September 4, 1992

Dr. Larry Newell
Senior Associate for Health and Safety
American Red Cross
431 18th St. NW 5th floor
Washington D.C. 20006

Dear Dr. Newell:

This is in further action to your June 25 telephone conversation with a member of my staff concerning the review of Chapter 4 of the American Red Cross Emergency Response Guidebook, "Infectious Diseases." We regret the delay in providing this written response.

The purpose of this cursory review was to determine if this material, as well as the instructor manual and the employee self- assessment exercise, would be sufficient to comply with the training guidelines set forth in the Occupational Safety and Health Administration (OSHA) regulation, "Occupational Exposure to Bloodborne Pathogens," 29 CFR 1910.1030.

It is our understanding that this information will be used to train those individuals who are designated as first aid responders in business and industrial settings and not to train those individuals who work in health care facilities. We also understand that the training will be conducted by certified American Red Cross (ARC) trainers.

Based on our review of the material provided, it is OSHA's determination that the information contained in Chapter 4 would be sufficient to meet some of the generalized training requirements detailed in the standard, but would not fulfill the specific training requirements such as site specific training on the exposure control plan, personal protective equipment, work practice controls, Hepatitis B vaccine availability and efficacy, actions to be taken in the event of an emergency, exposure incident protocols and appropriate followup procedures, details on the signs and labeling system used and engineering controls.

For your consideration, the following are specific comments on the text as currently written.

STUDENT TEXT

In the "Objectives" section, information on OSHA's Bloodborne Pathogen Standard is necessary. A brief statement on the contents of the regulation, with particular emphasis on the training requirements, detailed in the regulation would be helpful. Additionally, a statement is needed on how to recognize tasks and activities which may involve exposure to blood or potentially infectious materials. Definitions of bloodborne pathogens and other potentially infectious materials would be useful.

In the "How the Diseases are Spread" section, it may be helpful to provide examples of blood-transmitted diseases, as has been done for vector-borne transmission.

In the "Specific Disease Discussion" section, as noted in particular in the Hepatitis and HIV/AIDS subsections, additional information on the other potentially infectious materials which are capable of transmitting bloodborne pathogens is necessary. This is important for emergency responders to understand, as universal precautions are to be used in situations where it is difficult or impossible to differentiate between body fluids.

In the "Hepatitis" subsection, it may be helpful to provide examples detailing bloodborne modes of transmission. A discussion on Hepatitis C should also be included in this subsection and in the chart. OSHA recognizes that bloodborne pathogens include other pathogenic microorganisms that are present in blood and can cause disease in humans. Other diseases transmitted by bloodborne pathogens should be listed either in this section or on the chart. Examples include, but are not limited to, Hepatitis C, malaria, syphilis, and, leptospirosis.

In the "HIV/AIDS" subsection, the second bullet point under item 3 is confusing. "Use of contaminated equipment or supplies" and "blood or broken skin" should be detailed further to more effectively explain how these activities could infect a care giver.

In the "Preventing Disease Transmission" section, a generalized definition or discussion on Universal Precautions should be detailed by the ARC trainer and explained in the text. It would also be helpful to explain in the text and also in the chart that personal protective equipment selection would be based upon the type of exposure anticipated during the task (e.g. splashing, spraying, and soaking) and the quantity of blood or other potentially infectious materials anticipated to be generated.

The third bullet point in this section does not mention that hands shall be washed after changing gloves and that disposable gloves are not to be reused.

In the Bloodborne Pathogens regulation, OSHA prohibits the shearing or breaking of contaminated needles and requires that contaminated needles and other contaminated sharps 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 procedure. Although first aid providers do not usually perform such actions, if recapping or needle removing must be performed, then it shall be accomplished through the use of a mechanical device or a one-handed technique. This point needs to be emphasized in the bullet point section.

In the bullet point which discusses cleaning and disinfection, several points need further clarification. OSHA requires that equipment and surfaces be cleaned and disinfected after contact with blood and other potentially infectious materials. It is also the employer's responsibility to determine and implement an appropriate written schedule for cleaning and method of decontamination based on the location within the facility, the type of surface to be cleaned, the type of soil present and the tasks or procedures being performed in the area. OSHA recognizes EPA-registered tuberculocidal disinfectants as acceptable for decontamination as well as bleach diluted between 1:10 or 1:100 with water.

Disposal of contaminated clothing needs to be addressed further. For example, the bullet point should emphasize that personal protective clothing needs to be disposed of in either a color- coded container or in appropriately labeled receptacles. The label shall include the Biohazard legend and shall be fluorescent orange, or orange red or predominantly so with letters or symbols in contrasting color.

In the "When an Exposure Occurs" section, an explanation is needed on the employer's role when an exposure incident occurs and what is required to be provided to the employee when an exposure incident occurs. Here, as in the previous section, on immunization, details on the employer's responsibility to offer the Hepatitis B vaccine to employees should be provided.

INSTRUCTORS MANUAL

Some of the suggestions as noted above need to be incorporated in the training manual.

Additionally, under the "Primary Points" section, Universal Precautions are not addressed. A detailed discussion on Universal Precautions would be useful. See notes above.

STUDENT SELF-ASSESSMENT EXERCISE

The disinfection question needs to be further evaluated. Other questions that address the comments noted above will also have to be revised.

In summary, these comments are not meant to be all-inclusive and are based on a cursory review of the text. They are intended as guidance for revisions of the text. OSHA encourages you to examine the Bloodborne Pathogens regulation for further additional information and would be available to meet with you to address any additional concerns. We would like to emphasize the fact that OSHA does not endorse or approve training programs, so that this review does not constitute, in any fashion, official sanction of this program.

Any further questions can be directed to the Office of Health Compliance Assistance, at (202) 523-8036.

Sincerely,



Patricia Clark, Director
Directorate of Compliance Programs