Why is the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogen Standard relevant to artists? Dancers? Maybe the better question to ask is who comes in contact with blood or body fluids?
In reality, while most artists, conservators, performers, and teachers don't have occupations that specifically involve work-related blood exposures, there are some cases where the standard’s protocol is useful. While blood spills may be unlikely, there are a variety of situations that can cause concern. Certain activities may have a risk of a blood exposure. For example, wardrobe attendants who remove foot wrappings of dancers may come into contact with blood. Art teachers who have machinery in the classroom have a higher potential for accidents.
The Human Immunodeficiency Virus (HIV) damages certain white blood cells causing the Acquired Immune Deficiency Syndrome (AIDS). HIV is a bloodborne virus, and airborne vectors (coughing, sneezing, drinking from the same cup) do not transmit the virus. HIV must also occur in high concentrations to be transmitted; saliva, sweat, and urine do not transmit AIDS. HIV can be transmitted through blood, sex, and from a nursing mother to her baby, or from a pregnant woman to the fetus. Hepatitis B (HBV), a liver disease, can be transmitted the same ways as HIV, and also through deep bites.
There are also cases in which there is a lot of fear and concern, although the actual risk is very unlikely. An example of this would be make-up artists who apply cosmetics to many performers. All concerned individuals need to analyze their particular circumstances to estimate risk. The most straightforward way of dealing with activities in which there may be exposures to infectious blood or body fluids is to utilize universal precautions. Specific comments on arts areas and a sample Specific Operating Procedure (SOP) - one part of the OSHA-required Exposure Control Plan - are presented below.
OSHA and the Bloodborne Pathogens Standard
In December 1991, OSHA published its final rule on Occupational Exposure to Bloodborne Pathogens Standard, (29 CFR 1910.1030). OSHA has determined that certain employees face significant health risks with occupational exposure to blood and other potentially infectious materials (OPIM) because of contamination by bloodborne pathogens. This refers to HBV (the virus that causes hepatitis B) and HIV. OSHA has set certain regulations concerning engineering and work practices controls, personal protective equipment, training, medical surveillance, HBV vaccination, signage and labeling, and more in attempt tominimize or eliminate the hazard.
Who is Covered?
This standard applies only in situations where employees could "reasonably be anticipated" to come into contact with blood or OPIM because of their job duties. Occupational exposure is defined as a "reasonably anticipated skin, eye, mucous membrane, or parenteral, (through the skin) contact with blood or OPIM that may result from the performance of an employee's duties." OPIM include: saliva in dental procedures, body tissues and organs, semen, cerebrospinal fluid, and amniotic fluid. While certain individuals may be exposed to OPIM, they may not be covered by the actual standard. Examples include:
Sole medical practitioners - a doctor working without a hygienist, aide, or nurse. Public sector employees - this includes state, county, and local government employees in states that do not have federally-approved safety and health plans. States with state plans must cover public sector employees.
Volunteers - since they are not employees. Employers are encouraged to provide training and safety equipment. Good Samaritans - interpreted as a volunteer co-worker who provides first aid out of kindness rather than duty.
First-aid responders - Individuals who are designated first-responders in emergency situations must be trained in accordance with the standard, but can be offered a post-exposure (rather than a pre-exposure) hepatitis B vaccination if they give aid involving exposure to blood or other potentially infectious materials. Reporting requirements may be more stringent in these cases. Every other aspect of the standard applies.
Purpose: To limit occupational exposure to blood and other potentially infectious materials since any exposure could result in transmission of bloodborne pathogens that could lead to disease and death. Scope: Covers all employees who could be reasonably anticipated, as a result of performing their job duties, to come into contact with blood and other potentially infectious materials. Good Samaritan acts such as assisting a co-worker with a nosebleed would not be considered occupational exposure. Definitions:
Blood - Human blood, human blood components, and products made from human blood.
Bloodborne Pathogens - Pathogenic microorganisms that are present in human blood and cause disease in humans. These pathogens include hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Contaminated - The reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Decontamination - Physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling use or disposal. Engineering Controls - Controls (e.g. disposal containers) that isolate or remove the bloodborne pathogens hazard.
Exposure Incident - A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee's duties.
Handwashing Facilities - A facility providing an adequate supply of running potable water, soap, and single-use towels or hot air drying machines.
Occupational Exposure - 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.
Personal Protective Equipment - Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, shirts) intended to function as protection against a hazard are not considered personal protective equipment.
Regulated Waste - Liquid or semi-liquid blood or OPIM that could release blood or OPIM if compressed or squeezed out, or items that are caked with dried blood or OPIM and capable of releasing this material during handling. Also included are contaminated needles and other sharp objects.
Universal Precautions - An approach to infection control. According to this concept, all human blood and certain human blood fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Exposure Control Plan: OSHA requires employers to develop an Exposure Control Plan that identifies in writing all the job classifications, and specific operations and tasks, that may involve work-related exposures to blood and OPIM. This plan must set forth the training of employees and implementation for recordkeeping, signage, and other aspects of the standard, as well as specifying the procedures for evaluating circumstances involving exposure incidents. The Exposure Control Plan must be available and accessible to both the employees and to OSHA. Annual review and updates of the exposure control plan are required.
Exposure Determination: Employers are required to prepare an exposure determination if they have employees with occupational exposure. A list is needed of all job classifications in which some and all employees have occupational exposure; The exposure determination must be made without regard to the use of personal protective equipment.
Methods of Compliance: UNIVERSAL PRECAUTIONS shall be observed to prevent contact with blood or other potentially infectious materials. This means that all body fluids shall be considered potentially infectious materials. Engineering and work practice controls will be emphasized to eliminate or minimize employee exposure. If occupational exposure remains after engineering controls are implemented, personal protective equipment shall be used. Handwashing will be stressed following the exposure to any type of body fluids even if gloves were worn.
Employees will be provided with appropriate antiseptic hand cleanser (towelettes) when handwashing facilities are not feasible. When antiseptic cleansers (towelettes) are used, hands shall be washed with soap and running water as soon as possible.
Hepatitis B Vaccination: Vaccinations and training will be made available to all employees who have occupational exposure to blood and OPIM. Employees who initially decline the vaccination but later accept will also be provided this vaccination and training.
Waste Disposal A written schedule for cleaning is required, along with decontamination and cleaning procedures. Handling and labeling of laundry is specified. The laundry bags must be sent in leak-proof receptacles. All individuals who come into contact with laundry must wear appropriate protective equipment. All waste receptacles must be labeled, inspected, and decontaminated on a scheduled basis. Post-Exposure Evaluation and Follow Up: Following a report of an exposure, the exposed employee(s) will be provided a confidential medical evaluation and follow-up by an accredited laboratory at no cost to the employee. The circumstances of the exposure will be documented. A description of the exposed employee's duties as they relate to the incident will be provided to the healthcare professional. The employer will provide a copy of the OSHA regulation (29 CFR section 1910.1030) to the healthcare professional.
Healthcare Professional's Written Opinion: The employer shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation after an exposure incident. The written opinion will inform the employee of the results of the evaluation. The written opinion will inform the employee about any medical conditions resulting from the exposure to blood or other potentially infectious materials which require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written report.
Recordkeeping: The employer shall establish and maintain an accurate record for each employee with occupational exposure for the duration of employment plus 30 years. A copy of all results of examinations, medical testing, and follow-up procedures will be maintained. Hazard Communication: The orange or orange-red biohazard symbol must be displayed on any container with OPIM. Red bags may be substituted for this label. This symbol will be reproduced below. Information and Training: Initial and annual training is required on the standard, on the specific employer's exposure control plan, engineering work practices and controls, bloodborne diseases, exposure control, HBV vaccination, emergency response, signage, and follow-up after exposure.
Arts-Related Exposure to OPIM
Shared Make-up and Cosmetics
Many performing artists and makeup artists have asked us about the hazards of sharing the make-up and tools for application. Some types of cosmetics can possibly be vehicles for biological transmission of disease. Transmission of HIV or Hepatitis B, which is passed through sexual or blood contact, is not likely. However, other bacterial infections, such as staphylococcus, impetigo, and streptococcus can be passed through make-up. HIV-positive individuals aren't likely to catch opportunistic infections from other people via shared make-up. Individual make-up utensils and applicators, and handwashing procedures are recommended.
Shared Musical Instruments
Sharing instruments is routine in elementary and secondary schools, where students practice on borrowed instruments for part of the year. Also, in some college level or conservatory specialty music classes, instruments can be shared. The Centers for Disease Control (CDC) stated that there really is no risk of transmission of HIV or HBV because of the lack of blood-to-blood, sexual fluid, or blood-to-mucous membrane contact. There have been no cases of transmission of HIV through saliva, although there was one documented case of HBV transmission through oral contact, via a deep human bite.
Herpes transmission is extremely unlikely because there needs to be direct skin-to-skin contact for the virus to be transmitted. While theoretically TB could be transmitted via inhalation of bacteria previously coughed into an instrument, this situation would be highly unlikely.
The greatest hazard involves the transmission of colds or influenza to the musicians sitting right in front of the bells of the brass or horn instruments. Specific protocol for cleaning and handling of shared musical instruments is outlined in our newsletter article. Musical instruments that are shared in educational or other settings should be cleaned with EPA-approved disinfectants for each new student.
Those involved in helping performers change costumes or in cleaning and maintaining the performers’ wardrobe may come into contact with bloody materials. A specific example of a wardrobe attendant's potential for exposure would be the handling of dancers' bleeding feet and bloody foot wraps or shoes. A Standard Operating Procedure (SOP) will be given below.
Schools and Colleges
During a training session for elementary school teachers (who are often responsible for the arts curriculum), it was revealed that this group of teachers saw blood frequently because of accidents, bloody noses, and fist fights. They estimated once every three days. A standard operating procedure for the school was drafted including a protocol for action during accidents, use of clean-up kits, utilization of nursing staff, and licensed medical waste disposal.
Arts and Vocational School Classes
In classrooms and workshops where there is machinery, especially machines equipped with sharp blades or needles, (e.g. sewing arts classes and woodworking), the potential for a blood spill is greater. In cases where disposable sharp items are responsible for bloody wounds, (e.g disposable Exacto blades) these should be handled and disposed of like sharps waste. If the tool is more permanent, (e.g. a table saw), then clean-up with EPA-approved disinfectant and clothing is necessary. These classrooms should have the proper protective equipment to handle an incident.
Museums and Historic Sites
Historic Site Preservation
Historic sites (and even other buildings such as school buildings) may have to clean up potentially infectious material like blood, used syringes, feces, etc., from their sidewalk and outside areas. Again, whenever this kind of maintenance is necessary, there needs to be an exposure control plan in place. Certainly, rubber gloves, aprons, and boots are recommended. If working with pressurized water, personnel should wear a face shield and goggles. An EPA-approved disinfectant should be used (e.g. 1:10 bleach).
The Center for Safety in the Arts has sometimes been asked for recommendations for art installations that involve blood or blood products. For example, in creative response to the AIDS crisis, many artists have used blood as an art medium. In this type of circumstance, slaughterhouse rather than human blood should be used. Performance art using human blood should never be done if there is any possibility of a blood splash or contact.
Anything can happen. Accidents do occur, and blood spills may happen because of a badly supervised stunt scene, or because of a bloody nose from filming at high altitudes. In these situations, everyone involved should try to maintain procedures consistent with universal precautions.
Sample Standard Operating Procedure for Wardrobe Attendants
If wardrobe attendants are involved in changing bloody bandages, or in first-aid procedures, they should have training in accordance with the standard. Gloves, clean-up materials, sealable plastic bags for disposal, and handwashing facilities should be available.
Any performer with open lesions (i.e., bloody cuts, sores, foot-corns, acne-with draining lesions) should dress his or her own wounds in such a way that they are effectively and securely covered with a bandage or gauze. During rehearsal and performance, disposable latex gloves, sealable plastic bags, paper towels, sanitary absorbent material, disposable alcohol towelettes, liquid soap and water, alcohol, and bleach or another disinfectant should always be on hand. Gloves should be discarded if peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration. In the case of injury that results in a blood/body fluid spill, encourage the individual to clean and wrap his/her own wounds, bloody nose, etc. If this is not possible follow Standard Operating Procedure: Wear disposable latex gloves and use disposable towels/clean gauze for each injury. Any blood-stained first aid supplies should be placed in a sealable plastic bag. Follow proper glove removal procedures and place in a sealable plastic bag. Wash hands thoroughly with soap and water. If open lesions or wounds have come into contact with blood from another person, the affected area should be scrubbed with soap and running water. A skin disinfectant (i.e., 70% alcohol, Betadine, Hibiclens) should be applied after washing. When the skin is intact, have the performer wear gloves and wash his/her own skin using a disposable towel containing soap and water or with soap under running water. Gloves and towels should be discarded in a plastic bag. Hands should be washed thoroughly. Sharing of drinking cups and make-up should be discouraged. EPA-approved disinfectants should be used for clean-up. Use products according to the manufacturer's instructions. Agents should belong to one of the following classes of disinfectants: Sodium hypochlorite (1:10 dilution of household bleach). It is important to remember that this solution must be made fresh for each use and is effective against both HIV and Hepatitis B. Ethyl or isopropyl alcohol (70-90%).- Quaternary ammonium germicidal detergent solution in a 2% aqueous solution. (e.g. Tri-quat, Mytar or Sage). Iodophor germicidal detergent (500 ppm available iodine) (e.g. Wescodyne). Phenolic germicidal detergent solution in a 1% aqueous solution (e.g Lysol). Floors, toilets, and sinks of all rooms used to clean up after any blood spills should be cleaned and disinfected with an EPA-approved disinfectant. Cleaning tools like mops should be soaked in a disinfectant solution for 20 minutes. While regulated waste refers to liquid or semi-liquid blood materials, if items such as bandages are saturated with blood, then these should be placed in a sealed, labeled, and secure red plastic bag and disposed of by a licensed medical waste disposal company, or laundered by a company employing universal precautions. The Biohazard label appears below.