Worker protections against occupational exposure to infectious diseases
Comparing the universal precautions of OSHA’s Bloodborne Pathogens standard to the standard precautions and
the transmission-based precautions used by healthcare practitioners for infection control
OSHA standards for bloodborne pathogens (BBP, 29 CFR 1910.1030) and personal protective equipment (PPE, 29 CFR 1910 Subpart I) require employers to protect workers from occupational exposure to infectious agents. The BBP standard applies when workers have occupational exposure to human blood or other potentially infectious materials (OPIM), as defined in paragraphs (a) and (b) of the BBP standard, and requires the use of universal precautions to prevent contact with these materials.1 Adhering to standard and transmission-based precautions in healthcare settings is recommended by Centers for Disease Control and Prevention (CDC), and protects workers from a wider range of infectious disease hazards than the BBP standard.
Employers and workers should be familiar with several key approaches to infection control, including universal precautions, standard precautions and transmission-based precautions.
- Universal precautions (UP), originally recommended by the CDC in the 1980s, was introduced as an approach to infection control to protect workers from HIV, HBV, and other bloodborne pathogens in human blood and certain other body fluids, regardless of a patients’ infection status.2 UP is an approach to infection control in which all human blood and certain human body fluids are treated as if they are known to be infectious. Although the BBP standard incorporates UP, the infection control community no longer uses UP on its own.
- Standard precautions (SP), introduced in 1996 in the CDC/Healthcare Infection Control and Prevention Advisory Committee’s "1996 Guideline for Isolation Precautions in Hospitals," added additional infection prevention elements to UP in order to protect healthcare workers not only from pathogens in human blood and certain other body fluids, but also pathogens present in body fluids to which UP does not apply. SP includes hand hygiene; the use of certain types of PPE based on anticipated exposure; safe injection practices; and safe management of contaminated equipment and other items in the patient environment. SP is applied to all patients even when they are not known or suspected to be infectious.
- Transmission-based precautions (TBP) for contact-, droplet-, and airborne-transmissible diseases augment SP with additional controls to interrupt the route(s) of transmission that may not be completely interrupted using SP alone.3 The different types of TBP are applied based on what is known or suspected about a patient’s infection.
The BBP standard requires the use of UP, and extends UP to protect workers against pathogens found in saliva during dental procedures and body fluids in situations where it is difficult or impossible to differentiate between body fluids (e.g., vomit mixed with blood).
During recent outbreaks of emerging infectious diseases, other body fluids to which UP and the BBP standard do not apply have been identified as potential sources of worker exposures and infections. For example, the CDC identified contact with urine, saliva, feces, vomit, and breast milk as potential sources of Ebola virus exposure.4, 5 Studies also found that urine of individuals with Zika can contain high concentrations of infectious virus that could persist in urine longer than it is detectable in serum, a component of blood.6, 7 (Note that exposure to urine has not been a recognized cause of Zika transmission.)
By using SP in healthcare settings, additional protection is provided by expanding UP to protect workers where UP and the BBP standard do not apply. For example, SP applies, without limitation, to urine, feces, nasal secretions, sputum, vomit, and other body fluids that may be potential sources of worker exposure to infectious agents. SP assumes that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. Since SP was developed to integrate principles of UP and body substance isolation,8 the infection prevention and control methods used under SP encompass what employers should already be implementing to protect workers against exposures under the BBP standard and its requirements for use of UP. Other OSHA requirements, such as the PPE standards (see 29 CFR 1910 Subpart I) and Section 5(a)(1), the General Duty Clause, of the Occupational Safety and Health Act, 29 USC 654, also may apply.9
The following tables highlight key distinctions among UP as originally written, the BBP standard (which incorporates UP), and SP. Table 1 outlines the body fluids and other materials to which each applies.
Table 1. Body fluids to which UP, the BBP standard, and SP apply
|Saliva in dental procedures2|
|Any body fluid that is visibly contaminated with blood2|
|All body fluids in situations where it is difficult or impossible to differentiate between body fluids2||10|
|Saliva, other than in dental procedures11|
Table 2 compares selected controls, actions and other measures for the protection of workers against exposure to blood and OPIM and for the protection of workers against exposure to material that is not blood or OPIM. Note that Table 2 discusses only selected provisions of the BBP standard, as well as only selected elements of SP and TBP, and is not intended to describe all provisions with which employers may need to comply. The General Duty Clause of the Occupational Safety and Health Act and additional OSHA standards, including those for personal protective equipment in 29 CFR 1910 Subpart I, also may apply.
Table 2. Selected elements of infection prevention and control under BBP, SP, and TBP
Control, action or other measure
To protect workers against exposure to...
|Blood and OPIM1||Material that is not blood or OPIM, including body fluids not covered under OPIM (e.g., urine6 and feces)|
|Blood and body fluid precautions for all patients, regardless of infection status||BBP, SP||SP|
|Exposure control plan and required elements thereof12||BBP|
|Hand hygiene||BBP, SP||SP|
|Safe injection practices||BBP, SP||SP|
|Safe sharps management/disposal||BBP, SP||SP|
|Prohibiting eating, drinking, smoking, or application of cosmetics or lip balm and handling of contact lenses in areas where there is a reasonable likelihood of occupational exposure13||BBP|
|Separating food and drink from areas where blood and OPIM are present13||BBP|
|Prohibiting mouth pipetting and suctioning of blood or OPIM13||BBP|
|Safe specimen storage, packaging, shipment13||BBP|
|PPE – Gloves, gowns, masks, eye protection (e.g., goggles), face shields||BBP,14 SP, TBP||SP, TBP|
|PPE – Aprons and other protective body clothing||BBP, TBP||TBP|
|PPE – Surgical caps||BBP, TBP||TBP|
|PPE – Shoe/boot covers||BBP, TBP||TBP|
|PPE – N95 or higher respirators for aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols||SP, TBP||SP, TBP|
|PPE – Any additional appropriate equipment to prevent 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. See 29 CFR 1910.1030(d)(3)(i).||BBP|
|PPE – Any additional appropriate equipment (i.e., not specifically listed already) to protect workers against transmission of infectious agents||TBP||TBP|
|Housekeeping and environmental control procedures||BBP, SP||SP|
|Post exposure evaluation and follow-up after occupational exposure to a bloodborne pathogen(s)15||BBP|
Employers always should train workers about sources of infectious agent exposure and appropriate precautions for preventing infections. Two of the relevant OSHA standards requiring training are those for PPE and BBP. Under the PPE standards, employers must provide training to workers required to use PPE, including training on what equipment is necessary, when and how they must use the equipment, and how to dispose of the equipment. In addition, where workers are exposed to blood or other potentially infectious materials, employers must provide the training required by the BBP standard, including information about how to recognize tasks that may involve exposure and the methods to reduce exposure, including appropriate engineering controls, work practices, and personal protective equipment.
- Safety and Health Topics page on Bloodborne Pathogens and Needlestick Prevention. Occupational Safety and Health Administration, U.S. Department of Labor.
- 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Healthcare Infection Control and Prevention Advisory Committee, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
- Guidelines for Environmental Infection Control in Health-Care Facilities. Healthcare Infection Control and Prevention Advisory Committee, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
- NIOSH Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, and Hepatitis C page. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
- Respiratory Protection eTool. Occupational Safety and Health Administration, U.S. Department of Labor.
- NIOSH Respiratory Protection page. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
- CDC/NIOSH/OSHA Hospital Respiratory Toolkit. National Institute for Occupational Safety and Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; and Occupational Safety and Health Administration, U.S. Department of Labor.
- Infectious Diseases Rulemaking (RIN: 1218-AC46). Office of Information and Regulatory Affairs, Office of Management and Budget.
1 "Other Potentially Infectious Materials," as defined in the OSHA Bloodborne Pathogens standard (29 CFR 1910.1030(b)), means:
- 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;
- Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
- 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.
2 The CDC initially defined "universal precautions" as applying to blood and other body fluids containing visible blood. See: CDC (1988). "Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR Morb Mortal Wkly Rep, 37(24): 377-82, 87-8." OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) applies universal precautions to the prevention of contact with blood or other potentially infectious materials (OPIM). See footnote 1 for additional information about OPIM.
3 For additional information about transmission-based precautions for specific infectious agents, see "Part III: Precaution to Prevent Transmission of Infectious Agents" and "Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions" of the HICPAC "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings."
4 Dixon, M. G., & Schafer, I. J. (2014). Ebola viral disease outbreak—West Africa, 2014. MMWR Morb Mortal Wkly Rep, 63(25), 548-51.
5 Cardile, A. P., Murray, C. K., Littell, C. T., Shah, N. J., Fandre, M. N., Drinkwater, D. C., ... & Vento, T. J. (2015). Monitoring exposure to Ebola and health of US military personnel deployed in support of Ebola control efforts—Liberia, October 25, 2014–February 27, 2015. MMWR Morb Mortal Wkly Rep, 64, 690-4.
6 Although an infectious dose or ID50 of Zika virus is not known, urine of Zika patients is known to have significant viral load. For example, Fourcade et al. (2016) detected as much as 74,000 copies of viral RNA per mL of urine in a Zika-infected male and as much as 5,550 copies/mL in a Zika-infected female. See: Fourcade, C., Mansuya, J. M., Dutertre, M., Delpech, M., Marchou, B., Delobel, P., ... & Martin-Blondel, G. (2016). Viral load kinetics of Zika virus in plasma, urine and saliva in a couple returning from Martinique, French West Indies. Journal of Clinical Virology, 82: 1-4.
7 Centers for Disease Control and Prevention [CDC]. (2016). Interim Guidance for Zika Virus Testing of Urine — United States, 2016. MMWR Morb Mortal Wkly Rep, 65.
8 Body substance isolation focused on the isolation of all moist and potentially infectious body substances (blood, feces, urine, sputum, saliva, wound drainage, and other body fluids) from all patients, regardless of their presumed infection status, primarily through the use of gloves.
9 OSHA is considering the promulgation of an infectious diseases standard to supplement the infection control requirements of the BBP standard. This new standard would require, among other things, the use of SP and TBP when healthcare and healthcare support workers have occupational exposure to sources of infectious agents.
10 UP as originally defined by CDC does not necessarily apply in situations where it is difficult or impossible to differentiate between body fluids; OSHA’s BBP standard expanded application of UP under the standard to include such situations.
11 Under the category "Any body fluid that is visibly contaminated with blood," UP and the BBP standard would apply when there is visible contamination of these fluids with blood.
12 OSHA recommends that employers develop and implement exposure control plans for all types of infectious agents.
13 OSHA recommends that employers implement this control for all types of infectious agents.
14 Paragraph (d)(3)(ix) of the BBP standard requires gloves to be worn when it can be reasonably anticipated that the employee may have hand contact with mucous membranes, non-intact skin, and certain other potential sources of exposure, in addition to blood and other potentially infectious materials covered under the standard.
15 OSHA recommends implementing post exposure evaluation and follow-up for all types of infectious agents.