This refers to the practice of treating all human/primate blood and other body fluids, tissues, and cells (including cell lines) as if they were known to be infectious for bloodborne pathogens. Precautions include frequent hand washing, proper disposal of biohazardous/medical waste, and prohibiting mouth pipetting, food, and drink in the lab.
In addition, universal precautions employ engineering controls and personal protective equipment (PPE). Engineering controls include biosafety cabinets, ventilation systems, closed top centrifuge rotors, etc. as primary methods to control exposure. PPE such as gloves, lab coats, eye protection, or face shields must be worn and used as appropriate. Areas subject to universal precautions must have appropriate signage posted on doors and equipment. Signs can be obtained from EH&S. See Universal Precautions for additional information.
Cal/OSHA requires any laboratory using human or primate blood, blood products, cell lines, tissues, or other potentially infectious materials to use needleless systems/and or engineered sharps. Engineered sharps are commonly used items such as scalpels, syringes, and needles incorporating various mechanical devices to decrease the occurrence of injury.
If a Principal Investigator (PI) or supervisor decides that a non-compliant sharp is necessary, he or she must document the reason in the Bloodborne Pathogen Exposure Control Plan.
Under the following conditions, you may use your own or your fellow lab member’s blood for experimental purposes:
- The underlying procedures correspond to a terminal experiment. Examples include harvesting genomic DNA for genetic characterization, or harvesting peripheral blood mononuclear cells (PBMCs) as a control in western blotting.
- Blood cells must not be cultured, transformed, immortalized, or inoculated with an infectious agent. Self-inoculation of these cells could give these cells the ability to evade host immune systems, thereby increasing the risk of disease.
- Blood collection must be performed by experienced personnel, e.g., a physician, medical fellow/resident or certified phlebotomist.
- The blood donor and researchers must complete both Bloodborne Pathogens Training (EHS-1600) and an Exposure Control Plan, overseen by their Principal Investigator or supervisor.
- If this experiment is part of a human research study, Institutional Review Board (IRB) approval is required.
See this page for more information. Please contact Biosafety at (650) 723-0448 with questions.
If exposure (e.g., needle stick, splash, or ingestion) or injury occurs during work hours and does not result in a medical emergency, go to the Stanford University Occupational Health Clinic (SUOHC). After hours and on weekends, go to the Stanford Hospital Emergency Department. Detailed information is available at SUOHC.
Visit SUOHC for more information.
Bloodborne pathogens (BBPs) are microorganisms present in human blood that can cause human disease. These include the hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Other potentially infectious materials (OPIM) are also treated as BBPs. You can seek training programs, institutional and local control plans, and vaccination programs to minimize exposure.
The following questions will help determine if your work is covered by the BBP standard. Will you:
- Work with human blood, blood products, or body fluids?
- Work with unfixed human cells (including tissue culture cells and cell lines), human tissues, or organs?
- Work with non-human primates (NHP) or NHP blood, blood products, or body fluids?
- Work with unfixed NHP cells (including tissue culture cells and cell lines), NHP tissues, or organs?
- Work with bloodborne pathogens, e.g. HIV, HBV, HCV, or other infectious agents able to be spread via blood?
- Work with animals or animal tissues that have been infected with a BBP?
- Perform tasks that may potentially result in exposure to human or animal blood, body fluids, organs, or tissues infected with HBV or other BBPs?
If the answer to any question above is yes, then you may be considered to be at occupational risk of contracting bloodborne pathogens and should take the Bloodborne Pathogen Training (EHS-1600).
Local Bloodborne Pathogen Exposure Control Plan
The Stanford University Institutional Exposure Control Plan (Institutional ECP) is designed to comply with the California OSHA Bloodborne Pathogens Standard (8 CCR • 5193). The Institutional ECP addresses issues related to the elimination or minimization of Stanford University personnel to human blood/bloodborne pathogens (BBPs)/other potentially infectious materials (OPIM). Principal Investigators (PIs) and supervisors should refer to the Institutional ECP as a resource for exposure control background, issues and regulatory procedures.
The Local Bloodborne Pathogen Exposure Control Plan (Local ECP, Local ECP-NL) is designed to aid the PI/Supervisor in completing requirements for the BBP Standard. It is the responsibility of the PI/Supervisor to review the Local ECP with input from employees covered by the Bloodborne Pathogen Standard, with the goal of minimizing personnel exposure to bloodborne pathogens (BBPs) in blood or other potentially infectious materials (OPIMs).
For personnel working in laboratories and clinical workers
Use the Local ECP to:
- Guide identification of procedures and materials in the laboratory that have the possibility of exposing personnel to BBPs (Appendix A of the Local ECP Documention)
- Review methods of compliance to ensure a safe work environment, document training (Appendix B of the Local ECP Documention)
- Determine appropriate engineering and work practice controls, including appropriate use of safety sharps (Appendix C of the Local ECP Documention)
- Review requirements for reporting and documenting sharps injuries
- Ensure participation in the Stanford University Medical Surveillance Program
The Local ECP shall be completed and reviewed by the PIs/Supervisor and personnel annually and/or as needed by job changes. Upon review, complete Appendixes A and B of the Local ECP Documention; complete Appendix C as needed. The completed Local ECP shall be located in the laboratory for reference and documentation of compliance.
For personnel not working in laboratories
A separate Local ECP, the Local Exposure Control Plan Non-Laboratory (Local ECP-NL), is specifically tailored for use by personnel. Some examples of potential occupational exposure issues are:
- Law enforcement officers may face the risk of exposure to blood during the conduct of their duties. For example, at the crime scene or during the processing of suspects, law enforcement officers may encounter blood-contaminated hypodermic needles or weapons, or be called upon to render emergency aid. Therefore law enforcement personnel are covered under the ECP for bloodborne pathogens and are offered hepatitis B immunization and will receive appropriate training.
- Fire and emergency response personnel often provide emergency medical services and, therefore, encounter exposures common to those experienced by paramedics and emergency medical technicians. Job duties may be performed hurriedly in the pre-hospital setting under uncontrolled conditions. Fire and emergency response personnel are, therefore, covered under the ECP for bloodborne pathogens and are offered HBV immunization and will receive appropriate training.
The Local ECP-NL shall be completed and reviewed by the Supervisor and personnel annually and/or as needed by job changes. Upon review, complete Appendix A ECP-NL and Appendix B ECP-NL of the Local ECP-NL Documentation; complete Appendix C ECP-NL as needed. The completed Local ECP-NL shall be located in the workplace for reference and documentation of compliance.
- Stanford University Incident Report
- Sharps Injury Report
- Hepatitis B Declaration
- Contact Information
- Local ECP Check Sheet
- This document is provided to assist in recording and documenting personnel names, positions, dates and information during completion of required ECP segments. Attach filled Check Sheet to appendixes. The use of this sheet is optional.
This program helps ensure the health of employees who:
- Have been exposed in the workplace to particular health hazards (e.g., high noise levels or animal allergens) known to pose a risk for a potentially serious health condition, illness, or injury
- Perform specific work tasks (e.g., respirator use or driving commercial vehicles) that require a certain degree of health and fitness to ensure health and safety, either for the employee or the public
The surveillance program utilizes the Stanford University Occupational Health Center (SUOHC), a campus-based medical clinic that offers University staff evaluation and treatment for work-related injuries and illnesses, preventive medical services necessitated by work, and OSHA- and departmentally-mandated medical surveillance programs.
The Stanford University Institutional Aerosol Transmissible Disease Program (Institutional ATD) is designed to comply with the California OSHA Aerosol Transmissible Disease Standard (Title 8, Section 5199). The Institutional ATD addresses issues related to the elimination, minimization, and protection of Stanford University personnel to airborne transmissible diseases from both humans and animals (zoonotic diseases). Principal Investigators (PIs) and supervisors should refer to the Institutional ATD as a resource for exposure control background, issues, and regulatory procedures.
The Local Aerosol Transmissible Disease Biosafety Plan – Laboratories (Local ATD-Labs) are specifically directed towards research laboratory workers. The ATD requires labs to adopt standard biosafety practices to protect laboratory workers when handling materials containing pathogens that may be spread through aerosols and that can cause serious disease.
The Local Aerosol Transmissible Disease Biosafety Plan – Department of Public Safety (Local ATD-DPS) supplements the Institutional ATD for the DPS. The Local ATD-DPS addresses how to eliminate or minimize exposure to materials containing pathogens that may be spread through aerosols and that can cause serious disease.
The Local Aerosol Transmissible Disease Plan- Zoonotic (Local ATD-Zoonotic) supplements the Institutional ATD for employees with exposures to animals.
Use the below procedures as a guideline for biohazardous/recombinant and synthetic nucleic acid molecule spill cleanup. If the spill is considered too large or too dangerous for laboratory personnel to safely clean up, secure the entire laboratory and call EH&S at (650) 723-0448 immediately for assistance.
- Biohazardous or rDNA Spill Cleanup Inside a Biosafety Cabinet
- Biohazardous or rDNA Spill Cleanup Inside a Lab
- Biohazardous or rDNA Spill Cleanup Inside a Centrifuge
- Biohazardous or rDNA Spill Cleanup Outside the Laboratory
Bleach is recommended as a standard disinfectant, however, other disinfectants may be used provided they are effective against the particular agents, along with the appropriate dilution and contact time.