward, CA
(510) 583-7980 - Also provides pick-up
services for sharps, glutaraldehyde
√
√
AZ, CA, CO, ID, MT, NM, NV, OR,
WA
AERC Recycling Solutions
Allentown, PA
(610) 797-7608 – Main Corporate Office
www.aercrecycling.com
CA Only–San Francisco, Sacramento area
√
Mail-In
AL, AR, FL, GA, LA, MS, OK, TX
AERC Recycling Solutions
Allentown, PA
(610) 797-7608 – Main Corporate Office
www.aercrecycling.com
Company/Contact Information
Lead Aprons,
Collars
Radiograph-Related
Waste
Radiographs
Dental Waste Recyclers ProvidingRegional or State Services Only
Type of
Dental Amalgam-Related Waste
Program
Medical Waste
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL[&
c
c
c
Pick-Up
√
√
Liquid
Mercury
√
√
Non-Contact
Amalgam
√
Extracted
Teeth w/
Amalgam
Contact
Amalgam
Mail-In
No information supplied to us from the company regarding compliance with Specification No. 109.
Environmental Recycling
Bowling Green, OH
(800) 284-9107
www.envrecycle.com/
IN, MI, OH
Envirolight & Disposal, Inc.
St. Petersburg, FL.
(800) 600-3738
www.envirodisp.com/
FL
Fixer Solution
√
√
Lead Foil
Packages
√
√
√
√
Lead Aprons,
Collars
Amalgam
Traps &
Filters
Radiograph-Related
Waste
√
√
Radiographs
Dental Waste Recyclers Providing Regional or State Services Only, cont’d.
Type of
Company/Contact Information
Dental Amalgam-Related Waste
Program
Medical Waste
Sludge
Waste Management Appendix D
BestManagement
Practicesfor
AmalgamWaste
AmericanDentalAssociation¥October2007
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL['
Uifgpmmpxjohjogpsnbujpoefnpotusbuftipxup
nbobhfboesfdzdmfefoubmbnbmhbnxbtufupifmq
qspufduuiffowjsponfou/
GlossaryofAmalgamWasteTerms
¦Amalgamcapturedevicejtbobqqbsbuvttvdibt
bdibjstjefusbq-wbdvvnqvnqÝmufspsbnbmhbn
tfqbsbupsuibudpmmfdutbnbmhbnqbsujdmft/
¦Bnbmhbntmvehfjtbnjyuvsfpgmjrvjeboetpmje
nbufsjbmuibudpmmfdutxjuijowbdvvnqvnqÝmufst-
bnbmhbntfqbsbupstpspuifsbnbmhbndbquvsf
efwjdftuibunbzcfvtfe/
¦Contactamalgamjtbnbmhbnuibuibtcffojo
dpoubduxjuiuifqbujfou/Fybnqmftbsffyusbdufe
uffuixjuibnbmhbnsftupsbujpot-dbswjohtdsbq
dpmmfdufebudibjstjef-boebnbmhbndbquvsfecz
dibjstjefusbqt-Ýmufst-pstdsffot/
¦DentalBestManagementPracticesbsfbtfsjft
pgbnbmhbnxbtufiboemjohboeejtqptbmqsbdujdft
uibujodmvef-cvubsfopumjnjufeup-jojujbujohcvml
nfsdvszdpmmfdujpoqsphsbnt-vtjohdibjstjef
usbqt-bnbmhbntfqbsbupstdpnqmjbouxjuiJTP
222542boewbdvvndpmmfdujpo-jotqfdujohboe
dmfbojohusbqt-boesfdzdmjohpsvtjohbdpnnfsdjbm
xbtufejtqptbmtfswjdfupejtqptfpguifbnbmhbn
dpmmfdufe/
¦Emptyamalgamcapsulesbsfuifjoejwjevbmmz
eptfedpoubjofstmfgupwfsbgufsnjyjoh
qsfdbqtvmbufeefoubmbnbmhbn/
¦Non-contactamalgam)tdsbq*jtfydfttnjy
mfgupwfsbuuiffoepgbefoubmqspdfevsf/
UifBEBsfdpnnfoetbhbjotuuifvtfpgcvml
fmfnfoubmnfsdvsz-bmtpsfgfssfeupbtmjrvjepssbx
nfsdvsz-gpsvtfjouifefoubmpgÝdf/Tjodf2:95-
uifBEBibtsfdpnnfoefevtfpgqsfdbqtvmbufe
bnbmhbnbmmpz/
Jgzpvtujmmibwfcvmlfmfnfoubmnfsdvszjouif
pgÝdf-zpvtipvmesfdzdmfju/Difdlxjuibmjdfotfe
sfdzdmfsupefufsnjofxifuifsuifzxjmmbddfqucvml
nfsdvsz/Epopuqpvscvmlfmfnfoubmnfsdvszxbtuf
jouifhbscbhf-sfecbhpsepxouifesbjo/Zpvbmtp
tipvmedifdlxjuizpvstubufsfhvmbupszbhfodzboe
nvojdjqbmjuzupÝoepvujgbcvmlnfsdvszdpmmfdujpo
qsphsbnjtbwbjmbcmf/Tvdicvmlnfsdvszdpmmfdujpo
qsphsbntqspwjefbofbtzxbzupejtqptfpgcvml
nfsdvsz/
StepsforRecyclingAmalgamWaste
1.Tupdlbnbmhbndbqtvmftjobwbsjfuzpgtj{ft
upnjojnj{fuifbnpvoupgbnbmhbnxbtuf
hfofsbufe/
2.BnbmhbnxbtufnbzcfnjyfexjuicpezÞvjet-
tvdibttbmjwb-pspuifsqpufoujbmmzjogfdujpvt
nbufsjbm-tpvtfqfstpobmqspufdujwffrvjqnfou
tvdibtvujmjuzhmpwft-nbtlt-boeqspufdujwf
fzfxfbsxifoiboemjohju/
3.Dpoubdubobnbmhbnxbtufsfdzdmfsbcpvuboz
tqfdjbmsfrvjsfnfoutuibunbzfyjtujozpvsbsfb
gpsdpmmfdujoh-tupsjohboeusbotqpsujohbnbmhbn
xbtuf/
JgzpvoffeupÝoebsfdzdmfs-difdlxjuizpvsdjuz-
dpvouzpsmpdbmxbtufbvuipsjuzuptffxifuifs
uifzibwfbobnbmhbnxbtufsfdzdmjohqsphsbn/
4.Tupsfbnbmhbnxbtufjobdpwfsfeqmbtujd
dpoubjofsmbcfmfeÒBnbmhbngpsSfdzdmjohÓpsbt
ejsfdufeczzpvssfdzdmfs/Zpvssfdzdmfsnbzibwf
jutpxosfrvjsfnfout-tpbtlzpvssfdzdmfsbcpvu
dpoubjofstboexibunbzcfqmbdfejouifn/
5.MpplgpssfdzdmfstxipdpnqmzxjuiuifBEB.
BOTJtuboebse/Uijttuboebsejtnfbouup
fodpvsbhfsfdzdmjoh/
QuestionstoAskYourAmalgamWaste
Recycler
Cfmpxjtbmjtupgrvftujpotzpvnbzxbouupbtl
zpvsbnbmhbnxbtufsfdzdmfs/Opufuibuopubmm
sfdzdmjohdpnqbojftbddfqufwfszuzqfpgbnbmhbn
xbtuf-boeuiftfswjdftpggfsfeczsfdzdmfstwbsz
xjefmz/UifBEBsfdpnnfoetuibuzpvdpoubdub
sfdzdmfscfgpsfsfdpwfsjohbnbmhbnboebtlbcpvu
boztqfdjÝdiboemjohjotusvdujpotuifsfdzdmfsnbz
ibwf/Jnqpsuboumz-tfmfdubsfqvubcmfdpnqbozuibu
dpnqmjftxjuibqqmjdbcmfgfefsbmboetubufmbxboe
qspwjeftbefrvbufjoefnojÝdbujpogpsjutbdutboe
pnjttjpot/Mpplgpssfdzdmfstxipdpnqmzxjui
BOTJ0BEBTqfdjÝdbujpo21:;QspdfevsftgpsTupsjoh
EfoubmBnbmhbnXbtufboeSfrvjsfnfoutgps
BnbmhbnXbtufTupsbhf0TijqnfouDpoubjofst/2Uijt
tuboebsejtnfbouupfodpvsbhfsfdzdmjoh/
ª3115-3118BnfsjdboEfoubmBttpdjbujpo/BmmSjhiutSftfswfe/Opodpnnfsdjbmvtf-sfqspevdujpoboeejtusjcvujpopgbmmpsbozqpsujpopguifBnfsjdboEfoubm
BttpdjbujpoÕtCftuNbobhfnfouQsbdujdftgpsBnbmhbnXbtufjtqfsnjuufetpmfmzgpsfevdbujpobmpstdjfoujÝdqvsqptft-qspwjefeuibuuijtdpqzsjhiuopujdfjtqspnjofoumz
ejtqmbzfepofbdidpqzpguifxpsl/UijseqbsujftbsffyqsfttmzqspijcjufegspndsfbujohefsjwbujwftpguijtxpslxjuipvuuifqsjpsxsjuufoqfsnjttjpopguifBnfsjdbo
EfoubmBttpdjbujpo/Uijtxpsljtfevdbujpobmpomzboeepftopudpotujuvufmfhbmpsqspgfttjpobmbewjdf/
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL['
AskYourRecyclerÉ
¦Xibuljoepgbnbmhbnxbtufepzpvbddfqu@
¦Epzpvqbzgpsdmfboopo.dpoubdubnbmhbn
)tdsbq*@
¦Epzpvstfswjdftjodmvefqjdlvqpgbnbmhbnxbtuf
gspnefoubmpgÝdft@Jgopu-dbobnbmhbnxbtufcf ¦Epzpvbddfqufyusbdufeuffuixjuibnbmhbn
tijqqfeupzpv@
sftupsbujpot@
¦Epzpvqspwjefqbdlbhjohgpstupsbhf-qjdlvqps
tijqqjohpgbnbmhbnxbtuf@
¦EpftzpvsdpnqbozibwfboFQBpsbqqmjdbcmf
tubufmjdfotf@
¦Jgqbdlbhjohjtopuqspwjefe-ipxtipvmeuifxbtuf
cfqbdlbhfe@
¦Epftuifdpnqbozvtfuifqspqfsgpsntsfrvjsfe
czuifFQBboetubufbhfodjft@
¦Xibuuzqftpgxbtufdbocfqbdlbhfeuphfuifs@
¦EpzpvsqspdfevsftdpnqmzxjuiBOTJ0BEB
TqfdjÝdbujpo21:;QspdfevsftgpsTupsjohEfoubm
BnbmhbnXbtufboeSfrvjsfnfoutgpsBnbmhbn
XbtufTupsbhf0TijqnfouDpoubjofst@3
¦EpzpvbddfquxipmfÝmufstgspnuifwbdvvn
qvnqgpssfdzdmjoh@
¦Jtejtjogfdujposfrvjsfegpsbnbmhbnxbtuf@
¦Ipxnvdiepzpvstfswjdftdptu@
BestManagementPracticesforAmalgamWaste
DO
Epvtfqsfdbqtvmbufebmmpztboetupdlbwbsjfuzpg
dbqtvmftj{ft
DONÔT
EpoÕuvtfcvmlnfsdvsz
Epsfdzdmfvtfeejtqptbcmfbnbmhbndbqtvmft
EpoÕuqvuvtfeejtqptbcmfbnbmhbndbqtvmftjo
cjpib{bsedpoubjofst-jogfdujpvtxbtufdpoubjofst
)sfecbht*pssfhvmbshbscbhf
Eptbmwbhf-tupsfboesfdzdmfopo.dpoubdubnbmhbn EpoÕuqvuopo.dpoubdubnbmhbnxbtufjocjpib{bse
)tdsbqbnbmhbn*
dpoubjofst-jogfdujpvtxbtufdpoubjofst)sfecbht*ps
sfhvmbshbscbhf
Eptbmwbhf)dpoubdu*bnbmhbnqjfdftgspn
EpoÕuqvudpoubdubnbmhbnxbtufjocjpib{bse
sftupsbujpotbgufssfnpwbmboesfdzdmfuifbnbmhbn dpoubjofst-jogfdujpvtxbtufdpoubjofst)sfecbht*ps
xbtuf
sfhvmbshbscbhf
Epvtfdibjs.tjefusbqt-wbdvvnqvnqÝmufstboe
bnbmhbntfqbsbupstupsfubjobnbmhbnboesfdzdmf
uifjsdpoufout/
EpoÕusjotfefwjdftdpoubjojohbnbmhbnpwfsesbjot
pstjolt
Epsfdzdmfuffuiuibudpoubjobnbmhbnsftupsbujpot/
)Opuf;Btlzpvssfdzdmfsxifuifspsopufyusbdufe
uffuixjuibnbmhbnsftupsbujpotsfrvjsf
ejtjogfdujpo*
EpoÕuejtqptfpgfyusbdufeuffuiuibudpoubjo
bnbmhbnsftupsbujpotjocjpib{bsedpoubjofst-
jogfdujpvtxbtufdpoubjofst)sfecbht*-tibsqt
dpoubjofstpssfhvmbshbscbhf
Epnbobhfbnbmhbnxbtufuispvhisfdzdmjohbt
nvdibtqpttjcmf
EpoÕuÞvtibnbmhbnxbtufepxouifesbjopsupjmfu
Epvtfmjofdmfbofstuibunjojnj{fejttpmvujpopg
bnbmhbn
EpoÕuvtfcmfbdipsdimpsjof.dpoubjojohdmfbofstup
Þvtixbtufxbufsmjoft
JoufsobujpobmTuboebsetPshboj{bujpo22254;2:::/EfoubmFrvjqnfouÐBnbmhbnTfqbsbupst/
2
BnfsjdboEfoubmBttpdjbujpoDpvodjmpoTdjfoujÝdBggbjst/BnfsjdboObujpobmTuboebse0BnfsjdboEfoubmBttpdjbujpoTqfdjÝdbujpoOp/21:/Qspdfevsftgpstupsjohefoubm
bnbmhbnxbtufboesfrvjsfnfoutgpsbnbmhbnxbtuftupsbhf0tijqnfoudpoubjofst-3117/
3
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL['
PracticalGuidetoIntegratingBMPsIntoYourPractice
Non-contact(scrap)amalgam
¦Nblftvsfuifdpoubjofsmjejtxfmmtfbmfe/
¦Qmbdfopo.dpoubdu-tdsbqbnbmhbnjoxjef.
npvuife-dpoubjofsuibujtnbslfeÒOpo.dpoubdu
BnbmhbnXbtufgpsSfdzdmjoh/Ó
¦Xifouifdpoubjofsjtgvmm-tfoejuupbsfdzdmfs/
¦Nblftvsfuifdpoubjofsmjejtxfmmtfbmfe/
¦Sfqmbdfuifusbqjoupuifdibjs.tjefvoju)Epopu
sjotfuifusbqvoefssvoojohxbufsbtuijtdpvme
jouspevdfefoubmbnbmhbnjoupuifxbtuftusfbn/
¦Xifouifdpoubjofsjtgvmm-tfoejuupbsfdzdmfs/
VacuumpumpÜlters
Amalgamcapsules
¦DibohfuifÝmufsbddpsejohupuifnbovgbduvsfsÕt
sfdpnnfoefetdifevmf/Opuf;Uifgpmmpxjoh
¦Tupdlbnbmhbndbqtvmftjobwbsjfuzpgtj{ft/
jotusvdujpotbttvnfuibuzpvssfdzdmfsxjmmbddfqu
¦Bgufsnjyjohbnbmhbn-qmbdfuiffnquzdbqtvmftjo
xipmfÝmufst<tpnfsfdzdmfstsfrvjsfejggfsfou
bxjef.npvuife-bjsujhiudpoubjofsuibujtnbslfe
iboemjohpguijtnbufsjbm-tpdifdlxjuizpvs
ÒBnbmhbnDbqtvmfXbtufgpsSfdzdmjoh/Ó
sfdzdmfsÝstu/
¦Dbqtvmftuibudboopucffnqujfetipvmemjlfxjtf
¦SfnpwfuifÝmufs/
cfqmbdfejobxjef.npvuife-bjsujhiudpoubjofs
¦QvuuifmjepouifÝmufsboeqmbdfuiftfbmfe
uibujtnbslfeÒBnbmhbnDbqtvmfXbtufgps
dpoubjofsjouifcpyjoxijdijuxbtpsjhjobmmz
Sfdzdmjoh/Ó
tijqqfe/Xifouifcpyjtgvmm-uifÝmufsttipvmecf
¦Nblftvsfuifdpoubjofsmjejtxfmmtfbmfe/
sfdzdmfe/
¦Xifouifdpoubjofsjtgvmm-tfoejuupbsfdzdmfs/
Amalgamseparators
Disposablechair-sidetraps
¦Tfmfdubobnbmhbntfqbsbupsuibudpnqmjftxjui
¦Pqfouifdibjs.tjefvojuupfyqptfuifusbq/
JTP22254/
¦Sfnpwfuifusbqboeqmbdfjuejsfdumzjoupb
¦GpmmpxuifnbovgbduvsfsÕtsfdpnnfoebujpotgps
xjef.npvuife-bjsujhiudpoubjofsuibujtnbslfe
nbjoufobodfboesfdzdmjohqspdfevsft/
ÒDpoubduBnbmhbnXbtufgpsSfdzdmjoh/Ó
Linecleaners
¦Nblftvsfuifdpoubjofsmjejtxfmmtfbmfe/
¦Vtfopo.cmfbdi-opo.dimpsjofÐdpoubjojohmjof
¦Xifouifdpoubjofsjtgvmm-tfoejuupbsfdzdmfs/
dmfbofst-xijdixjmmnjojnj{fbnbmhbnejttpmvujpo-
¦Usbqtgspnefoubmvojutefejdbufetusjdumzup
tvdibtuiptfmjtufejouifBeejujpobmSftpvsdft
izhjfofnbzcfqmbdfejoxjuiuifsfhvmbshbscbhf/
tfdujpopguijtepdvnfou/
Reusablechair-sidetraps
¦Pqfouifdibjs.tjefvojuupfyqptfuifusbq/
¦Sfnpwfuifusbqboefnquzuifdpoufoutjoupb
xjef.npvuife-bjsujhiudpoubjofsuibujtnbslfe
ÒDpoubduBnbmhbnXbtufgpsSfdzdmjoh/Ó
AdditionalResources
UifgpmmpxjohbsujdmftqvcmjtifejouifKpvsobmpguifBnfsjdboEfoubmBttpdjbujpobsfbwbjmbcmfuispvhiuifBEBEjwjtjpo
pgTdjfodfboebmtpbsfbwbjmbcmfupBEBnfncfstpomjof/
GpsjogpsnbujpopoqspqfsnfsdvszizhjfofqsbdujdfttffÒEfoubmNfsdvszIzhjfofSfdpnnfoebujpotÓ/
3114;245)22*<25:9.:/
Gpsjogpsnbujpopodipptjohmjofdmfbofstuibunjojnj{fuifejttpmvujpopgnfsdvszgspnbnbmhbntff;ÒUiffggfdupg
ejtjogfduboutboemjofdmfbofstpouifsfmfbtfpgnfsdvszgspnbnbmhbnÓ3117;248)21*<252:.36/
Gpsjogpsnbujpopobnbmhbntfqbsbupsttff;
¦ÒMbcpsbupszfwbmvbujpopgbnbmhbntfqbsbupstÓ3113;244<688.9:/
¦ÒFwbmvbujohbnbmhbntfqbsbupstvtjohbojoufsobujpobmtuboebseÓ3117;248<:::.2116/
¦ÒQvsdibtjoh-jotubmmjohboepqfsbujohefoubmbnbmhbntfqbsbupst;QsbdujdbmjttvftÓ3114245;2165.76/
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3DJH
:DVWH0DQDJHPHQW$SSHQGL['
Section 5: Other Regulatory Issues
Backflow Prevention
In some areas, state and local regulatory authorities are increasingly requiring dentists to
install testable backflow prevention devices in their offices. The installation of such devices
can cost thousands of dollars, with additional costs associated with their annual maintenance
and testing, again, at the dentist’s expense.
The primary concerns of the local regulators are centered on the supposed need to protect
cross-connected water systems from potential aspiration of oral fluids through the high-speed
handpiece, air/water syringe, and cuspidor. Such aspiration, which has been hypothesized
might occur during a sudden drop in water pressure, has apparently resulted in concerns about
bloodborne diseases being transmitted via water systems cross-connected to the dental unit.
As a result of these concerns, both the ADA and CDC have published statements (attached)
on this issue, which stress the negligible risk of bloodborne disease transmission as a result
of backflow from the dental unit. It is hoped that these statements will help educate state
and local regulators and minimize such regulatory activity in the dental office.
____________________________________________________________________________________________________________
01/2008
Page 1
Other Regulatory Issues
CDC - Backflow - Fact Sheets - Infection Control in Dental Settings - Oral Health
MENU
CDC A-Z
SEARCH
Division of Oral Health
Backflow Prevention and the Dental Operative Unit
Share
Infection Control
On this Page
The Centers for Disease Control and Prevention (CDC) has been asked by the
Backflow Prevention Devices
American Dental Association (ADA), state and local health departments, and local
Public Water Supplies
water regulators to provide guidance and scientific information regarding the risk of
Cross-connections
contamination from cross-connections from the dental operative unit. The dental
Viruses
operative unit is a medical device at each dental chair through which water and
Risk of Contamination
compressed air flow during dental procedures. Cross-connections are the links
Selected References
through which contaminated materials may enter a potable water supply system
when the pressure of the polluted source exceeds the pressure of the potable source (e.g., during a water main break).
Backflow Prevention Devices
Backflow prevention devices can be used to prevent back-siphonage of contaminated fluids into the public water supply
and are regulated by the health authority or the plumbing-code enforcement agencies having jurisdiction. (Note: Antiretraction valves, used to prevent aspiration of patient materials into some dental handpieces and waterlines, are
regulated by the Food and Drug Administration (FDA) and are not considered backflow prevention devices.)
Public Water Supplies
In some locations water regulators have required dental offices to install backflow prevention devices at the service
connection or on individual dental operative units. Many of these requirements appear to be based on two assumptions.
First, if a sudden drop in water pressure occurs, oral fluids may be aspirated from a patient's mouth into cross-connected
water systems. Second, if aspiration does occur, it may result in a significant risk of transmission of blood-borne viruses
from an infected patient to other patients or to persons who are using the same water system. Regulatory interventions
____________________________________________________________________________________________________________
01/2015
Page 2
Other Regulatory Issues
CDC - Backflow - Fact Sheets - Infection Control in Dental Settings - Oral Health
of complex
backflow
prevention
CDCrequiring
- Backflow the
- Factinstallation
Sheets - Infection
Control in Dental
Settings
- Oral Healthdevices
in certain dental offices are based on the conclusion
that a high degree of hazard of contamination exists. Available science suggests, however, that there is an extremely
low risk of such contamination of public water supplies from cross-connections in dental operative units.
Cross-connections in Dental Operative Units
Possible sites for cross-connection in the dental operative unit are the cuspidor, high-speed handpiece, and air/water
syringe. Today, most dental offices do not use cuspidors and those that are currently manufactured include an air-gap,
which prevents backflow. Although a cross-connection is inherent in the design of the high-speed handpiece and air and
water syringe, this cross-connection should be considered as very low risk. Both of these devices must have water to
operate properly and, when in use, are observed continually by the dentist or hygienist. If water flow is disrupted for any
reason, the dental worker would discontinue use of the device. Furthermore, in the unlikely event that a sudden drop in
water pressure caused backflow to occur, the volume of aspirated fluid would be minuscule.
Bloodborne Viruses (e.g., HIV, hepatitis B)
One concern expressed during meetings with local water regulators is the possibility of contamination of public water
supplies with blood-borne viruses such as human immunodeficiency virus (HIV)—the virus that causes acquired immune
deficiency syndrome (AIDS). Scientific evidence indicates, however, that the route of transmission of blood-borne
viruses is through intimate contact with blood or other potentially infectious body fluids. Transmission of bloodborne
diseases has not been reported through the use of any type of water source and is considered highly unlikely. Unlike
bacteria or fungi, viruses are unable to reproduce outside a living host, and any virus introduced into a water source
would be greatly diluted and would probably become noninfectious. Because the hepatitis B virus (HBV), another bloodborne virus, is found in much higher concentrations in blood than is HIV, HBV is considered a more infectious agent.
Studies show that the risk of transmission of HBV in sewage and other water is very low, thus, the risk of HIV
transmission would be even less. –
For a bloodborne infection to be transmitted, four conditions, known as the "chain of infection," must be present:
a susceptible host, or a person who is not immune
an opening through which the microorganism may enter the host
a microorganism that causes disease
sufficient numbers of the organism to cause infection.
The chance of all of these events happening in sequence represents the "risk of infection." Any break in one or more of
these "links" in the chain would effectively prevent infection. This information strongly suggests that the risk of
transmission of a bloodborne disease through contaminated water supplies is very low.
Risk of Contamination from Cross-connections
Although a theoretical possibility of contamination from cross-connections from dental operative units does exist,
____________________________________________________________________________________________________________
01/2015
Page 3
Other Regulatory Issues
http://www.cdc.gov/oralhealth/infectioncontrol/factsheets/backflow.htm[11/20/2014 1:44:46 PM]
CDC - Backflow - Fact Sheets - Infection Control in Dental Settings - Oral Health
available scientific evidence strongly implies that this risk is nearly zero. Installation of backflow prevention devices,
when required, should be consistent with this very low degree of hazard. These suggestions are based on the following:
HIV is not transmitted by water.
Published evidence of a public health risk due to cross-connections in the dental operative unit does not currently
exist.
The American Water Works Association (AWWA) statement of policy recommends that the installation of backflow
prevention devices be consistent with the degree of hazard resulting from cross-connections.
Increasingly, dentists are using self-contained dental operative unit water systems that are not connected to the
public water supply.
In addition, the manufacturers' current infection control recommendations and directions for maintenance of each dental
operative unit should be followed. The CDC's Division of Oral Health will continue to assess scientific information related
to the quality of dental operative unit water and the safety of patient care delivery.
Selected References and Additional Resources
CDC. HIV and Its Transmission. En español.
CDC. Viral Hepatitis B.
Environmental Protection Agency. Cross-Connection Contol Manual
[PDF–1.5M]
.
Related by Topic
Overview for Infection Control
Guidelines for Infection Control
Fact Sheets for Infection Control in Dental Settings
FAQs for Infection Control
File Formats Help:
How do I view different file formats (PDF, DOC, PPT, MPEG) on this site?
Adobe PDFfile
Page last reviewed: July 10, 2013
Page last updated: July 10, 2013
____________________________________________________________________________________________________________
01/2015
Page 4
Other Regulatory Issues
CDC - Backflow - Fact Sheets - Infection Control in Dental Settings - Oral Health
Content source:
Division of Oral Health, National Center for Chronic Disease Prevention and
Health Promotion
Follow CDC
CDC Media
About CDC
Legal
Contact CDC
Contact Us
____________________________________________________________________________________________________________
01/2015
Page 5
Other Regulatory Issues
Radiation Safety
Dental radiation contributes a small percentage to the total radiation burden of the general
population. Similarly, occupational exposure in dentistry is low compared to exposures in
hospitals and medical offices.i However, use of appropriate measures ensures that dental
radiation exposures remain as low as reasonably achievable.
The limit for occupationally exposed personnel is 50 millisieverts (mSv) in any 1 year.
The lifetime occupational effective dose is limited to 10 mSv times the value of the individual’s
age. The National Council on Radiation Protection and Measurementi concludes that no dental
personnel will receive occupational exposures that exceed these limits unless there are problems
with the facility design, equipment, performance, or operating procedures. The radiation exposure
limit for pregnant women is 0.5 mSv in a month.
State laws and regulations set specific requirements that must be met for the equipment,
frequency of inspections, etc. Contact your state radiation protection program to identify
requirements for use of ionizing radiation (which includes x-rays) in your state. Training
requirements for dental office personnel who take dental x-rays are frequently different
and less intensive than for personnel who take medical x-rays. Training requirements for
dental office personnel may typically be found in state dental practice acts or dental board
regulations.
Listing of state radiation protection programs: www.crcpd.org/Map/map.asp
Questions to ask regarding state requirements for use of ionizing radiation:
1.What are the inspection and testing requirements for the facility, x-ray machine, radiation
monitoring equipment and radiograph processing equipment?
2. Are there any permit or licensing requirements for dental offices using x-ray machines?
3. Is individual supervision of personnel required?
4.Are personnel required to wear dosimetry badges?
5.What is the training (and retraining) or certification requirement for personnel taking x-rays?
6. What are the dental office design requirements?
7. What are the shielding requirements?
8. What are the record keeping requirements?
9. What are the general equipment requirements?
i
ational Council on Radiation Protection and Measurements. NCRP Report No. 145: Radiation Protection in Dentistry.
N
2003.
____________________________________________________________________________________________________________
01/2008
Page 6
Other Regulatory Issues
ERGO TIPS
Low Back Pain
Dentists and the dental team spend many hours a day
assuming physically stressful body postures as they provide
oral health care.
This can ultimately contribute to the development or
aggravation of low back pain, impacting not only the
well being of the individual, but the efficiency and
productivity of the office as well.
Tips For Controlling Low Back Pain
Symptoms
•
Adjust the height of your seat so that your feet can
be flat on the floor and your knees are a little below
the level of your hips (your thighs are slanted slightly
downward). Allow the thighs to be supported.
•
Use proper lighting and magnification to reduce the
amount of bending and twisting you must do to see
the field of your work.
•
Let the loops do the work, not your back/neck.
•
Have your equipment and instruments placed so that
you are not twisting to reach for them.
Properly balanced posture and mindful use of one’s body
may decrease cumulative trauma and may control
the amount of pain one experiences.
Low back pain may include aching, throbbing or stiffness
in the lumbar and sacral areas of the back, and may also
be experienced as sharp and piercing pain. It may also be
experienced as numbness, tingling and /or shooting pain
radiating down the back of the legs and into the feet and
toes, or as weakness in the hips, legs, feet or toes.
Causes
The cause of low back pain can be varied and complex
But very common sources of pain are tiny tears and
inflammation of the muscles, tendons and ligaments
supporting the spinal column, and pressure on nerve
roots from vertebral changes, such as herniated discs,
narrowing of joint spaces, and/or stenosis of the
vertebral canal or foramen. There are also times when
the cause of the pain is not known and this is often
referred to as non-specific low back pain.
Through OSHA’s Alliance Program this Ergo tip sheet was developed as a product of the OSHA and ADA Alliance for
informational purposes only. It does not necessarily reflect the official views of OSHA or the U.S. Department of Labor.
___________________________________________________________________________________________________________
01/2014
Page 7
Other Regulatory Issues
ERGO TIPS
Low Back Pain
•
Position yourself, relative to the patient, so that
you do not have to twist or maintain an unbalanced
posture to gain access to the oral cavity (sitting in
a 12:00 position is ideal). Move the position of the
patient, rather than bending and twisting your body,
to do your work.
•
After mild trauma, such as slipping and landing on
buttocks, in those older than 50 years
•
When sleep is disrupted or pain is worse at rest
•
With a history of prolonged steroid use
•
With a history of osteoporosis
•
Have a musculoskeletal evaluation and foot screening
to see whether orthotics could be useful in easing
the stress on your back.
•
With a history of recent infection or a temperature
over 100º F
•
With a prior history of cancer or night pain
•
Take a few minutes every hour to stretch the spine,
moving backwards and forwards if you have been
standing up straight, or moving in the opposite
direction of a posture you have been holding.
•
Loss of bowel or bladder function
•
Numbness or tingling in the groin or lower
extremities
•
If standing for a long period of time, rest one foot on
a small stool or step, alternating feet; also alternate
doing this with standing on both feet.
Other Resources
•
Rotate the scheduling of long, difficult cases with
short, easier cases.
American Academy of Orthopedic Surgeons
www.aaos.org
•
Take a break in between or during long cases.
•
Wear properly fitting, comfortable clothing, sterile
gloves, masks, and shoes.
McKenzie Institute International
www.mckenziemdt.org
•
•
Develop your core strength and loose excess
abdominal weight to lessen the burden on your back.
Exhaust all conservative treatment options before
considering surgical intervention, unless there are
extenuating circumstances.
American College of Sports Medicine
www.acsm.org
Athlete’s Performance
www.athletesperformance.com
Arthritis Foundation
www.arthritis.org
American Physical Therapy Association
www.apta.org
Seek Medical Consultation
Healthy People 2010
www.healthypeople.gov
Seek medical consultation for low back pain, especially in
the following instances:
North American Spine Society
www.spine.org
•
After recent significant trauma such as a fall from
a height, a motor vehicle accident or other such
accidents
____________________________________________________________________________________________________________
01/2014
Page 8
Other Regulatory Issues
ERGO TIPS
Hand Pain
Dentists, dental hygienists and dental assistants may
experience hand pain in performing dental procedures.
Typical Hand Motions That Aggravate
Hand Pain
Ganglion cysts non-cancerous, fluid-filled lumps usually
found on the back of the wrist.
Hand pain may include throbbing, aching, numbness and
tingling, stiffness or diminished strength. Performing
dental procedures in which you use your finger, thumb or
wrist muscles frequently or for prolonged periods of time
can lead to or aggravate conditions that cause hand pain.
Trigger finger Swelling of the tendon or sheath
surrounding the tendons of the finger or thumb joints
causing resistance to movement and sometimes a
popping noise.
Carpal tunnel syndrome pressure on the median nerve
as it enters the hand through a small opening (carpal
tunnel) in the wrist, resulting in pain, numbness or
tingling of the thumb, index and middle fingers.
For further information see: http://orthoinfo.
aaos.org/brochure/thr_report.cfm?thread_
id=8&topcategory=Hand
Helpful Hints
Holding the Wrist in a Non-Neutral Position: The
wrist is bent (flexed) while the fingers arebeing used.
Work with wrist in neutral position, when possible.
In a neutral position, the wrist is held straight or in a
slight extension.
Tight Pinch Grip: The distal index finger joint is straight
or hyperextended in a tight grip.
Common Conditions That Cause
Hand Pain
Tendonitis/Tenosynovitis Inflammation or thickening
of a tendon or the tendon sheath which may result in
pain or difficulty of movement.
Use a more relaxed grip, when possible. The distal
finger joint is slightly flexed in arelaxed grip.
Osteoarthritis Adegenerative joint disease
characterized by erosion of the joint cartilage. Often
results in pain and swelling of the finger joints, and
development of nodules at the joint.
____________________________________________________________________________________________________________
01/2014
Page 9
Other Regulatory Issues
ERGO TIPS
Hand Pain
Exercise your hands after doing procedures by
stretching your wrists and fingers. Especially stretch
the area between the thumb and index finger.
Use larger diameter instruments. Try them out to
get one that feels right for you. Use instruments that
reduce the time doing a procedure, such as an ultrasonic
scaler, with variable and rapid speeds. Wear gloves that
fit properly and do not restrict hand movement.
http://www.shelterpub.com/_fitness/_office_fitness_
clinic/OFC_hwf.html
Reduce the force on your hands and fingers, and the
torquing of your hands by using hand instruments and
powered tools that are lighter in weight, balanced, and
well sharpened.
Pace your work. Try not to schedule difficult
procedures back to back. Try to break up or alternate
tasks to minimize the amount of time spent doing the
same task.
Stabilize your hand when doing precise hand tasks.
Your hand can be stabilized by resting the 4th and/or 5th
digits on the cross arch or opposite arch; or resting the
elbow on the chair back or arm.
Adjust chair heights and position yourself so that you
are working with your elbow placed lower than your
shoulder, and your wrist placed even with or lower than
your elbow.
Ensure that all cords and hoses are long enough so you
do not need to exert finger force to pull or support hoses
and cords.
If Pain Continues
Seek medical evaluation and treatment of the condition.
Most of these conditions are treated conservatively with
modification of activities, splints, and anti-inflammatory
medication. However, some cases may require steroid
injections or surgery. Early treatment can help avoid
injections or surgery.
http://www.jdentaled.org/cgi/content/full/69/4/453/F3
Through OSHA’s Alliance Program this Ergo tip sheet was developed as a product of the OSHA and ADA Alliance for
informational purposes only. It does not necessarily reflect the official views of OSHA or the U.S. Department of Labor.
____________________________________________________________________________________________________________
01/2014
Page 10
Other Regulatory Issues
ERGO SUCCESS
Neck Pain
The Use of Loupes Improves Posture and Health of
One Hygienist
The use of loupes while performing work on dental patients
allowed hygienist to minimize the use of awkward postures.
The Problem
A few years into practicing dental hygiene, the hygienist
began to experience back and neck pain. She realized
that the postures she used were probably not ideal but
was not sure how to correct them while still maintaining
adequate views of the patient’s mouth. When the pain
became more chronic she went to see a chiropractor.
X-rays were taken of her spine and it was determined
that the problems were muscle related. She went in
for a series of adjustments with subsequent massage
and ultrasound therapy which alleviated the pain, but
required visits 3 times a week. This became very time
consuming and eventually impossible to fit into her busy
schedule. She self medicated with an occasional Motrin
or Advil from that point on, but still worked in pain.
The Solution
In February 2006, she attended a seminar at the
Midwinter Meeting of the American Dental Association
on the topic of ergonomics. The speaker was a
hygienist who discussed many changes that can be
made in a hygienist’s workstation and equipment to
improve the dental hygienist’s posture and extend the
longevity of her career She advocated the use of surgical
loupes because they provide much greater magnification
than normal corrective eyeglass lenses. They improve
the field of vision so the hygienist can then work with
less bending and hunching of the body and with less
eyestrain. Loupes can also be purchased with attached
lighting, which more fully illuminates the field of work,
again further reducing eyestrain and the attendant
body tension. After the course, she stopped by a
manufacturer’s booth to “test them out”
and was very impressed. She made an appointment to
have a technician come into the office to fit her for a
pair. The technician measured the distance between
the hygienist’s eyes and the patient’s mouth while the
hygienist sat with proper posture in her clinician’s chair.
The magnification was then tailored to suit her individual
needs. No other changes were made to the workstation.
The Impact
The hygienist has been using surgical loupes for a little
over a year and says she feels feel 100% better. Her
back and neck pain are gone and she feels less tired after
a day of work. In addition to working in a private dental
practice, she is also on the faculty of a dental school.
She shares her experience with her students, and uses
loupes when demonstrating procedures. She does not
recommend that students use loupes during their first
year treating patients because they may have difficulty
mastering mirror usage and the difference between
direct and indirect vision, but
approximately 50% of the second year students now use
loupes.
Although loupes are expensive, the savings in pain,
fatigue, and the cost and time of medical visits have
justified the expense.
Kim Fvasula, RDH, works in a private dental practice in Chicago, and
is on the faculty at the College of Dentistry, University of IllinoisChicago.
Through OSHA’s Alliance Program this Ergo tip sheet was developed as a product of the OSHA and ADA Alliance for
informational purposes only. It does not necessarily reflect the official views of OSHA or the U.S. Department of Labor.
____________________________________________________________________________________________________________
01/2014
Page 11
Other Regulatory Issues
ERGO SUCCESS
Neck Pain
Other Resources
American College of Sports Medicine
www.acsm.org
American Academy of Orthopedic Surgeons
www.aaos.org
McKenzie Institute International
www.mckenziemdt.org
Athlete’s Performance
www.athletesperformance.com
Arthritis Foundation
www.arthritis.org
American Physical Therapy Association
www.apta.org
Healthy People 2010
www.healthypeople.gov
North American Spine Society
www.spine.org
____________________________________________________________________________________________________________
01/2014
Page 12
Other Regulatory Issues