Administration Policies




Responsible VP/AVP

Dawn M. Rhodes, MBA

Policy Statement

1. Preamble

This Policy sets forth the principles and general practices of UMB with respect to prevention and management of infection with bloodborne pathogens. All related policies, guidelines and practices of UMB's schools and other units are expected to be consistent with this Policy. This Policy shall be communicated to the UMB community and to prospective students and employees. Notice of this Policy and the opportunity to review it upon request shall be afforded to current and potential clients and patients through appropriate means.

As an employer, UMB must comply with the laws and regulations relating to bloodborne pathogens which have been enacted or issued by the United States Government and by the State of Maryland. Other UMB policies specifically address compliance with those regulations. This Policy shall be interpreted to be consistent with State and Federal law and regulations in all respects. This Policy also shall be interpreted and applied consistent with the applicable Maryland and federal laws of professional licensure, informed consent, and confidentiality of student and other personally identifiable records. The President of UMB may waive or modify this Policy as required to attain compliance with such other laws and regulations.

2. Definitions

In this Policy, the following terms have the meanings set forth in this paragraph:

  1. Bloodborne Pathogens means hepatitis B virus, human immunodeficiency virus, and hepatitis C virus. In the future, the President of UMB may identify additional pathogens as Bloodborne Pathogens if such pathogens are identified by the Occupational Safety and Health Administration, the Centers for Disease Control, or a relevant State or federal law or regulation as requiring control or prevention measures similar to those required for HIV, HBV or HCV under the OSHA Standard.
  2. Confirmed Source Individual means a Source Individual known, as a result of pre-exposure or post-exposure testing, to be infected with a Bloodborne Pathogen.
  3. Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of the duties or assignments of any UMB Personnel.
  4. HBV means hepatitis B virus.
  5. HCV means hepatitis C virus.
  6. HIV means human immunodeficiency virus.
  7. Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of UMB Personnel's duties or assignments, including assigned work, volunteer tasks, academic programs, and practicum experiences. Occupational Exposure may occur in many contexts, including but not limited to, patient care, client services, research activities, classroom work, housekeeping, maintenance and security services.
  8. OSHA Standard means the Bloodborne Pathogens Standard issued by the Occupational Safety and Health Administration, United States Department of Labor, as amended from time to time and published as 29 CFR 1910.1030.
  9. School means any of the following schools which comprise UMB's educational units: School of Medicine, School of Nursing, School of Social Work, School of Law, Dental School, School of Pharmacy, University of Maryland Graduate School - Baltimore.
  10. Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of Occupational Exposure to UMB personnel. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.
  11. UMB Personnel means (i) all part-time and full-time students of UMB, as well as any special students who are not registered; (ii) all employees of UMB, including full-time, part-time, temporary, contractual, and visiting personnel in any employment category; and (iii) all volunteers participating in UMB activities.
  12. Unit means any administrative, service, or research unit of UMB which does not report, directly of indirectly, to the Dean of a School.
  13. Universal Precautions is an approach to infection control according to which all human blood and certain human body fluids are treated as if known to be infectious for Bloodborne Pathogens. More specifically, Universal Precautions means the universal precautions recommended by the Center for Communicable Diseases, U.S. Public Health Service.
  14. Any term used in this Policy which is defined in paragraph (b) of the OSHA Standard shall have the meaning set forth in the OSHA Standard unless a different meaning is set forth in this part of this Policy.

3. Non-Discrimination

All Schools and Units of UMB shall make their facilities and services for health care and client services available to patients and clients without regard to their status as Source Individuals or Confirmed Source Individuals. However, as medically appropriate, some Source Individuals and Confirmed Source Individuals may be referred to treatment in special settings or denied access to some programs in order to safeguard their welfare, the health of other patients or clients, and the safety of UMB Personnel. All UMB Personnel who provide health care, counseling or other client services are required to provide services to all eligible patients and clients.

All program brochures, catalogues, and other materials for clients, patients, students and employees shall provide notice of the policy of non-discrimination and the expectation that UMB Personnel will provide service to all patients and clients.

4. Universal Precautions

Each School and Unit is responsible to identify its UMB Personnel who have Occupational Exposure and are at risk of an Exposure Incident; to ensure that these UMB Personnel receive training in Universal Precautions; and to require the use of Universal Precautions by these UMB Personnel. Failure to use Universal Precautions as required is grounds for dismissal or discipline.

5. Education and Communication on Bloodborne Pathogens

Each UMB School and Unit shall communicate with its UMB Personnel concerning known biohazards and shall educate its UMB Personnel on aspects of HIV infection, Acquired Immune Deficiency Syndrome, and HBV and HCV infection appropriate to expected educational and job-related behaviors. The requirements of paragraph (g) of the OSHA Standard shall be followed for employees and, to the fullest extent practical and appropriate, shall be followed for other UMB Personnel.

6. Admissions and Hiring Practices

Inquiries about infection with HBV, HCV or HIV will not be made of prospective UMB Personnel. Neither admission nor employment will be denied any otherwise qualified individual on the basis of infection with Bloodborne Pathogens. However, limitations on the training and professional activities which may result from infection with Bloodborne Pathogens will be communicated to prospective students and employees. (See next section.)

7. Advice on Risks and Limitations

Each School and Unit in which UMB Personnel have Occupational Exposure will provide advice to those UMB Personnel having Occupational Exposure concerning risk of infection with Bloodborne Pathogens and, for health care students and employees, possible relationships between infection and career opportunities for health care workers. Such advice will also be provided to applicants for the benefit of applicants who know themselves to be infected with Bloodborne Pathogens. This will include information on possible limitations resulting from infection with Bloodborne Pathogens as a health care worker in the specific profession or pursuit to which the application is being directed.

Advice will include notice that modifications of activities may be necessary for infected individuals engaged in patient care activities at UMB or at affiliated training or employment sites. Although UMB has no policies limiting the health care activities of individuals infected with Bloodborne Pathogens who have no physical or mental impairment as a result of their infection, some affiliated health care sites have imposed restrictions and it is possible that State licensing bodies will limit health care activities of infected individuals.

Applicants who are infected with Bloodborne Pathogens are not required to identify themselves to UMB. Advice to applicants will be provided in a general form available to all applicants.

If infection with a specific Bloodborne Pathogen (e.g., HBV) could prevent a person from completing the curriculum or subsequently practicing the intended profession as a result of scientifically established contagion risk, this information will be included in the general information which the School distributes to applicants.

8. Testing

Testing for infection with Bloodborne Pathogens is not required for employment or admission or as a condition of continued enrollment or employment. Absence of infection with Bloodborne Pathogens is not utilized as a criterion in selecting successful applicants for academic enrollment or employment.

Voluntary testing is strongly encouraged for prospective students or employees who will have Occupational Exposure. These persons are well advised to be aware of their status with respect to Bloodborne Pathogens infection and should be advised that free testing is available through local government health testing facilities. Knowledge of status is valuable baseline information for evaluating outcomes of Exposure Incidents.

UMB Personnel who are or will be engaged in invasive procedures in the course of caring for patients have Occupational Exposure and should be aware of their status with respect to infection with Bloodborne Pathogens. Such personnel are encouraged to maintain awareness through periodic voluntary testing.

Voluntary testing will be available to UMB Personnel on request through Student and Employee Health. Any costs incurred must be covered by health insurance or by the tested individual. Free testing is available through other local health testing facilities.

Student and Employee Health will not inform School or Unit administrators of positive HIV, HBV or HCV tests of UMB Personnel unless the tested individuals provide written consent.

9. Immunization Against HBV

Students enrolling in academic programs that will involve participating in invasive or exposure-prone procedures must be vaccinated against HBV at their own expense unless an individual School has elected to provide vaccination at no cost to its students. Students may be vaccinated at Student and Employee Health. Those who were immunized prior to enrollment must provide evidence of immunization to the enrolling School. Immunization can be waived only for documented medical contraindications. Each School, in consultation with Student and Employee Health, will establish the schedule for students to obtain vaccination or present evidence of immunization.

As required by the OSHA Standard, UMB shall make available the HBV vaccine and vaccination series to all UMB employees who have Occupational Exposure or have had an Exposure Incident. The vaccination shall be offered at no cost to employees. Employees who decline the vaccination must sign a Hepatitis B Vaccine Declination Statement.

Any UMB Personnel who are neither students nor employees, and who have Occupational Exposure, shall be offered the HBV vaccine and vaccination at their own expense. Alternatively, the School or Unit in which such personnel work may support the cost of vaccination, at the discretion of the responsible administrator.

10. Voluntary Disclosures; Confidentiality

Persons who are not engaged or to be engaged in invasive patient care activities are not required or encouraged to disclose infection with a Bloodborne Pathogen. Prospective or current students, employees, or other UMB Personnel who are infected with a Bloodborne Pathogen, and whose work or academic program does or will include invasive procedures, are strongly encouraged but not required to disclose infection to the appropriate School- or Unit- specific Bloodborne Pathogens Review Panel described under section 12 below. Any person's disclosure of infection will be maintained in confidence by the individual affiliated with UMB to whom the disclosure was made unless other persons must be informed in order to implement this Policy.

A statement encouraging disclosures by persons who may or will be involved in invasive procedures may be included in School and Unit bulletins that advertise or describe academic programs to prospective and current students. Information regarding Review Panels and disclosures may be provided at enrollment, or soon thereafter, and at employee orientations. By one of these means it is expected that all students, employees, and other UMB Personnel currently or prospectively involved in invasive procedures will be informed by their School or Unit that

(a) voluntary disclosure is encouraged;

(b) the health status of a person who discloses infection will be held in confidence by UMB, and only persons who have a need to know the status in order to implement this Policy will be made aware of the status;

(c) voluntary and timely disclosure permits the School or Unit to assist in developing appropriate accommodations of maximum benefit to the disclosing individual; and

(d) disclosure itself cannot be the basis for academic dismissal or termination of employment, which would only follow careful consideration of a person's situation as discussed in this Policy.

11. Ombudsman

Each School and Unit will appoint a standing ombudsman or advocate to whom any applicant, student or employee can go in confidence for advice on policies and procedures related to infection with Bloodborne Pathogens and on the implications of testing and disclosure for enrollment or employment status.

12. Review Panels

UMB Personnel infected with a Bloodborne Pathogen who will be engaged in invasive procedures as a part of employment, educational program, or volunteer activities, are encouraged to disclose their status to their School or Unit Review Panel rather than to an administrative or academic official of the School or Unit. Each School or Unit will have a Bloodborne Pathogen Review Panel whose core membership will be determined under procedures developed by that School or Unit. Core membership should include: an individual knowledgeable about modes and risks of transmission of infection by Bloodborne Pathogens; a person expert in the practice of the professional discipline or work activities of the School or Unit; and a representative of the School's or Unit's infection-control group (where such a group exists). This membership may be drawn from individuals appointed or employed in other Schools or Units as well as from the School or Unit of the infected person.

To facilitate availability of qualified individuals for Review Panels, especially the panels of Schools or Units that may have an insufficient number of persons with the necessary experience or knowledge to serve on Review Panels, each School and Unit will compile a list of qualified individuals in its employ who would be available for service on its own Review Panel and other UMB Review Panels.

For each case pending before a Review Panel, the panel may seek information and recommendations from the infected person's personal physician (if available and authorized by the person to participate); a discipline-specific consultant if the infected individual is engaged in specialized work; and other consultants as needed to provide informed evaluation and recommendations.

The Bloodborne Pathogen Review Panel, after confidential review and deliberation, will recommend one or more of the following:

(a) no restriction of activities;

(b) appropriate accommodation through changing the conditions of academic program or employment;

(c) restrictions of permitted activities;

(d) discontinuance of enrollment or employment. Recommendation (d) will be made only if the infected individual is physically or mentally incapable of performing required workrelated or academic activities or, although capable, poses a medically determined risk of transmission to patients, and there are no reasonable means by which accommodation and changes of activities could be devised which would allow continued employment or enrollment and completion of the academic program or employment responsibilities.

Review Panels will function under the general principle that not all health care workers infected with HIV, HBV or HCV need be prohibited from engaging in all invasive procedures; rather, each case will be individually considered, taking account of the skills and possible impairment of the individual.

For a student, the Review Panel's recommendations will be transmitted confidentially to the Dean of the student's School, who will develop a plan of action in consultation with the Review Panel, UMB legal counsel and the UMB President. The Dean may consult other University administrators, School faculty, licensing bodies, and medical consultants before reaching a decision concerning the Review Panel's recommendations or other actions. With respect to all consultations, the Dean shall preserve the confidentiality of the student. In determining whether to permit a student to continue in an educational program, the Dean will take into account the policies of affiliated teaching sites where the student would be assigned to complete educational requirements. The Dean's decision, i.e., the final plan, will be transmitted confidentially to the student and, with anonymity preserved, to the President and University legal counsel.

For an employee or other member of UMB Personnel, the Review Panel's recommendation will be transmitted to the concerned Dean or Unit head. The Dean or Unit head may consult with intermediate supervisors, University legal counsel, other University administrators, licensing bodies, and medical consultants before reaching a decision concerning the Review Panel's recommendation or other action. With respect to all consultations, the Dean or Unit head shall preserve the confidentiality of the individual under consideration. In determining whether to permit an individual to continue in employment or volunteer activities, the Dean or Unit Head will take into account the policies of affiliated sites where the individual would be assigned. The Dean or Unit head's decision will be transmitted confidentially to the infected individual and, with anonymity preserved, to the President and University legal counsel.

13. Accommodations

When necessary and reasonable, appropriate accommodations, including modifications of activities, curriculum, and job responsibilities, may be made for infected students or employees who otherwise would be engaged in invasive procedures or exposed to medically unacceptable risks of opportunistic infection. Inquiries with respect to competencies of prior performances by such individuals may be made by a Review Panel, a Dean or a Unit head as an aid to designing appropriate accommodations.

Curriculum modifications will be subject to decisions of each School's advancement or curriculum committee (as determined by the School) and the School's Dean.

14. Monitoring

If any restriction of activity is imposed as a result of considering recommendations from a Bloodborne Pathogen Review Panel, the Dean or Unit head imposing the restriction will assign (an) individual(s) to monitor compliance with the restrictions. The individual(s) ordinarily will be selected from among those who have significant responsibility for supervision of the person whose activities are restricted. Assignment of monitoring responsibilities will be in accordance with a plan that is to be included in recommendations from the Review Panel.

Non-compliance with any approved restrictions or with a monitoring plan shall be reported to the Dean or Unit head, who, using the Review Panel as an advisory body, will decide whether further restrictions, modifications of activities, or discipline are warranted. The affected individual will be given full information about alleged violations of restrictions and the opportunity to present arguments to the Dean or Unit head before a decision is imposed. Due to confidentiality concerns, violations of monitoring requirements will not be referred for action under regular misconduct or disciplinary policies of the Schools or the UMB campus unless the infected individual requests such action.

15. Affiliated Institutions

Many UMB Personnel perform health care services in affiliated institutions having their own infection control policies and, in some cases, their own policies concerning the scope of activities allowed for health care workers infected with Bloodborne Pathogens. Most of the affiliated institutions require that UMB Personnel assigned to them be subject to the institutions' infection control and Bloodborne Pathogens policies. UMB Personnel assigned temporarily or permanently to affiliated institutions are expected to know and follow the policies of those institutions concerning disclosure of health care workers' infections to the institution. If an affiliated institution places restrictions on the activities of UMB Personnel infected with a Bloodborne Pathogen, and those restrictions exceed the restrictions, if any, imposed by an individual's Dean or Unit head, the School or Unit will attempt to reassign the individual to a site where he or she can carry out activities permitted by UMB.

16. Look-Back Studies

The utility of look-back studies after potential exposure of patients to HIV-infected health care workers is not supported by the evidence from previous studies. Therefore, UMB will not conduct such look-back studies except in extraordinary cases as determined by the President of the campus. With respect to other Bloodborne Pathogens, look-back studies may have medical value and will be given consideration.

17. Notification to Patients and Clients

UMB patients and clients who have been served by an individual among the UMB Personnel who is known, or becomes known, to be infected by a Bloodborne Pathogen, may be informed of the individual's infectious status if there was an Exposure Incident involving the blood or other body fluids of the individual. In such cases, testing and pre-test and post-test counseling will be made available without cost to the patient or client. Under other circumstances, patients ordinarily would not be contacted.

18. Management of Exposure Incidents

(a) Management of Exposure Incidents of UMB Personnel will comply with the OSHA Standard. Exposure Incidents involving students during experiences that are required or are otherwise part of their UMB educational program will be managed under the OSHA Standard notwithstanding that the Standard applies only to employees. Occupational Exposure plans shall be developed by schools and publicized among students. These plans shall provide information about the steps to be followed in the event of an Exposure Incident.

(b) Following a suspected or known Exposure Incident, the affected UMB Personnel should report the incident to the appropriate School or Unit authority identified in the Occupational Exposure plan. Testing of UMB Personnel following a reported Exposure Incident will be available through Student and Employee Health. Testing is at the option of the exposed individual, and will be performed only after obtaining written informed consent. It is recommended that a blood sample for testing be drawn immediately after an Exposure Incident, even if a decision to consent to testing of the sample has not been made. Pre-test and post-test counseling will be provided.

(c) Costs of testing, counseling and treatment for students, other than AZT prophylaxis or other anti-viral medications, are covered under the Student Health fee. Testing, counseling and treatment, other than AZT prophylaxis or other anti-viral medications, will be provided at no cost to UMB employees. Costs for other UMB Personnel are the responsibility of the individuals being tested unless a School or Unit agrees to assume such costs.

(d) Counseling will include a review of the advantages and disadvantages of AZT prophylaxis or administration of other currently appropriate anti-viral preventive medication, which generally can be offered by (but usually is not paid for by) UMB. It will be available at the individual's cost if it is desired. The individual's School or Unit will be responsible for any uninsured cost of AZT or other recommended medication administered to UMB Personnel upon medical recommendation immediately following a massive exposure to blood of a Source Individual or Confirmed Source Individual during a work or education activity.

(e) If UMB students choose to be tested and receive care off campus, UMB will not be responsible for costs, even in instances of massive exposure.

(f) Exposure Incidents of UMB personnel while at affiliated sites optimally should be handled by an appropriate exposure control plan and procedures in place at that site; however, if appropriate procedures are not available, Student and Employee Health will provide testing, counselling and treatment services as specified above.

(g) If an Exposure Incident involves a patient in a Maryland hospital which is an affiliated site, the exposed UMB Personnel can request that the Source Individual be tested (with consent) for Bloodborne Pathogens. In order for the Source Individual to be tested, the exposed UMB Personnel must agree to be tested for Bloodborne Pathogens. If hospital infection control staff do not offer assistance in securing patient testing, the exposed UMB Personnel should notify Student and Employee Health and seek assistance.

(h) If an Exposure Incident involves as the Source Individual a patient or client who is not in a Maryland hospital, Student and Employee Health will assist in seeking consent of the Source Individual for testing.

(i) To the extent permitted by law, UMB will provide to exposed UMB Personnel, and will ask its affiliates to provide to exposed UMB Personnel, information about the infectious status of Confirmed Source Individuals involved in Exposure Incidents with UMB Personnel.

19. Respective Roles of Schools and Units and the Office of Environmental Health and Safety (EHS) in UMB Policies for Bloodborne Pathogens

In general, it will be the responsibility of Schools and Units of UMB to implement and monitor compliance with the OSHA Standard, this Policy, and other UMB, School and Unit policies (as applicable in specific cases) related to Bloodborne Pathogens. Each School or Unit required to do so by the nature of its activities will develop an exposure control plan. The plan should be developed in consultation with, and subject to approval by, the UMB Biosafety Committee. A single, campus-wide exposure control plan applicable in its entirety to all Schools and Units is not feasible.

Each School or Unit will be responsible for identifying its personnel having Occupational Exposure (such identification to be made on the basis of job responsibilities, not job title), communicating that determination to EHS for approval, and maintaining a list of such positions.

Each School or Unit should develop for its internal purposes a list of procedures within its educational or patient service purview that it considers to be invasive procedures as discussed above in this Policy.

Schools and Units will arrange with EHS appropriate training programs as required by the OSHA Standards. Such training may be accomplished either by course(s) developed and given by EHS, or by courses developed and given by the School or Unit after review and approval of course content and format by EHS. Development and conduct of training by Schools or Units, rather than by EHS, is preferred.

EHS will keep Schools and Units informed of changes in law and regulations pertinent to infection with or exposure to Bloodborne Pathogens.

20. Disability Insurance

UMB will review markets and opportunities for disability insurance at reasonable cost that insures UMB Personnel against loss of income due to disability resulting from infection by Bloodborne Pathogens. UMB will request that the State Department of Personnel likewise attempt to secure such coverage to protect UMB Personnel who are State of Maryland employees. However, UMB may not be able to make available policies that provide such coverage. UMB recommends that each student or employee who is not covered by appropriate disability insurance through the State of Maryland or University of Maryland System benefit system, or through an insurance plan through the individual's School or Unit, consider obtaining individual insurance.

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