August 22, 2002

The Honorable Don Nickles
United States Senate
Washington, DC 20510

Dear Senator Nickles:

This letter is in response to the letter you forwarded from your constituent, Dr. Joseph W. Hayhurst. His letter conveyed some concerns about performing elective cosmetic surgery on HIV-positive patients. Dr. Hayhurst wanted to know how OSHA's enforcement of the bloodborne pathogens standard, 29 CFR 1910.1030 would affect this issue. Most of Dr. Hayhurst's letter deals with issues involving the Americans with Disabilities Act, patients' rights, and actions of the state medical association. Since none of these issues falls within OSHA's jurisdiction we will not address them here.

The issue in Dr. Hayhurst's letter that does concern OSHA is occupational exposure to bloodborne pathogens during surgery. Dr. Hayhurst feels that, because of the possibility of contracting the Human Immunodeficiency virus (HIV), health care personnel should not perform medical procedures on known HIV patients if the procedure is not medically necessary. However, neither the OSHA bloodborne pathogens standard nor any other requirement under the Occupational Safety and Health Act of 1970 prohibit employees from performing such procedures.

The basis of infection and exposure control philosophy as well as for the bloodborne pathogen standard is that all blood or other potentially infectious materials must be handled with universal precautions. Specifically, in its 1987 document, "Recommendations for the Prevention of HIV Transmission in Health-Care Settings," the Centers for Disease Control state:

Since medical history and examination cannot reliably identify all patients infected with HIV or other bloodborne pathogens, blood and body-fluid precautions should be consistently used for all patients. This approach, previously recommended by CDC and referred to as "universal blood and body-fluid precautions" or "universal precautions" should be used in the care of all patients, especially including those in emergency-care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown.

Applying this concept, the bloodborne pathogen standard applies to all occupational exposure to blood or other potentially infectious materials (OPIM). The standard defines "Universal Precautions" as "...an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens."

Therefore, blood and tissue must be handled in the same manner regardless of a patient's perceived or known risk. Thus, if refraining from performing elective surgery were an abatement method under the bloodborne pathogens standard, all elective surgery would be barred; this was clearly not the intent of the standard. OSHA found that the standard, which requires engineering and work practice controls and personal protective equipment, among other things, "...will result in a substantial reduction of significant risk." (56 FR 64036).

OSHA specifically found, "...the above listed provisions of the standard will also reduce exposure to HIV infected body fluids and other materials thus reducing the risk of infection to HIV." 56 FR 64038 (Dec. 6, 1991). Finally in the Needlestick Safety and Prevention Act, PL 106-430, 114 Stat. 1901, passed in 2000, Congress found in Section 2: "(3) Compliance with the bloodborne pathogens standard has significantly reduced the risk that workers will contract a bloodborne disease in the course of their work;" and "(7) Numerous studies have demonstrated that the use of safer medical devices, such as needleless systems and sharps with engineered sharps injury protections, when they are a part of an overall bloodborne pathogens risk-reduction program, can be extremely effective in reducing accidental sharps injuries."

Dr. Hayhurst also specifically expresses concern about the possibility of HIV infection due to vaporization of tissue during liposuction. In the preamble to the bloodborne pathogen standard OSHA extensively discussed aerosolization of blood and other potentially infectious materials. Although two experts from the University of California at San Francisco presented data about a potential respiratory hazard from the inhalation of blood-containing aerosols and others supported their views, many experts, including those from CDC and the National Institute of Occupational Safety and Health (NIOSH), stated there were no cases of bloodborne disease traceable to airborne transmission. These conflicting opinions, coupled with the lack of information, prevented OSHA from regulating aerosols (56 FR 64120-22).

Dr. Hayhurst may wish to contact the National Institute for Occupational Safety and Health (NIOSH) to obtain further information from them on any studies they may be conducting regarding aerosolization exposure to infectious material during surgical procedures. NIOSH can be reached by calling 1-800-35-NIOSH.

As opposed to aerosols, solid or liquid particles, ranging in size from submicrometer to multi-micrometer which are suspended in a gas (56 FR 64120), the standard does regulate the generation of droplets. It states at 29 CFR 1910.1030(d)(2)(xi): "All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances."

Thank you for your interest in occupational safety and health. We hope this provides the clarification you were seeking. OSHA requirements are set by statute, standards and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult OSHA's website at http://www.osha.gov. If you have any further questions, please feel free to contact the Office of Health Compliance Assistance at (202) 693-2190.

Sincerely,



John L. Henshaw
Assistant Secretary