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Healthcare-Associated Infections: Reportable Exposures

If there has been an exposure to blood or other potentially infectious materials and you are unsure of what to do, please call the Wisconsin Healthcare-Associated Infections (HAI) Prevention Program at 608-267-7711 immediately.

Lab tech holding a blood sample with a tray of vials

An exposure requiring evaluation and medical attention occurs when blood or any other potentially infectious material (OPIM) is involved in:

  • A puncture of the skin with a needle, lancet, or other contaminated sharp item.
  • A splash, spray, or other transmission into the eyes, mouth, or nose.
  • Contact with blood or OPIM onto an open wound, an oozing lesion, or other area where there is significant skin breakdown.

Occupational Safety and Health Administration (OSHA) issued the Bloodborne Pathogens Standard 29 CFR Part 1910.1030 to protect health care workers and others who come in contact with blood and OPIM during their occupational duties. The purpose of the standard is to prevent occupational exposure to bloodborne pathogens (BBP), and to reduce the chances of infection when exposure does occur.

BBPs are microorganisms that cause disease and are present in human blood. They include, but are not limited to:

  • Human immunodeficiency virus (HIV)
  • Hepatitis B virus (HBV)
  • Hepatitis C virus (HCV)

In addition to blood, the following human body materials are considered to be potentially infectious with HIV, HBV, or HCV:

  • All body fluids where it is difficult or impossible to differentiate between body fluids
  • Amniotic fluid
  • Any body fluid visibly contaminated with blood
  • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
  • Blood, organs, or other tissues from experimental animals infected with BBPs
  • Cell, tissue, or organ cultures containing BBPs
  • Cerebral spinal fluid
  • Culture media or other solutions containing BBPs
  • Pericardial fluid
  • Peritoneal fluid
  • Pleural fluid
  • Saliva in dental procedures (whether or not there is visible blood present)
  • Semen
  • Synovial fluid
  • Vaginal secretions

The Bloodborne Pathogens Standard 29 CFR Part 1910.1030 requires employers to write and implement an exposure control plan for employees with occupational exposure to blood and OPIM, using administrative, engineering, and work practice controls to prevent or minimize employee exposure.

The exposure control plan must contain at least the following elements:

  • Cleaning or disinfection of contaminated equipment and surfaces
  • Exposure determination:
    • A list of all job classifications in which all employees in those classifications have occupational exposure (example: all employees classified as phlebotomists).
    • A list of job classifications in which some employees have occupational exposure.
    • A list of all tasks and procedures in which occupational exposure occurs (example: administering immunizations, doing finger sticks).
    • Most local public health agencies will probably not have entire job classifications in which all persons have occupational exposure, but may have certain personnel with assigned duties that involve occupational exposure.
  • Handling laundry
  • Hazard communication
  • Hepatitis B vaccination
  • Maintenance of sharps injury log
  • Post-exposure follow-up
  • Provision for hand hygiene practices
  • Safe management and disposal of sharps
  • Standard precautions: set of practices used with all clients to prevent contact with blood and OPIM
  • Use of personal protective equipment (PPE) 
  • Use of sharps with safety devices: Needlestick Safety and Prevention Act
  • Waste management
  • Work practices that reduce or eliminate exposure to blood and OPIM (for example, no eating or drinking in potentially contaminated areas, using leak-proof containers for specimen storage)

What staff members are required to be in a BBP exposure control plan?

  • If it is reasonable to anticipate skin, eye, mucous membrane, or parenteral contact with blood or OPIM during job duties and tasks, the staff member must be included in an exposure control plan. For example, a public health nurse assigned to administer immunizations may have contact with blood or body fluids.
  • Persons who give first aid as a “good Samaritan” act are not covered under the BBP exposure control plan, unless they perform these duties as a part of their jobs. However, it is recommended that employers provide the hepatitis B vaccine, if needed, and other post-exposure follow-up due to liability issues, and to help prevent disease transmission among staff even in non-occupational exposures.

How often do we have to train staff?

  • All staff need to have training at the time they are initially assigned duties with occupational exposure, and annually thereafter.
  • Training must be at the educational level and in the language of the employee.

What records do we need to keep?

  • Training records, which are kept for three years from the date on which the training occurred.
  • Medical records (such as hepatitis B vaccination status, exposure incidents, and follow-up), which are kept for the duration of employment plus 30 years.

How often does the BBP exposure control plan need to be reviewed and updated?

The plan must be reviewed annually and

  • Whenever new or modified tasks or procedures affect occupational exposure.
  • Whenever there are new employee positions with occupational exposure.

Who can perform training?

There are no official requirements for persons doing training for BBP exposure control programs, but it is in the best interest of the employer to choose people with knowledge of the subject matter required in the training.

Examples of knowledgeable staff include:

  • Nurses.
  • Nurse practitioners.
  • Infection control professionals.
  • Physician assistants.
  • Occupational health professionals.
  • Emergency medical technicians.

What constitutes an exposure to blood or OPIM?

Any of the following is an exposure and should be given immediate medical attention:

  • A puncture of the skin with a used needle, lancet, or other sharp item, whether or not there is visible blood or OPIM present.
  • Splashes or sprays of blood or OPIM into the eyes, nose, or mouth.
  • Contact with blood or OPIM onto an open wound, an oozing lesion, or other area where there is significant skin breakdown.

What employer responsibilities are required by the BBP standard?

Employers are required to implement the entire standard, which includes, but is not limited to:

  • Getting input from employees with occupational exposure on developing effective engineering and work practice controls.
  • Determining job classifications and job tasks that have occupational exposure.
  • Writing and implementing a written exposure control plan that includes engineering and work.
  • Practicing controls and use of personal protective equipment (PPE) to minimize occupational exposure.
  • Providing handwashing facilities readily available to employees, and ensuring that employees wash hands immediately or as soon as feasible after removing gloves and after contact with blood and OPIM.
  • Providing appropriate PPE, storing it in available locations, and maintaining PPE in good repair.
  • Ensuring that employees use PPE appropriately.
  • Ensuring that the worksite is clean and in sanitary condition.
  • Providing for appropriate management of infectious waste.
  • Using labels and signs to communicate hazards to employees.
  • Making hepatitis B vaccine and post-vaccination antibody testing available.
  • Providing post-exposure medical evaluation and follow-up.
  • Providing training.
  • Keeping medical and training records.

What employee responsibilities are required by the BBP standard?

Employers bear the entire responsibility of complying with the BBP standard. By properly doing the tasks below, staff can reduce their risk of BBP exposure:

  • Wear appropriate PPE for tasks and procedures in which occupational exposure may occur.
  • Use and activate safety devices when handling needles and lancets.
  • Dispose of infectious waste properly.
  • Notify supervisors immediately after experiencing an exposure.
  • Complete the required initial and annual training.
  • Comply with all other aspects of the BBP exposure control plan.

Do I need to wear gloves while administering immunizations?

  • The decision to wear PPE is based on the worker’s assessment of whether there is “reasonable anticipation” of an exposure to blood or OPIM. If exposure does not usually occur when giving immunizations, gloves are not necessary, but workers may choose to wear gloves, if they wish.
  • Gloves should always be available in case of emergency situations that result in contact with blood or OPIM.
  • The General Best Practice Guidelines for Immunization, 2017 (PDF) recommend washing hands with soap and water or waterless alcohol gel between each client in the immunization setting.
  • If gloves are worn, they should be removed after each client, and hand hygiene should be performed.

How should gloves that were used in immunization clinics be discarded?

Gloves and other PPE may be placed in regular plastic bags for disposal. If they are saturated or dripping with blood or OPIM, they should be placed in a red biohazard bag.

Department of Health Services resources

Bloodborne Pathogens: What Does an IP Need to Know?: Listen to the Wisconsin HAI Prevention Program Infection Preventionist Lunch and Learn session on bloodborne pathogens and other exposures. Bloodborne pathogens and other exposures presentation slides (PDF) are also available.

External resources


Questions about HAIs? Contact us!

Phone: 608-267-7711 | Fax: 608-261-4976

Last revised May 23, 2024