March 22, 2024

Brian C. Weiner, MD, MS, FACP, AGAF
7952 Mansfield Hollow Rd.
Delray Beach, FL 33446

Dear Dr. Weiner:

Thank you for your letter to the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). Your letter was forwarded to the Directorate of Enforcement Programs for a response. This is a reply to your letter and a subsequent phone call between you and a member of my staff, regarding application of OSHA's Occupational Exposure to Bloodborne Pathogens standard, 29 CFR § 1910.1030, to the clinical problem of rectal foreign bodies. This letter constitutes OSHA's interpretation only of the requirements herein and may not be applicable to any questions not delineated within your original correspondence.

Background: According to your letter, expert opinion supports the use of rectal digital examination during a medical evaluation of rectal foreign bodies. Because of the unknown nature of rectal foreign bodies, there is a possibility of a damaged foreign body developing sharp edges, and potentially placing the examiner at risk of percutaneous injury during the examination. In your opinion, this would create risk for a bloodborne infection.

You are an editor of an online medical textbook and provided OSHA a section on rectal foreign bodies dated, November 27, 2022. The following are excerpts regarding examiner safety:

Consider obtaining an x-ray prior to digital rectal examination, as punctures and lacerations have been reported by providers who stick fingers blindly into the rectum (p. 1).

Digital rectal exam may pose a risk of injury to the examiner and patient, depending on what object is retained. Consider direct visualization with anoscopy¹ when available prior to finger insertion, even if preliminary imaging does not show any radiopaque material (p. 8).

Question: Does OSHA's Bloodborne Pathogens standard apply to rectal digital examination for rectal foreign bodies?

Response: OSHA's Bloodborne Pathogens (BBP) standard defines occupational exposure, 29 CFR 1910.1030(b), as ". . . reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties."

OSHA recognizes that contact with feces and other possible disease-causing biological components (e.g., viruses, bacteria, parasites) that may be present in human wastes and encountered during a digital rectal exam may pose a number of health hazards. Generally, feces are not included in the definition of other potentially infectious materials (OPIM) in the BBP standard (See OSHA's February 23, 2011 letter to Mr. Walter Chun).² However, gastrointestinal perforation resulting from a rectal foreign body may be likely to expose an examiner to blood. Where any body fluid, including feces, is visibly contaminated with blood or where it is difficult or impossible to differentiate between body fluids, universal precautions (UP) and the BBP standard apply (See definition of OPIM).³ There may also be cases where patients with certain medical conditions (e.g., colitis) are more likely to have blood in their stool.⁴

Employers are responsible for determining which job classifications or specific tasks and procedures are reasonably anticipated to result in worker contact with blood or OPIM [29 CFR 1910.1030(c)(2)]. Where occupational exposure exists, to comply with the standard, an employer must use engineering and work practice controls that will eliminate or minimize employee exposure [29 CFR § 1910.1030(d)(2)(i)] to the lowest extent feasible, as explained in OSHA's Bloodborne Pathogens compliance directive [OSHA CPL 02-02-069, Section XIII, D.2.].⁵ Implementing the use of x-ray or anoscopy prior to performing a digital rectal exam would be considered to be work practice controls that are included as part of compliance with the BBP standard. The cited provision also states: “Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used.” 29 CFR § 1910.1030(d)(2)(i). Thus, in this case, gloves must be worn during the rectal digital examination pursuant to 29 CFR1910.1030(d)(3)(ix).

Thank you for your interest in occupational safety and health. I hope you find this information helpful. OSHA's requirements are set by statute, standards, and regulations. Letters of interpretation do not create new or additional requirements but rather explain these requirements and how they apply to particular circumstances. This letter constitutes OSHA's interpretation of the requirements discussed. From time to time, letters are affected when the agency updates a standard, a legal decision impacts a standard, or changes in technology affect the interpretation. To ensure that you are using the correct information and guidance, please consult OSHA's website at www.osha.gov. If you have further questions, please feel free to contact OSHA's Directorate of Enforcement Programs at 1-202-693-2100.

Sincerely,

Kimberly A. Stille, Director
Directorate of Enforcement Programs

¹ See National Library of Medicine Anoscopy at https://medlineplus.gov/lab-tests/anoscopy/.

² See https://www.osha.gov/laws-regs/standardinterpretations/2011-02-23-2.

³ See https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030.

⁴ See CDC Inflammatory Bowel Disease at https://www.cdc.gov/ibd/index.htm.

⁵ See https://www.osha.gov/enforcement/directives/cpl-02-02-069-0.