Emergency Department » Biological Hazards – Infectious Diseases

Workers in hospital settings may be exposed to a variety of common and emerging infectious disease hazards, particularly if proper infection prevention and control measures are not implemented in the workplace. Examples of infectious disease hazards include seasonal and pandemic influenza; norovirus; Ebola; Middle East Respiratory Syndrome (MERS), tuberculosis, methicillin-resistant Staphylococcus Aureus (MRSA), and other potentially drug-resistant organisms.

Infectious diseases are caused by agents that are transmissible through one or more different routes, including the contact, droplet, airborne, and bloodborne routes. The transmission of infectious agents through the bloodborne route—a specific subset of contact transmission—is defined in the Bloodborne Pathogens (BBP) standard, 29 CFR 1910.1030 ().

An effective infection control program normally relies upon a multi-layered and overlapping strategy of engineering, administrative and work practice controls, and PPE. It is OSHA’s intent in this eTool to highlight some – not all – of the controls that would be necessary to the development and implementation of an effective program. Implementing the controls highlighted here alone will not typically protect workers from infection hazards.

Follow standard and transmission-based precautions to prevent worker infections (see also the OSHA page: Worker protections against occupational exposure to infectious diseases). Early identification and isolation of sources of infectious agents (including sick patients), proper hand hygiene, worker training, effective engineering and administrative controls, safer work practices, and appropriate personal protective equipment (PPE), among other controls, help reduce the risk of transmission of infectious agents to workers.

Employers must comply with the BBP standard to the extent that there is "occupational exposure" (i.e., to the extent employers should reasonably anticipate contact with blood or other potentially infectious materials (OPIM) that may result from the performance of duties). Employers must also comply with the PPE Standard, 29 CFR 1910 Subpart I, and the OSH Act’s General Duty Clause, 29 U.S.C. 654(a)(1), to protect their workers from infectious disease hazards. The General Duty Clause requires each employer to "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."

OSHA provides agent-specific guidance for a variety of pathogens that workers in hospital settings may encounter. See OSHA's Safety and Health Topics Pages for Biological Agents and Bloodborne Pathogens and Needlestick Prevention for additional information.

In this module, OSHA provides additional guidance specifically for:

Bloodborne pathogens are pathogenic microorganisms present in human blood that can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV) and Viral Hemorrhagic Fevers (e.g. Ebola). [29 CFR 1910.1030(b)]


Emergency Department workers are at particular risk for exposure to bloodborne pathogens because they are often exposed to blood and other fluids resulting from traumatic, life-threatening injuries treated in the emergency department.

Requirements under OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030

The Bloodborne Pathogens Standard requires precautions when there is occupational exposure to blood or OPIM (as defined by the standard). Under the standard, OPIM 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.

For a complete explanation, see Hospital-wide Hazards - Bloodborne Pathogens.

OSHA requires employers to:

  • Ensure that the biosafety officer or other responsible person conducts an exposure determination to determine the exposure of workers to blood or OPIM throughout the hospital setting. [29 CFR 1910.1030(c)(2)(i)].
  • Use engineering and work practice controls
    • Engineering (e.g., engineered safer needle devices and sharps) and work practice controls must be the primary means to eliminate or minimize exposure to bloodborne pathogens. Where engineering controls, including SESIP (Sharps with Engineered Sharps Injury Protection) will eliminate or minimize employee exposure, either by removing or isolating the hazard, they must be used. [29 CFR 1910.1030(d)(2)(i)]
  • Ensure that employees use appropriate personal protective equipment (PPE), (e.g., gloves, gowns, face masks), as required by the standard, when there is anticipated blood or OPIM exposure. [29 CFR 1910.1030(d)(2)(i), 29 CFR 1910.1030(d)(3)(ii)]
  • Ensure that employees discard contaminated needles and other sharp instruments into appropriate containers immediately or as soon as feasible after use. [29 CFR 1910.1030(d)(4)(iii)(A)(1)]
  • Establish a written Exposure Control Plan (ECP). The ECP must contain, among other elements, annual documentation of consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize exposure to blood and OPIM. 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. Document the solicitation in the Exposure Control Plan. Any change to the use of engineering controls (and any other change affecting exposure) must also be reflected in the ECP. [29 CFR 1910.1030(c)(1)]
  • Establish Universal Precautions:
    • Universal Precautions: An approach to infection control that treats all human blood and certain human bodily fluids as if they were infectious for HIV and HBV or other bloodborne pathogens. [29 CFR 1910.1030(b)]
    • The requirement to use Universal Precautions in the Bloodborne Pathogens Standard [29 CFR 1910.1030(d)(1)] means implementing the precautions required by the standard (e.g., engineering and work practice controls, appropriate PPE such as gloves, masks, and gowns) whenever there is exposure to blood or OPIM (or in some cases other body fluids).
    • Alternative concepts in infection control are called Body Substance Isolation and Standard Precautions. These alternatives define all body fluids and substances as infectious, and OSHA permits the implementation of these approaches, as an alternative to universal precautions, provided that facilities utilizing them adhere to all other provisions of the Bloodborne Pathogens Standard.
  • Establish and maintain a sharps injury log for recording needlestick/sharps injuries. [29 CFR 1910.1030(h)(5)] The confidentiality of the injured employee must be protected.
  • Make immediately available to an exposed employee a confidential medical evaluation and follow-up, after a report of a needlestick injury or other exposure incident. The initial medical evaluation often occurs in the emergency department. [29 CFR 1910.1030(f)(3)]
  • Provide BBP training to employees at the time of initial assignment where occupational exposure may take place and at least annually thereafter. [29 CFR 1910.1030(g)(2)]

Additional Information


Exposure of staff and patients to Multidrug Resistant Organisms (MDROs) resulting in nosocomial (hospital-acquired) infections. Common examples of these organisms include:

The CDC provides guidelines and recommends controls for MDRO hazards.

Additional Information

Methicillin-resistant Staphylococcus aureus (MRSA includes VRSA and VISA)


ED staff can be exposed to MRSA through contact with infected individuals (e.g., patients, visitors or staff members) or individuals who may be colonized. Colonization means that the organism is present in or on the body but is not causing illness. Most MRSA infections occur in people who have been in hospitals or other healthcare settings, such as nursing homes and dialysis centers. Staff can become infected and then become carriers who can infect other staff members or patients. As MRSA becomes more resistant to antibiotics such as methicillin and potentially vancomycin, it will become more difficult to treat.

Recognized Controls and Work Practices

  • Hospitals in different geographical locations will need to establish their own local MRSA data and provide treatment information to clinicians.
  • The CDC's recommendations for preventing transmission of MRSA in hospitals include Standard Precautions.
  • The CDC also recommends Contact Precautions, in addition to standard precautions, when additional precautions are needed. For more information about the CDC's recommendations for standard and contact precautions, see:
  • Infection control is the key to preventing the spread of MRSA. Ensure the availability of adequate facilities and supplies that promote good hand hygiene.
  • Perform routine housekeeping in the ED, including decontaminating equipment and surfaces with detergent-based cleaners. Use EPA-registered disinfectants and sterilants when appropriate.

For more information, see Hospital-wide Hazards - Methicillin-resistant Staphylococcus aureus (MRSA). Provides links with general information, answers specific questions for employers and employees, and offers resources for a variety of workplace settings and activities, including healthcare, schools, athletics, and childcare.

Additional Information

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. Generally, persons at high risk for developing TB disease fall into two categories:

  • Persons with medical conditions that weaken the immune system, and
  • Persons who have been recently infected with TB bacteria. This group includes persons who work or reside with people who are at high risk for TB in facilities or institutions such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with HIV.


Exposure to tuberculosis and other infectious agents from patients in waiting room and treatment areas. Staff may be treating an emergency and be unaware of other pre-existing infectious conditions.

Recognized Controls and Work Practices

The CDC discusses three types of controls for TB infection in healthcare settings:

  1. Administrative controls to minimize the number of areas where exposure to TB can occur
  2. Environmental controls to reduce the concentration of TB
  3. The use of respiratory protection in situations that pose a high risk for exposure

Recognized controls and work practices include:

  • Providing and practicing early patient screening in the ED to identify potentially infectious patients, and provide isolation to prevent employee exposures. Consistent with CDC guidelines, "a diagnosis of respiratory TB disease should be considered for any patient with symptoms or signs of infection in the lung, pleura, or airways (including larynx), including coughing for ≥3 weeks, loss of appetite, unexplained weight loss, night sweats, bloody sputum or hemoptysis, hoarseness, fever, fatigue, or chest pain."
  • Providing an area in the ED that is ventilated separately for TB patients (i.e., patients with suspected or confirmed TB) in facilities in which TB patients are frequently treated. If this is not possible, ensuring that TB patients wear surgical masks, stay in the ED the minimum amount of time possible, and be transferred promptly to isolation rooms.
  • Healthcare facilities serving populations that have a high prevalence of TB may need to supplement the general ventilation or use additional engineering controls in general-use areas where TB patients are likely to go (e.g., waiting-room areas, emergency departments, and radiology suites). These engineering controls include:
    • A single-pass, non-recirculating system that exhausts air directly to the outside.
    • A recirculation system that passes air through HEPA (High Efficiency Particulate Air) filters before re-circulating it to the general ventilation system.
  • Providing worker education, informational materials, and training about TB relevant to employees' work (e.g., symptoms, transmission, controls, and post-exposure protocols), as well as training specifically required by OSHA standards, as applicable. For more information see OSHA Directive CPL 02-02-078.

Requirements under OSHA's Respiratory Protection Standard, 29 CFR 1910.134

Other OSHA standards that may be applicable

  • Post a warning sign outside the ED respiratory isolation room to prevent accidental entry. [29 CFR 1910.145(a)(1)] 29 CFR 1910.145(e)(4) requires that a biological hazard warning shall be used to signify the actual or potential presence of a biohazard and to identify equipment, containers, rooms, materials, experimental animals, or combinations thereof, which contain, or are contaminated with, viable hazardous agents.

Additional Information


Exposure of ED staff to infectious diseases, such as seasonal or pandemic influenza*.

Healthcare workers, particularly physicians and nurses, are at a higher risk of acquiring influenza than healthy adults working in non-healthcare settings (Kuster et al., 2011).

Influenza can be transmitted by both symptomatic and asymptomatic individuals through respiratory tract secretions, mucus, cough and sneeze aerosols, and contaminated hands and materials.

Recognized Controls and Work Practices

  • Encourage workers to get vaccinated and make vaccinations available to workers. The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. health care workers get vaccinated annually against influenza.
  • Modify patient intake, triage, and other service areas to increase space between workers, coworkers, and patients and provide barriers against transmission when applicable (e.g., install sneeze guards or partitions).
  • If available, use airborne infection isolation rooms (AIIRs), for aerosol-generating procedures and limit the number of people present during the procedure.
  • Isolate and group flu patients when possible.
  • Limit patient transport. Conduct exams and procedures at the bedside, instead of transporting the patient to other areas of the facility. Place a surgical mask on the patient, if possible, when they are being transported out of the ED.
  • Use closed suctioning systems to suction a patient's airways and use high quality filters on the expiratory port of ventilators, when available.
  • Limit the staff entering patient isolation rooms to only those necessary for patient care.
  • Restrict visits for patients in isolation.
  • Use proper respiratory and cough etiquette and encourage hand washing by patients and visitors.
  • Wash hands with soap and water for at least 20 seconds before and after contact with patients, after using PPE, and after touching contaminated surfaces; use an alcohol-based hand rub if soap and water are not available.
    • When using soap and water, rub soapy hands together for at least 20 seconds, rinse hands with water, and dry completely.
    • If soap and water are not available, use of an alcohol-based hand rub is helpful as an interim measure until hand washing is possible. When using an alcohol-based hand rub, apply liquid to palm of hand, cover all surfaces of the hands with the liquid, and rub hands together until dry.
  • Monitor yourself for symptoms of the flu, such as fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, and fatigue (tiredness).
  • Follow standard cleaning and disinfection methods.
  • Use a facemask when entering a flu patient's room. A facemask is not a respirator. It will not protect workers during aerosol-generating procedures, which may create very fine aerosol sprays. A facemask can only be used to protect workers from contact with the large droplets made by patients when they cough, sneeze, talk or breathe.
  • Use a respirator during aerosol-generating procedures; a fit tested N95 disposable respirator or better is needed.
  • Use gloves, gowns, and eye protection for any tasks that might cause contamination or create splashes.
  • Put on and take off protective equipment in the correct order to prevent contamination.

* While the recognized control and work practices that protect workers from exposure to seasonal and pandemic influenza are basically the same, consult the CDC's "Interim Guidance for Infection Control Within Healthcare Settings When Caring for Confirmed Cases, Probable Cases, and Cases Under Investigation for Infection with Novel Influenza A Viruses Associated with Severe Disease," in the event of an influenza pandemic to determine if any higher level precautions should be implemented (i.e., the use of respirators rather than surgical masks when HCWs are engaged in direct patient care).

Additional Information