fireEMS ❘ By Katherine H. West
In 1991, the Occupational Safety and Health Administration (OSHA) issued the Bloodborne Pathogens Standard on occupational exposure to bloodborne pathogens (29 CFR 1910.1030). In accordance with OSHA’s regulations under this standard, fire/EMS (emergency medical services) have been required to provide initial hire and annual training to employees on bloodborne pathogens. The primary focus of much of this training since 1991 has been on the risk of human immunodeficiency virus (HIV) and hepatitis B (HBV) transmission for health care workers and protecting them by using personal protective equipment (PPE). Training often has fallen short of full compliance with OSHA’s requirements.
Although the training section of the Bloodborne Pathogens Standard references only HIV and HBV, many more diseases must be included. That has been OSHA’s expectation since the regulations were issued in 1991 and described in greater detail in its Compliance Directive CPL 02-02.069. The compliance directive, updated in 2011, is used by OSHA inspectors to determine if employers are in compliance. It is important to include the directive as a reference in your compliance program because it is more comprehensive than the Bloodborne Pathogens Standard itself. For example, the standard addresses only education and training for HIV and HBV, but the Compliance Directive lists many more diseases to be covered in training. For bloodborne pathogens, staff training must include epidemiology, modes of transmission, and symptoms of bloodborne diseases including HBV, HIV, hepatitis C (HCV), Syphilis, “and others if appropriate.”
Ryan White Law
Added to this list would be key diseases listed in the Ryan White Law, Part G, published in the Federal Register on November 2, 2011. Emergency responders have the legal right to be informed of the source patient disease status when exposures to bloodborne and airborne diseases have occurred. The Ryan White list includes HIV, HBV, HCV, tuberculosis, measles (Rubeola), chickenpox, N. meningitis, mumps, pertussis (whooping cough), rubella (German measles), and influenza. All of these should be included in training. Tuberculosis training is also required by OSHA’s enforcement of the Centers for Disease Control and Prevention (CDC) Tuberculosis Guidelines (since 1993). The latest version of these CDC TB Guidelines was published in December 2005.
Many older diseases, especially childhood diseases, are once again appearing as outbreaks across the country. It is important to include in training how to identify signs and symptoms of these diseases and what preventable vaccines are available to remove concerns about contracting a disease in an exposure situation. Training on all of these diseases is needed for new hires as well as annual update training in the workplace. The material included in this training must, according to OSHA, be presented by a qualified trainer. Rotation of staff in the training position could impact the training provided. All of this begs the following questions:
- How well are departments meeting these requirements?
- Does new hire training address airborne and droplet diseases?
- How much time is allotted to new hire training?
- How is your training delivered?
- Is your department training department specific?
To determine current practices, a voluntary survey was developed on compliance with these requirements in the fire/EMS workplace. Data were collected from departments both small and large across the country over a 12-month period. Participation was low—a total of 57 surveys were submitted from 13 states. Department size ranged from 50 to 75 members (10 departments) to more than 150 members (11 departments). The surveys returned represented 44 career and 11 volunteer departments. The survey was short (14 questions), focused primarily on new hire training, and specifically addressed training on diseases and infection control.
One key question addressed infection control in new hire training. Only 41 (72%) of departments reported that communicable diseases and infection control were part of their new hire training.
Annual update training was offered by 45 (78.95%) departments. Time allotted for training in 11 (19.3%) departments was less than one hour; 13 (27%) departments allocated three to four hours.
OSHA requires that training be department specific and that it offer the opportunity for questions and answers (with an instructor) during the training. When asked how training was presented in their departments, 78.95% stated that training was offered in person; 42.11% stated that training was offered by video or DVD; and 45.61% stated that they provided their training online. Department-specific training was provided by 35 departments; 22 did not offer department-specific training.
With regard to specific topic areas addressed in training, cleaning routines for vehicles and equipment were addressed by 33 (58%) departments; 24 (42%) reported this information was not covered. Definitions of an exposure were addressed by 44 (72%) departments.
OSHA requires that the department Exposure Control Plan (ECP) be reviewed in new-hire training. Only 43 (75%) departments acknowledged including their ECP in new-hire training.
A key element of an ECP is identification of a designated infection control officer (DICO) who serves as the liaison between medical facilities and an exposed employee for exposure situations. When asked if the DICO was part of new-hire training, 25 (44%) stated the DICO role was addressed, including how to contact that person 24/7. Department procedures/protocol for postexposure medical follow-up were presented in training in 35 (61%) of the departments responding.
Training on proper donning and doffing of PPE, which would seem to be an important part of personal protection, was explored. Thirty-one departments (17.67%) said they included it in training.
When discussing postexposure medical follow-up, it is important that staff be aware of the HIV testing law in their state since every state law differs to some degree. Only nine (14%) departments listed this information as being addressed in training.
Knowledge of state medical waste regulations is also important. Every state has medical waste regulations, but definitions of medical waste vary somewhat. There is a significant cost associated with collection and disposal of medical waste; being aware of local definitions has an impact on cost to the department or to the medical facility. For example, most states define medical waste as sharps and any item dripping with blood (or saturated with blood). Most EMS waste, according to this definition, is general trash. To the question of whether the medical waste regulation/definition was presented in training, 35 (19.95%) replied that this was covered.
The survey listed the key bloodborne pathogens, inquiring which were covered in training. HBV was presented in training by 46 (80.7%), HCV by 37 (63%), and HIV by 52 (91%). Viral hemorrhagic fevers (Ebola, Lassa fever, and Marburg) were included 11.4% of the time; syphilis was addressed 22.81% of the time.
Questions addressing airborne diseases (chickenpox, tuberculosis, and measles) revealed that the primary disease covered in training was tuberculosis (87.72%). Chickenpox was covered by 16.42% and measles by 22.81%. Droplet transmitted diseases (mumps, meningitis, and influenza) were included in training as follows: mumps (19.3%), meningitis (61.4%), and influenza (61.4%).
Limitations of this survey include a small sample size and questions that were very broad and did not allow for more specific responses. For example, was training using DVD or online platforms edited in-house to include department specifics? Viral hemorrhagic fevers should have been broken down to address each one. Ebola was likely assumed by respondents because of recent cases in the United States. Responses, despite being less than anticipated, came from a variety of states and department sizes, including a mixture of both career and volunteer departments.
The summary of responses demonstrates low compliance with training requirements that have been in place for many years. Overall, it would appear that there is a need to expand education and training on diseases in accordance with OSHA requirements as well as the Ryan White disease list published by the CDC in 2011. Some responses seemed to conflict with others. For example, several responses indicated that training was department specific, but it was delivered using purchased DVDs or online content. The low percentage of training on exposure definitions and identification of the DICO is concerning, as these are key to postexposure notification and follow-up.
OSHA Enforcement Procedure for Bloodborne Pathogens Regulation, CPL 02-02.069, November 2001.
Implementation of Section 2695 (42 U.S.C. 300ff–131) of Public Law 111–87: Pat G—Notification of Possible Exposure to Infectious Diseases, S. 1793, U.S. Congress, 2009.
Infectious Diseases and Circumstances Relevant to Notification Requirements, Federal Register/Vol.76, No 212, Wednesday, November 2, 2011.
Implementation of Section 2695 (42 U.S.C. 300ff–131) of Public Law 111– 87: Infectious Diseases and Circumstances Relevant to Notification Requirements.
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, MMWR, December 30, 2005.
Compliance Directive CPL 02-02.078, Enforcement of Guidelines for Tuberculosis, December, 2015, CDC.
KATHERINE H. WEST, BSN, MSEd, has been working in the field of infection control since 1975. She lectures nationally and internationally on this topic. She publishes books, training materials, and articles on infection-control-related issues. She has served as a consultant to the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health. She has served as an education specialist for the National Institutes of Health and authored the Infectious Disease Handbook for Emergency Care Personnel, now in its third edition. She is a consultant to the U.S. Public Health Service, Federal Occupational Health. She was the recipient of the following awards: the Association for Professionals in Infection Control & Epidemiology’s “Hero in Infection Control & Prevention” in 2006, International Association of Fire Chiefs–EMS Section Meritorious Service Award, and the State of Virginia Governor’s award.