Bloodborne Pathogen Control Management Policy

General Statement of Purpose

The purpose of this policy is to outline measures to reduce occupational exposure to and minimize transmission of bloodborne pathogens, but are not limited to, Hepatitis B virus (HBV), Hepatitis C (HCV), Human Immunodeficiency Virus (HIV) that can be transmitted in the health care environment.

Policy

The Health system and its personnel are responsible for minimizing their risk for exposure to bloodborne pathogens. This plan outlines strategies to minimize and potentially eliminate occupational exposure to blood and other potentially infectious materials (OPIM) by providing a safe and healthful work environment, thereby minimizing the risk of infection in accordance with Occupational Safety and Health Administration (OSHA).

Scope

This policy applies to all members of the Northwell Health work force including, but not limited to employees, medical staff, volunteers, students, physician office staff, and other persons performing work for or at Northwell Health.

Definitions

Bloodborne pathogens are pathogenic microorganisms that are transmitted via human blood and cause disease in humans. They include, but are not limited to, HBV, HCV, and HIV.

Procedures & Guidelines

Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Plan

1. OSHA BLOODBORNE PATHOGEN PLAN
   The Bloodborne Pathogens Standard, codified as 29 CFR 1910.1030, pertains to individuals in facilities who could be "reasonably anticipated" to come in contact with blood or other potentially infectious material (OPIM). This Exposure Control Plan outlines the facilities efforts to decrease the occupational risk of acquiring a bloodborne disease. This plan:

   1. Identifies tasks and procedures as well as job classification where occupational exposure to blood occurs without regard to protective clothing and equipment.
   2. This exposure plan can be obtained upon request from the Safety Officer or Infection Preventionist. It is also accessible online via Health Port under Policies in the Infection Control Manual.
   3. Will be reviewed at least annually by the members of the Infection Prevention and Control Committee.

2. Training
   Training regarding strategies to minimize exposure to those who, as the result of performing their job duties, could be "reasonably anticipated" to come in contact with blood and OPIM occurs upon employment and at least annually thereafter. Each training session should provide an opportunity for questions and answers. Additional training according to responsibilities or prior to performing a new exposure prone task/procedure shall be given. The training shall emphasize prevention and management of an exposure when it occurs. The minimal training program elements are:

   1. A general discussion of bloodborne diseases, emphasizing epidemiology, symptoms of each disease, modes of transmission.
   2. An explanation of the appropriate methods for recognizing tasks and other activities that involve exposure to blood or other potentially infectious materials.
   3. Use of standard precautions.
   4. Explanation of work practices, engineering controls, and protective garments, known as personal protective equipment (PPE) to minimize/eliminate risk.
   5. An explanation of the reasons for selecting PPE.
   6. An explanation of the proper use, location, handling, decontamination, and disposal of PPE.
   7. Handling procedures for sharps, specimens, laundry, and regulated medical waste.
   8. Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, benefits of being vaccinated, and availability of the vaccine free of charge.
   9. Information on the appropriate actions to take and persons to contact when exposed to blood or OPIM.
   10. An explanation of the procedures to follow up if an exposure incident occurs.
   11. An explanation of the hazardous communication labels and signs that are in place on containers and around workstations
   12. An explanation of the Exposure Control Plan and how to obtain a copy of the written plan
   13. An opportunity for interactive questions and answers with the person conducting the training session.

3. EPIDEMIOLOGY, SYMPTOMS, MODES OF TRANSMISSION OF BLOODBORNE DISEASES:
   While HIV and hepatitis viruses are specifically identified in this Exposure Control Plan, the terms bloodborne pathogen or bloodborne disease includes any pathogenic microorganism that is present in human blood or OPIM that can infect and cause disease in persons who are exposed to blood containing the pathogen.

   1. HIV, the virus causes acquired immunodeficiency syndrome (AIDS), attacks and destroys the immune system (CD4 helper cells), leaving the individual unable to fight off many disease-producing organisms. In the early stages of HIV, there are no symptoms. As the disease progresses, the individual may develop recurrent fevers, diarrhea, weight loss, swollen lymph glands and yeast infections. When an individual develops diseases such as pneumocystis pneumonia, oropharyngeal candidiasis, Kaposi Sarcoma, etc., the diagnosis of AIDS is made.
   2. HIV is transmitted through sexual contact, exposure to infected blood or blood components and vertically (prenatal from mother to neonate). Infectious materials include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and body fluid visibly contaminated with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. They also include any unfixed tissue or organ other than intact skin from a human (living or dead) and human HIV containing culture medium or other solutions, as well as blood, organs or other tissues from experimental animals infected with HIV. Although HIV has been isolated in the above fluids, the modes of transmission in the healthcare setting are: puncture exposure with injury by a needle or other sharp object, mucous membrane exposure, including exposure of mouth, nose, or conjunctiva open wound exposure and contamination of open incisions, abrasions, or lacerations by infectious fluids.
   3. Viral Hepatitis: The predominant agents spread through the bloodborne route are hepatitis B, C and D. Hepatitis B and C have been associated with transmission in healthcare
      1. HBV: HBV replicates in the liver and causes hepatic dysfunction. HBsAg is found on the surface of the virus; it can be detected in serum 30-60 days after exposure to HBV. Another antigen, hepatitis B antigen (HBeAg), may be detected in samples of persons with acute or chronic HBV infection. The presence of HBeAg correlates with high infectivity. The incubation period of hepatitis B is long (45-160 days; average - 75), and the onset of acute disease is generally insidious. Clinical symptoms and signs include anorexia, malaise, nausea, vomiting, abdominal pain, jaundice, skin rashes, arthralgias, and arthritis. The case-fatality rate for reported cases is approximately 1.4%. Transmission occurs via percutaneous or permucosal routes, and infectious blood or body fluids can be introduced at birth, through sexual contact, or by contaminated needles. Infection can also occur in settings of continuous close personal contact (such as in households or among children in institutions for the developmentally disabled), presumably via unapparent or unnoticed contact of infectious secretions with skin lesions or mucosal surfaces. Transmission of infection by transfusion of blood or blood products is rare because of routine screening of blood for HBsAg and because of current donor selection procedures. Transmission of HBV from infected health-care workers to patients is uncommon but has been documented during types of invasive procedures. HBsAgpositive health-care workers need not be restricted from patient contact unless they have been epidemiological associated with HBV transmission or involved with invasive procedures and haves a high viral load.
      2. HCV: Like HBV, HCV virus poses an occupational risk to the HCW. HCV is the agent responsible for most cases (up to 40%) of parenterally transmitted non-A, non-B hepatitis. HCV has epidemiologic characteristics similar to those of HBV although the symptoms are usually milder and most children are asymptomatic. At present, there is no vaccine available to prevent HCV infection. Antiviral drugs have been approved for treatment of chronic HCV.

      3. Summary of Hepatitis B and C
         Type	Mode of Transmission in health care	Vaccine	Recommendations in addition to Standard Precautions
         B	Parenteral, contact with non-intact skin or mucous membranes.	Yes	-pre-exposure immunization -post-exposure prophylaxis (vaccine &/or hepatitis B immune globulin (HBIG)
         C	Parenteral, contact with non-intact skin or mucous membranes.	No	-baseline/follow-up testing -post-exposure prophylaxis based on post-exposure serology results

4. METHODS OF REDUCING EXPOSURE AND TRANSMISSION:
   An exposure is defined as percutaneous or mucous membrane exposure to blood or body fluids of any patient, including needle or other sharp stick or cut, blood splash on an open cut or wound, or splash to mouth or eyes. Individuals incur risk of infection and illness each time they are exposed to blood or OPIM. Therefore, reducing exposure incidents to bloodborne pathogens also reduces the risk of transmission. The following outlines the prevention strategies:

   1. ADMINISTRATIVE CONTROLSinclude the organization’s policies and procedures that aim to decrease the risk of exposure. This includes educating all healthcare workers and allocating resources to purchase safety devices.

   2. ENGINEERING CONTROLS: Engineering design plays an important role in the management of biohazards. The goal for engineering controls is the prevention of healthcare worker exposure to infection or injury by controlling worker exposure to the infectious agent. This is done by the following methods:

      1. Splash guards
      2. Leak proof, puncture-resistant containers for used needles and other contaminated sharp items.
      3. Designated cabinets or areas to hold PPE in proximity to patient care.
      4. Needle safety devices, i.e. safety butterfly, retractable lancet, intravenous connecting sets without needles, a device that covers a needle after use, and plastic capillary tubes. Introduction of a new product will follow the protocol outlined by the Health System Medical/Surgical Value Analysis Committee. Refer to Attachment C for the list of safety devices.
      5. Direct patient care providers’ input is solicited by a Sharps Safety questionnaire. The questions asked include: Can you indicate any work practice controls and/or engineering controls (i.e. sharps safety devices, instruments, equipment) that could further reduce your exposure to blood and/or body fluid, needle sticks and other sharps injuries. Responses are correlated and analyzed for engineering and work practice improvements.

   3. WORK PRACTICE CONTROLS means performing patient care activities in a manner that reduces the likelihood of a worker's exposure to blood or OPIM. Examples:

      1. Disposing of regulated medical waste in a red plastic bag with a biohazard symbol.
      2. Decontaminating equipment before reuse.
      3. Labeling contaminated equipment before servicing. Placing all specimens in a covered well constructed container when transporting a specimen; a secondary container or protective package shall be used if outer container is soiled.
      4. Always take care to minimize the formation of droplets, splatters, splashes, aerosols and spills of blood or body fluids.
      5. All expirations or body parts shall be placed in a fluid resistant body bag prior to transport.
      6. Replacing examination gloves when visibly soiled, torn, or punctured, or when their integrity is compromised.
      7. Not recapping, re-sheathing, bending, or clipping needles. When recapping is the only alternative, use the one-handed technique.
      8. Disposable syringes and needles (including self-sheathing needle products), scalpel blades, and other sharp items are placed in puncture-resistant containers for disposal; the containers shall be located as close as practical to the use area.
      9. Placing sharp containers at a height, which visualization of the opening of the container.
      10. Observing standard precautions.
      11. Adherence to the regulated medical waste protocol.
      12. Contaminated reusable equipment and instruments shall be cleaned and disinfected as per manufacturer guidelines between each patient/resident use.
      13. Use mouthpieces, resuscitation bags, or other ventilation devices for resuscitation.
      14. Never pipette by mouth. Always using pipetting aids.
      15. Using PPEs and removing when no longer needed.
      16. Using a protective covering i.e., plastic wrap, aluminum foil, or imperviously backed absorbent paper, to protect items or surfaces from contamination.
      17. Eating and drinking, plus storage of food shall be in areas separate from contaminated areas.
      18. During invasive procedures, the passing of a sharp object from one individual to another should be done using a neutral zone and announcing the object presence/location.
      19. If any accident occurs, (i.e. puncture, cut, contact with skin, mucous membrane, splash, etc.), wash affected area with large volumes of water. Report immediately to your supervisor and to Emergency Department for immediate medical evaluation.
      20. Do not allow sharps disposal containers to over fill. Replace when ¾ full. In the event a container needs to be changed prior to vendor scheduled pick-up, contact the Environmental Services Department.
      21. Identifying labels (i.e., biohazard, contents) on containers/carts/racks shall face outward.

   4. PPE: Engineering and work practice controls shall be used to eliminate and minimize exposure. Where occupational exposure remains after institution of these controls, personal protective equipment at no cost to the individual, shall also be used. A PPE is a specialized clothing or equipment used by workers to protect them from direct exposure to blood or OPIM. The following listed PPE are selected based on the task performed and the degree of exposure.

      1. Type:
         1. MASKS, EYE PROTECTION, AND FACE SHIELDS - Shall be worn if there is the possibility of exposure whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated. Items such as goggles or glasses with side shield, or chin face shields shall be worn if there is reasonably anticipated exposure of eyes, nose, or mouth. Prescription glasses shall be used as protective eyewear as long as they are equipped with side shields that are permanently affixed. If protective eyewear is chosen over the use of a face shield, the eyewear must be worn in combination with a mask to protect the nose and mouth. EXEMPTION: During microsurgery, when it is not reasonably anticipated that there would be any splattering, a surgeon would not be required to wear eye protection while observing surgery through the microscope.
         2. GLOVES - Single use gloves shall be worn if you or the patient/resident has broken skin, for all invasive procedures, internal examinations, touching mucous membranes, whenever handling at risk fluids or tissue, whenever handling soiled materials and equipment, cleaning up spills of blood or OPIM. For non-patient care activities utility gloves may be used and decontaminated for reuse if the integrity of the glove is not compromised.
         3. GOWNS, APRONS, AND OTHER PROTECTIVE BODY CLOTHING - Appropriate protective clothing such as, but not limited to gowns, laboratory coats, or other garments are indicated when contamination of clothing is likely. The type depends on the task and degree of exposure anticipated (fluid-proof/fluid-resistant).
         4. SURGICAL SHOE COVERS - When gross contamination of the feet can be reasonably anticipated shoe covers are required.
5. PPE selection

   Basic principles for PPE selection	Gloves	Gown	Mask	Goggles	Face shield
   Blood drawing	X
   Contact with not-intact skin	X
   Direct contact with excreta	X	XX
   Endoscopy/bronchoscopy	X	XX	XX	XX	X**
   Surgical procedures in the operating room	X	XX	XX	XX*	X**
   Minor surgery with minimal bleeding	X
   Handling soiled instruments	X
   Cleaning soiled instruments	X	XX	XX	XX	X**

   
   X – Always
   XX - Only when soiling is likely
   * - Exception, i.e. microsurgery
   **X – A face shield can be worn instead of a mask and goggles
6. HOUSEKEEPING PRACTICES:
   1. The work site shall be maintained in a clean and sanitary condition.
   2. Each department shall determine and implement an appropriate written schedule for
      1. cleaning based on the type of soil present and tasks/procedures being performed in the area;
      2. discarding of contaminated sharps/needles:
      3. handling regulated waste.
   3. All equipment and work surfaces shall be cleaned and decontaminated after contact with blood or OPIM
   4. Initial cleaning of areas contaminated with blood and OPIM shall be done. Then an approved hospital disinfectant that is an Environmental Protection Agency (EPA)-registered hospital approved EPA tuberculocidal solution or a solution that has a claim that it is effective against HBV and HIV is used to disinfect the surface. Labeling instructions regarding the amount of disinfectant and the length of time it must remain wet on the surface must be followed. Refer to the Blood Spill Protocol within the Infection Prevention Manual.
   5. Impervious coverings shall be used to cover equipment and environmental surfaces. They shall be removed and replaced as soon as feasible following overt contamination or at the end of the work shift, if they may have become contaminated during the shift.
   6. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood of becoming contaminated with blood or OPIM shall be decontaminated on a regularly scheduled basis or as soon as feasible upon visible contamination.
   7. Broken glassware that may be contaminated shall be cleaned up using a brush and dustpan, or other mechanical method, and not be picked up directly with the hands.
7. EQUIPMENT MANAGEMENT: Refer to the Cleaning and Disinfection of Patient Care Equipment within the Infection Prevention Manual.
8. LAUNDRY PRACTICES:
   1. Laundry practices also assist in preventing transmission. Laundry that is contaminated shall be bagged at the location where it was used and shall not be sorted or rinsed in patient areas.
   2. All linen is considered to be potentially infectious, shall be handled as little as possible, and be handled with gloves and any other appropriate PPE in order to prevent or reduce contact exposure to blood and OPIM.
   3. The linen shall be placed and transported in bags that prevent seepage.
   4. The bags shall be placed in impervious transport containers.
   5. Staff involved with the reprocessing of laundry shall wear gloves, gown, and mask when handling soiled linen.
   6. Laundry areas must have sharps containers easily accessible because of possible incidence of needles being mixed with laundry.
      If blood or OPIM penetrate a garment, the garment will be removed immediately or as soon as feasible. The soiled clothing item should be placed in a plastic bag and brought to an area that manages soiled linen. The garment shall be cleaned by the facility’s laundry or sent for cleaning and returned to the individual.
   7. Arrangement for laundering of the clothing items should be coordinated by the facility
   8. Refer to the EHS Policy/Procedure for details on post exposure follow-up.
9. HEPATITIS B VACCINE:
   The hepatitis B vaccine will be offered free of charge.
10. POST-EXPOSURE REPORTING AND FOLLOW-UP
    An exposure incident is defined as a specific eye, mouth, or other mucous membrane, nonintact skin, or parenteral contact with blood or other potentially infectious material. The following outlines post-exposure follow-up:
    1. Immediately wash exposed skin area with soap and water. If eyes are exposed, immediately flush with water. For mouth or other mucous membrane exposures, rinse with large amounts of water. The application of caustic agents (bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.
    2. The incident should be reported to the Department Director or his/her designee. An Employee Occurrence Report should be filled out by logging onto the Employee Self Service (ESS) portal and they will be reviewed by Injury Management/Workplace Safety.
    3. Information about the source person should be obtained and included within the Emergency Department assessment of the employee. The information should include the patient’s name, medical record number, and risks for HBV, HCV, and HIV if known.
    4. The exposed individual should go the Emergency Department as soon as possible after the incident and follow up with Employee Health Services (EHS). Follow-up is confidential; documentation includes circumstance of exposure, identification and testing of the sources, if feasible, and testing the exposed individual’s blood if he/she consents, post- exposure prophylaxis, counseling and evaluation of reported illnesses.
    5. The employer shall document the route of exposure, where exposure occurred, the brand of device involved in the exposure (safety or non-safety device), HBV and HIV status of source patient, history of antiretroviral therapy, viral load, if known, and the circumstances under which the exposure occurred. The information should be captured at the time of the incident on the occurrence report or on a subsequent visit to EHS.
    6. Source patient evaluation shall be done by the source patient’s physician or their designee. Blood for HBV, HCV, and HIV shall be sent to the laboratory for testing. The source patient’s physician will attempt to obtain verbal consent for HIV testing if unknown or known negative. If the patient is unable to consent, anonymous testing may be considered. Refer to the HIV Testing and Management Policy within the Administrative Policy and Procedure Manual. Testing for Hepatitis B and C may be performed on existing blood samples, or the patient may be asked to consent for blood drawing if not blood samples are already available.
    7. The employer shall collect a blood sample from the exposed employee and as soon as possible after the exposure incident to determination their HIV, HBV, and HCV status. If the employee is known HIV positive, testing will not be performed. When the employee is exposed to a high-risk or known positive source patient the exposed individual will be referred for follow-up with Infectious Disease, otherwise routine follow-up will be with Employee Health Services. The follow-up shall include counseling and medical evaluation of any acute febrile illness that occurs within 12 weeks. Refer to the Employee Health Services Policy for post-exposure follow-up.
    8. Post-exposure prophylaxis will be in accordance with the most recent recommendations by the Centers for Disease Control and Prevention (CDC).
    9. Information provided post-exposure includes: 1) a copy of the standard; 2) description of incident, routes and circumstances of the exposure 3) results of blood testing 4) relevant medical records, including vaccination status 5) Written opinion within 15 days of completion of the original evaluation 6) Information regarding their hepatitis B vaccine status, including education for vaccine and whether such vaccine was initiated.
    10. Records from the Emergency Department shall be maintained until EHS picks up the completed form. There should be documentation in sufficient detail about the incident and documentation about use of engineering controls, PPE that was used, device, work practices followed at the time of the incident, etc.
    11. EHS shall compile data on a monthly basis. The injuries shall be categorized by type of exposure. The information shall be presented to the Safety Committee and Infection Prevention and Control Committee. The EHS in coordination with the members of the Safety and The Infection Control Committee shall evaluate the injuries to identify trends and make recommendations.
    12. New York State Laws shall be followed regarding disclosing results of the source individual’s testing to the exposed individual.
    13. Refer to the EHS Policy/Procedure for details on post exposure follow-up.
11. RECORDKEEPING:
    The employer shall maintain a record for each occupational exposure.
    1. The occupational exposure record shall include:1) Name 2) Job duties as they relate to the exposure incident 3) Date and time of exposure
    2. Documentation of the route and circumstances of exposure include where, how and severity of exposure. For percutaneous exposure: depth of injury and whether fluid was injected; for skin/mucous membrane exposure: the estimated volume of material and the condition of the skin (chapped, abraded or intact).
    3. Type and brand of device involved in the exposure incident, whether or not it was a safety device, and when in the course of handling the device the exposure occurred.
    4. An evaluation of the exposure incident.
    5. Collection and test results of the individual’s blood if not already known.
    6. Information/test results of source patient if applicable.
    7. Hepatitis B vaccination status including the dates of all the hepatitis B vaccinations/vaccine response status and any medical record relative to receive vaccination.
    8. A copy of all results of examinations, medical testing, and follow-up procedures.
    9. The employer’s copy of the health care professional’s written opinion.
    10. A copy of the information provided to the healthcare worker with details about counseling, post-exposure management, and follow-up.
    11. The information will be kept confidential per the facility’s protocol.
12. The term “Privacy Case” will be indicated the OSHA 300 Log. The training records maintained by the Department Head shall include the following:
    1. The dates of the training session.
    2. The content or a summary of the training session.
    3. The names and qualifications of persons conducting the training.
    4. The names and job titles of all persons attending the sessions. All records shall be maintained for three (3) years from the date on which the training occurred.
13. AVAILABILITY:
    1. . All records required to be maintained by this section shall be made available upon request for examination and copying to the exposed individual and regulatory agencies.
    2. Medical records shall be provided upon request for examination and copying to the individual and to regulatory agencies.
14. TRANSFER OF RECORDS:
    1. The employer shall comply with the requirements involving transfer of records.
15. REPORTING:
    1. EHS on a monthly basis will compile data. Needle stick injuries will be categorized and presented to the Infection Prevention and Control Meeting and Safety Committee.
16. EXPLANATION OF THE SIGNS AND LABELS REQUIRED BY CODE:
    Specific labeling is required to identify potential hazards. The tag and symbol state that a specific hazardous condition exists and specialized handling is required. The orange or orange-red with the biohazard label in a contrasting color, shall be affixed to containers of regulated waste, refrigerators and freezers and other containers which are used to store or transport blood or OPIM.
    1. The signs must be posted at the entrance to work areas where work with biohazardous materials is performed or where biohazardous materials are stored. These signs must bear the signal word "BIOHAZARD" or "BIOLOGICAL HAZARD", or the universal "BIOHAZARD" symbol.
    2. The labels/tags shall be an integral part of the container and affixed as close as safely possible to their respective hazard by string, wire, or adhesive to prevent their loss or removal.
    3. Red containers/receptacles will be used to substitute for labels on containers use to dispose of regulated medical waste.
    4. The following lists the types of equipment and places where biohazard warning labels should be affixed:
       1. At entrances to areas where biohazards are used or stored
       2. On refrigerators, freezers, or containers where biohazards are stored
       3. To the outside of packages in which biohazards are shipped
       4. On the equipment which may be potentially contaminated with biohazardous materials (e.g., centrifuges, incubators, biosafety cabinets, homogenizers, etc.)

          LABELING REQUIREMENTS
          Item	No label		Biohazard label		Color container
          Regulated waste container			X	or	X
          Reusable contaminated sharps			X	or	X
          Refrigerator/freezer holding blood/OPIM			X	or	X
          Blood/blood products released for clinical use	X
          Specimen containers of blood/OPIM	X	or	X	or	X
          Specimens shipped from the primary facility to another facility			X	or	X
          Individual containers of blood/OPIM placed in a labeled container during storage, transport, shipment or disposal	X
          Contaminated equipment needing service or shipping			X
          Contaminated laundry			X	or	X

17. REGULATED MEDICAL WASTE
    Disposal of all infectious waste shall be in accordance with Federal, State, and local regulations. Regulated medical waste containers must bear a required label or color-coding. Refer to the Regulated Medical Waste Protocol within the Infection Prevention Manual.
18. COMPLIANCE MONITORING:
    The Safety Officer and/or responsible individuals for the Infection Prevention and Control Program should assess the program by assessing data, interviewing staff, and observing practices during routine rounds. When monitoring reveals repeated failures to follow recommended practices after additional supplies, education and/or training, and counseling has been provided disciplinary action may be necessary

POTENTAL EXPOSURE ACCORDING TO JOB CLASSIFICATION (Personnel in the following Departments)

INDIVIDUALS BY JOB TITLE WITH NO EXPOSURE TO BLOOD OR BODY FLUID

TASK AND PRECAUTIONS (PPE)

SHARP SAFETY DEVICES