Sample Policy and Procedures: Blood-Borne Pathogens

Athletic departments must have policies in place addressing the prevention of transmission of blood-borne pathogens in the athletic environment. The blood-borne pathogens of concern include (but are not limited to) Hepatitis B, Hepatitis C and HIV. Other types of infectious diseases, specifically skin infections, are highly transmissible, especially in certain contact sports such as wrestling. It is important that all educational institutions establish policies to aid in preventing transmission of blood-borne pathogens.  Educational institutions should establish guidelines for certain sports regarding return to play of athletes with infectious skin diseases. The following policy is consistent with guidelines recommended in the 2008-09 NCAA Sports Medicine Handbook and National Federation of State High School Associations Sports Medicine Handbook.
As with all sample policies or procedures, don’t use them verbatim.  Always submit proposed drafts to your institution’s legal counsel for review to be sure all provisions confirm to both institutional policy and applicable local, state and federal laws.
Policies and Procedures Regarding Blood Borne Pathogens and Infectious Diseases

The Athletics Director or designee shall be responsible for the administering the following policies and procedures pertaining to blood-borne pathogens and infectious diseases.
1.0     General - Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV).  Both HBV and HIV viruses can be transmitted through sexual contact and exposure to infected blood or blood products. The current state of medical knowledge of Hepatitis C (HCV) is incomplete but it does appear to be transmitted by blood. No definite guidelines exist for HCV.

1.1    HBV Infection.  HBV infection generally results in reversible liver damage and full recovery. However, a small number of cases will result in fulminate hepatitis and permanent liver damage and death. Recovered individuals will clear the virus and subsequently develop immunity and are no longer infectious. However, about 5-10% of acutely infected individuals become chronically infected and are considered HBV carriers. The risk of HBV transmission is presumed to be low. However, athletes participating in contact sports, especially those without protection such as wrestling, may be at increased risk.

1.1.1     Acute HBV Infection.  Participation by athletes who are acutely infected with HBV will generally depend on their symptomatology, severity of illness, and presence of abnormal labs, just as with any other viral illness. Therefore, the simple presence of HBV infection does not preclude athletic participation.  However, NCAA recommendations (NCAA Sports Medicine Handbook 2009-2009) shall be followed in the case of acute HBV infection: “If a student athlete develops acute HBV illness, it is prudent to consider removal of the individual from combative, sustained close –contact sports (e.g. wrestling) until loss of infectivity is know. (The best marker for infectivity is the HBV antigen, which may persist up to 20 weeks in the acute stage). Student athletes in such sports who develop chronic HBV infections (especially those who are e-antigen positive) should probably be removed from competition indefinitely, due to the small but realistic risk of transmitting HBV to other student athletes.”

1.2    HIV Infection.  HIV infection is considered, at this time, to be a chronic illness which can progress to AIDS (Acquired Immunodeficiency Disease) and death. Some HIV positive individuals will rapidly progress to AIDS while others may show no clinical symptoms of acute or chronic disease for many years.

1.2.1    Asymptomatic HIV.  Participation by athletes who are HIV positive depends on their level of health. In those individuals who are symptom-free and without immunologic deficiencies, athletic participation should not be restricted. Athletic participation has not been shown to be detrimental to the health of the asymptomatic HIV positive athlete. However, studies with HIV athletes engaged in high intensity training over long periods of time have not been done. It is important that the athlete receive care from a health care provider skilled in the care of HIV positive patients. The athlete will also be encouraged to discuss their medical condition with the team physician. The athlete’s personal physician, and the team physician can then coordinate medical care and discuss with the athlete what level of participation is healthy and safe.    Risk of Transmission.  Valid documentation of a case of HIV transmission in sport does not exist. There are no epidemiologic studies to determine the precise risk of transmission. The risk could increase in sustained close contact sports such as wrestling. However, studies do suggest the risk is extremely low. The Institution shall therefore follow NCAA recommendations (Sports Medicine Handbook 2008-9): “there is no recommended restriction of student athletes merely because they are infected with HIV.“    Mandatory HIV Testing.  The institution shall not require mandatory HIV testing of student athletes simply for the purpose of determining clearance to participate in their sport. Rather, student athletes who practice high risk behaviors, such as IV drug use or who have multiple sexual partners and unprotected sex, shall be encouraged to be tested and know their HIV status since medical treatments are continuing to improve for HIV positive patients.

2.0    Other Infectious Diseases.   Infectious disease transmission, beyond those transmitted by blood as described in 1.0 above, are a part of life. It is up to the athlete and the team physician to decide if an athlete with an infectious disease (1) is too ill to play or (2) poses an unacceptable risk of transmission of the disease to others. The team physician, in discussion with the athlete, shall make the final determination on these issues.

3.0    Skin Conditions.  There are certain infectious diseases, particularly certain skin conditions, which shall preclude the athlete in close-contact sports such as wrestling from participation, consistent with NCAA established guidelines (Sports Medicine Handbook- 2008-2009). These categories of skin conditions include, but may not be limited to:
a.    Bacterial infections: such as impetigo, erysipelas, carbuncle, folliculitis, staphylococcal disease including MRSA infections;
b.    Viral Infections: such as herpes infection and molluscum;
c.     Fungal Infections: such as tinea corporis; and
d.    Parasitic Infections: such as scabies
The Institution shall ensure that infected wrestlers or other athletes in close contact sports are properly identified by a knowledgeable individual (ATC or other health care personnel) and properly treated to prevent further spread of these skin conditions.

3.1    Adherence to NCAA Rules Regarding Skin Infections.  Team physicians, athletic trainers, coaches, and others who work directly with wrestling shall refer to the current year’s NCAA Wrestling Rules Book or Wrestling Championships Handbook for specific rules regarding skin infections.

4.0     Methicllin Resistant Staphylococcus Aureus (MRSA).  MRSA infections have become a particular concern in the general population and have increased in incidence in the athletic population. MRSA commonly causes skin infections that are resistant to many types of antibiotics. If not treated properly, MRSA can potentially cause more serious systemic infections. Therefore, appropriate antibiotics need to be used in the treatment of this potentially serious skin infection. MRSA is spread from person to person or through contact with shared items or surfaces that have touched a person’ infection. Prevention of spread is critical so as not to cause local outbreaks. MRSA can stay on surfaces for weeks; therefore surfaces need to be properly cleaned on a daily basis.   If MRSA infection is identified in an student-athlete, the Institution shall notify proper health authorities and take immediate and aggressive action to initiate decontamination procedures.

5.0    Obligation to Report Skin Infections.  Athletes must report all potential skin infections to their coaches who must then have the athlete evaluated before return to play. Athletes will be excluded from play if wounds cannot be properly covered during participation. The team physician shall make the final determination on return to play.

6.0    Standard Precautions.  Institution shall follow the following recommendations, termed “Standard Precautions”, designed to further minimize the risk of transmission of infectious organisms. Institution shall be responsible for training both care-givers and others (e.g. coaches) who will be in direct contact with athletes, in the implementation of these guidelines.  Standard Precautions applies to blood, body fluids, secretions and excretions except sweat, regardless of whether or not they contain blood.

6.1    Immediate and Aggressive Treatment.  Open wounds or skin lesions that have the potential risk of transmission of disease shall be immediately and aggressively treated. The athlete should be removed from competition and the bleeding controlled and the wound covered sufficiently to keep others from exposure should the athlete be allowed to return to competition.

6.2    Decision to Return to Play.  The decision to return to a practice or game will be made by the certified athletic trainer or other health care personnel and/or sports officials.

6.3    Minor Cuts and Abrasions.  Minor cuts or abrasions do not require interruption of play or removal of the participant from competition. These injuries should be cared for at scheduled breaks in play, such as time outs. The Institution shall adhere to guidelines as published in the most current issue of the NCAA Sports Medicine Handbook.  

6.4    Necessary Equipment and Supplies.  Institution shall supply necessary equipment and supplies to comply with Standard Precautions. This equipment should include vinyl gloves, disinfectant, bleach (diluted 1:100 with water), antiseptic, bandages/dressings, and appropriate receptacles for soiled equipment/clothing/needles/syringes/ scalpels as outlined in the most current issue of the NCAA Sports Medicine Handbook. 

6.5    Proper Personnel Training.  Institution shall ensure that personnel are trained in the proper cleaning of a contaminated environment according to OSHA Standards for Blood- Borne Pathogens and guidelines contained in the most current issue of the NCAA Sports Medicine Handbook These guidelines mandate the use of disposable gloves. The environment should be sprayed with the proper germicide and wiped clean. The contaminated items which may include clothing, along with the contaminated gloves, should be properly disposed of in waste receptacles according to facility protocol.

6.6    Personal Hygiene Items.  Athletes shall be reminded not to share personal hygiene items, clothing, or water bottles, and to shower with soap and water immediately after participation in their sports.

6.7    HBV Vaccination.  An effective vaccine exists to prevent HBV infection. This vaccine is recommended for all college students by the American College Health Association (ACHA) and shall be provided by the Institution to all student-athletes, coaches and other staff member who have the potential of coming into contact with bleeding individuals.

--     Sports Management Resources with thanks to Lauren Costello, M.D. for her assistance in the development of this policy