Handbook of Operating Procedures

I. POLICY AND GENERAL STATEMENT

The University of Texas Health Science Center at Houston (“University”) works to safeguard the health and safety of employees, trainees, visitors, patients and the general public against contact with and spread of infectious diseases. Recognizing that Human Immunodeficiency Virus ("HIV"), Hepatitis B Virus ("HBV") and Hepatitis C Virus ("HCV") are serious public health threats, the University has adopted the following policy and procedure to: 1) prevent the spread of HIV, HBV, HCV and other bloodborne pathogens to members of the University community and the general public and 2) protect the rights and well-being of those individuals who may be infected with HIV, HBV, HCV, or other bloodborne pathogens. The University is also sensitive to the needs and rights of any members of the University community who have contracted diseases that might be infectious to others during the performance of “exposure prone” procedures.

The University has adopted the use of Universal/Standard Blood and Body Fluid Precautions and a Bloodborne Pathogens Exposure Control Plan. It is the responsibility of each employee, health care worker, or visitor/observer (see HOOP 125, Visitors) with the potential for occupational exposure to bloodborne pathogens and other potentially infectious materials to complete University awareness training on bloodborne pathogens and abide by these guidelines in the conduct of employment and educational activities. Failure to do so may result in disciplinary action.

The University will not use a person’s HIV, HBV or HCV status to decide employment or student status, service delivery or to deny services. Refer to HOOP Policy 183, Nondiscrimination, Anti-Harassment and Equal Opportunity.

II. DEFINITIONS

Bloodborne Pathogens:  Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, HBV, HCV, and HIV, and lentiviruses and retroviruses used in research laboratories.

Exposure-prone procedure:  Procedure(s) determined by the Infectious Diseases Review Panel to pose a direct and significant risk of transmission of bloodborne pathogens from a patient to a health care worker, or from an infected health care worker to a patient.  See also Institutional Biosafety Manual and the Society for Healthcare Epidemiology of America (SHEA) Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus for examples of activities performed by health care workers and the risk of bloodborne pathogen transmission for each such activity.    

Health care worker:  Employees, residents, students, postdoctoral research fellows, visitors or anyone conducting health care related or exposure prone work under the auspices of the University.

Infectious Diseases Review Panel:  A subcommittee of the University’s Institutional Biosafety Committee whose members are appointed by the President to review instances of HIV, HBV, HCV, or other bloodborne pathogen infections in health care workers, to identify exposure-prone procedures, and to determine those circumstances, if any, under which a health care worker who is infected with HIV,HCV, HBV virus and is Hepatitis B e-Antigen (HBeAg) positive, or any other bloodborne pathogens may perform such procedures.

III. PROCEDURE

A. Work or Educational Activity-Related Exposure to HIV, HBV, HCV or Other Bloodborne Pathogens

Any incident that may be regarded as having potential HIV, HBV, HCV or other bloodborne pathogen exposure implications must be reported immediately to the employee’s supervisor, or for students, to the appropriate supervisor, attending clinician, or to the UT Student Health Clinic, all of whom will follow the guidelines for reporting exposures as stated in the Needlestick / Bloodborne Pathogen Exposure Control Plan.

If a health care worker reports unverified possible exposure to HIV, HBV, HCV or any other bloodborne pathogen while performing the duties of employment or while performing duties of his or her educational assignment, that individual will be informed that he or she may request testing and counseling at the University’s expense, if:

• the health care worker can document the possible exposure to bloodborne pathogens while performing duties of employment or while performing duties of his or her educational assignment, and
• the health care worker alleges exposure to bloodborne pathogens in a manner that is capable of transmitting bloodborne pathogens as determined by guidelines developed in accordance with statements of the Texas Department of State Health Services and the Centers for Disease Control and Prevention.

If a health care worker is exposed to another individual's (“source patient”) blood or body fluid in the course of the health care worker's assignment, the University may test that health care worker and the source patient for HIV, HBV, HCV or other bloodborne pathogen infection with or without the source patient's consent, provided the test is performed under the post exposure protocol.  If the source patient refuses to give consent, the health care workers treating the source patient, in consultation with UT Health Services or the UT Student Health Clinic, as appropriate, will determine on a case-by-case basis how to proceed. All testing, whether with or without consent, and the results will be handled in accordance with existing state and federal law.

Any employee who claims Workers' Compensation Insurance (WCI) benefits as a result of alleged bloodborne pathogens exposure must provide a written statement of the date and circumstances of the exposure and document that, within 10 calendar days after the exposure, the employee had a test result that indicated absence of HIV, HBV, HCV or other bloodborne pathogens infection. An employee who may have been exposed to bloodborne pathogens while performing duties of employment may not be required to be tested, but refusal to be tested may jeopardize workers' compensation benefits.

UT Health Services and the UT Student Health Clinic offer or refer employees and students for confidential and anonymous HIV, HBV and HCV counseling and testing following workplace exposures. Health care workers may also contact the Texas HIV/STD InfoLine, 1-800-299-AIDS, which is a toll-free HIV/AIDS and STD information and referral service.

B.  Testing

The University will not test University community members for HIV, HBV,HCV or other bloodborne pathogen infection without their informed consent unless required by law or court order or as specified in section III.A of this policy. It shall, however, encourage University community members who have HIV, HBV, HCV or any other bloodborne pathogen infection or who have been potentially exposed to HIV, HBV,HCV or other bloodborne pathogens to inform UT Health Services and/or the UT Student Health Clinic. These University community members are also encouraged to seek counseling and testing either from UT Health Services and/or the UT Student Health Clinic or from any other appropriate resource. (For work-related exposure, refer to section III.A of this policy.)

The University will report HIV, HBV, HCV and other bloodborne pathogen infection test results in compliance with all applicable statutory requirements.

Except when a release is required or authorized by law, information concerning the HIV, HBV, HCV or other bloodborne pathogen status of University community members and any portion of a medical record will be kept confidential and will not be released without written consent. HIV, HBV,HCV or other bloodborne pathogen status in workers' compensation files will remain confidential and have the confidentiality status of medical records.  HIV, HBV, HCV or other bloodborne pathogen status information will not be placed in an individual’s personnel or student file.

C. Health Care Workers Infected with HIV, HCV, HBV who are HBeAg Positive, or Any Other Bloodborne Pathogen

A health care worker infected with HIV, HCV, HBV and is HBeAg positive, or any other bloodborne pathogen may not engage in activities that might require him or her to perform exposure-prone procedures unless the Infectious Diseases Review Panel has prescribed the circumstances under which he or she may perform such procedures. Health care workers infected with HIV, HCV, HBV and are HBeAg positive, or any other bloodborne pathogen and whose regular duties or activities at the University require him or her to perform exposure-prone procedures must report their status to UT Health Services or the UT Student Health Clinic either upon employment or admission or immediately upon becoming aware of such status.

Health care workers whose practices are modified due to infection with HIV, HBV, HCV, or any other bloodborne pathogen should be offered opportunities to continue appropriate patient-care activities, if practicable; receive career counseling and job retraining; or, to the extent reasonable and practicable, be counseled to enter an alternative curriculum, if the health care worker is a student. The Infectious Diseases Review Panel may receive guidance from documents such as those published by the SHEA in order to determine the procedures in which the healthcare worker can and cannot participate.

A health care worker whose practice is modified because of HIV, HBV, HCV or other bloodborne pathogen infection may request periodic redeterminations by the Infectious Diseases Review Panel based on a change in the worker's disease status.

The appropriate supervisor should advise health care workers that failure to comply with the preceding precautionary measures and limitations will subject the workers to disciplinary procedures by their licensing entities when applicable, and/or by the University, in accordance with HOOP Policies 187 Discipline and Dismissal of Classified Employees, 133 Faculty Termination and 186 Student Conduct and Discipline.

D. Educational Efforts

1. Employees:Employees who have the potential for occupational exposure to bloodborne pathogens, such as in the laboratory or in hands-on patient care activities, must complete awareness training on bloodborne pathogens initially upon employment and annually thereafter. (https://www.uth.edu/safety/training/index.htm). Additionally, per Texas law, EHS will provide each new employee during new employee orientation with educational materials about methods of transmission and prevention of HIV infection. EHS will also provide the educational materials on HIV to current employees annually during refresher training.

2. Students: Upon request, the UT Student Health Clinic will provide information on the prevention of HIV infection. Students who have the potential for occupational exposure to bloodborne pathogens, such as in the laboratory or in hands-on patient care activities, must complete awareness training on bloodborne pathogens initially when exposure potential exists and annually thereafter. 

The deans of each school, in coordination with faculty, will structure the curricula of their respective schools to include information about methods of transmission and methods of prevention of HIV infection; federal and state laws, rules, and regulations concerning HIV infection and AIDS; and universal/standard precautions if a potential for bloodborne pathogens exposure exists for the students as part of their educational experience.

IV. CONTACTS

• • University Relations & Equal Opportunity (questions regarding rights in relation to ADA or religious accommodations)
  • 713-500-2255
  • https://www.uth.edu/hr/department/equal-opportunity/
• • Environmental Health and Safety (safety related information regarding bloodborne pathogens)
  • 713-500-8100
  • https://www.uth.edu/safety/
• • The University of Texas Health Services (voluntary testing and counseling information, employees)
  • 713-500-3267
  • https://www.uthealthservices.com/
• • The University of Texas Student Health Clinic(voluntary testing and counseling information, students)
  • 713-500-5171
  • https://www.uth.edu/studenthealth/student-health-services/services.htm
• • Applicable Student Affairs Office (students who have questions about their rights in

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