May 29, 1998

Janiva Toler, Administrator
The Leaves
1230 Spring Valley Road
Richardson, Texas 75080

Dear Ms. Toler:

This is in response to your letter of February 16, 1998, to our Dallas Regional Office requesting permission for a modified bloodborne pathogen program. Your letter was forwarded to our office for response.

Your letter states that your institution has very little contact with blood. It also states that you have no medical staff, no invasive procedures, no needles, and no medical devices. It also states that you do not perform diagnostic procedures, nor collect or handle blood. Your employees' primary contact with blood is during the cleansing and covering of wounds and the only employees who come in contact with blood are your nurses.

You have stated in your program that you will offer the hepatitis B vaccine, provide initial and annual training on bloodborne pathogens to nurses who may come in contact with blood, provide personal protective equipment such as disposable gloves and dispose of soiled dressings and potentially contaminated waste according to biohazardous regulations. However, the program suggests that it only applies to nurses who have contact with patients diagnosed with or suspected of having HIV or hepatitis B. In a phone conversation with Mark Lerner in our Solicitor's office, we understand that you have no objection to affording these protections, regardless of a patient's diagnostic status. Your program should be changed to delete the references to a patient's diagnostic status. It should be made clear that the use of personal protective equipment is required only when there is reasonably anticipated exposure to blood or other potentially infectious materials. Thus, for example dressing a wound would require the wearing of a glove, but, as a general rule, bathing a patient would not.

You have also stated that your nurses will clean patients rooms daily with a bleach solution or disinfectant, launder patients' clothing and linens using a bleach solution and be require to wear rubber gloves, when there is a potential exposure, if a patient has been diagnosed or is suspected of having HIV or hepatitis B. Your program is vague about who will clean contaminated surfaces in patients' rooms and handle contaminated laundry if the patient is not a diagnosed or suspected HIV or hepatitis B patient. If housekeepers or maintenance staff perform these functions, you probably should consider them for inclusion in your bloodborne pathogen program.

The incidence of disease from HIV, Hepatitis B and other bloodborne pathogens has increased in recent years from contact with patients, many of whom were not diagnosed or suspected of having, HIV or Hepatitis B. It is OSHA's belief that practicing universal precautions will reverse this trend. This practice alone is expected to prevent thousands of deaths to workers who have contact with blood or other potentially infectious materials. Using gloves for all contact with blood, rather than just for contact with diagnosed patients, must become a standard procedure. The health care worker does not have to evaluate the patient. The patient does not have added concerns that his treatment is markedly different from others. All patients are treated equally.

The use of universal precautions must be a key element in every bloodborne pathogen program. We must maintain that not practicing universal precautions continues to be considered a serious violation of our standards. Your plan should be clearer on post-exposure evaluation and follow-up.

We hope this clarifies OSHA's position on the practice of universal precautions and its inclusion in the Exposure Control Plan. If you have any further questions, please contact our [Office of Health Enforcement at (202) 693-2190].

Sincerely,


John B. Miles, Jr., Director
[Directorate of Enforcement Programs]

[Corrected 6/2/2005]