#58584: Infection Control for Dental Professionals: The California Requirement

The OSHA Standard requires employers whose employees have exposure to blood or other potentially infectious material (OPIM) to implement safe work practices, education, and barriers to exposure. OPIM includes saliva in dental procedures and all bodily fluid in situations where it is difficult or impossible to differentiate between bodily fluids; any unfixed tissue or organ (other than intact skin) from a human (living or dead); human immunodeficiency virus (HIV)-containing cell or tissue cultures, organ culture and blood, or other tissues from experimental animals [9]

The OSHA Bloodborne Pathogens Standard requires that all DHCP who may have contact on the job with blood or other bodily fluids must receive specific annual education, which includes instruction in the basics of infection control and prevention. Training must also cover bloodborne pathogens, modes of transmission, the proper use of needles, and Transmission-Based Precautions [2,3].

In 2009, Cal/OSHA adopted the nation's first aerosol transmissible disease (ATD) standard, which remains in effect today. The standard is designed to protect healthcare workers from diseases spread by an airborne or droplet route. The ATD standard requires employers in health care to develop exposure control procedures and train employees to follow those procedures [4]. Basic exposure precautions, such as source screening, infection control, hand hygiene, and cleaning and decontamination procedures, are a fundamental part of the standard. Employees must be included in the periodic review and assessment of these procedures.

According to the California ATD Standard, California dental offices whose patients have suspected or confirmed illnesses that require Airborne or Droplet Precautions, such as tuberculosis (TB) or other respiratory illnesses, must comply with the ATD standards [4]. Key points include:

A simple screening procedure can be done by the first person who comes in contact with a patient. For example, the patient may be asked "How are you feeling today?" or "Do you have any coughs, fever, or flu-like symptoms?" If the patient is not feeling well or gives a positive answer to any part of the second question, the dental treatment should be rescheduled.

Outpatient dental clinics or offices are not required to comply with this standard if they meet all of the following conditions [4,21]:

As of 2024, California remains the only state with such a permanent standard; however, the coronavirus disease (COVID) pandemic of 2019–2022 highlighted the need for a standard addressing infectious pathogens spread by aerosols or droplets. During the pandemic, OSHA did issue interim guidance for safe workplaces, and some states issued emergency temporary standards. Experts have called for these requirements to be codified in order to ensure the safety of professions and patients, but this has not yet been accomplished [15]. Full guidance on aerosol-transmissible diseases can be found in the 2023 California Workplace Guide to Aerosol Transmissible Diseases at https://www.dir.ca.gov/dosh/dosh_publications/ATD-Guide.pdf [4].

The most common modes of transmission in the healthcare setting are through contact, both direct and indirect. Because it addresses the weakest link in the chain of transmission, hand hygiene is the single most important procedure for preventing the spread of infection. Items moving between patients should be cleaned and sterilized after each use to avoid indirect transmission of pathogens. Standard Precautions in conjunction with identified Contact Precautions are often used in the dental setting.

Aerosols, droplets (produced by the respiratory tract), and splatter contaminated with blood and bacteria are produced during many dental procedures. Devices such as dental handpieces, ultrasonic and sonic scalers, air polishers, air-water syringes, and air abrasion units produce visible aerosol clouds and possible airborne contamination. Splatter generated by dental procedures such as drilling is a primary risk for transmission of bloodborne pathogens. In general, because of their smaller size, aerosols pose the greatest risk for airborne infection [9].

Several studies have shown that airborne or droplet nuclei may extend up to 6 feet away from the source and can remain airborne for up to 30 minutes after a procedure. Tuberculosis (TB) is of special concern because it is a large particle that can remain airborne or can dry on a surface and become airborne again as part of a dust particle.

In 2024, the World Health Organization (WHO) and the Centers for Disease Control and Prevention from the United States, China, Europe, and Africa, published a global consensus of the terminology for pathogens that transmit through the air. Key changes include [8]:

Due to the existing research and recommendations primarily using the terms and definitions of "aerosol" and "droplet," these terms will continue to be used throughout this course, unless otherwise noted.

The American Dental Association recommends that in addition to using Universal and Standard Precautions, such as masks, gloves, and eye protection, Transmission-Based Precautions, including the proper sterilization of instruments and treatment of dental unit waterlines is necessary to reduce or eliminate this source of potentially contaminated dental aerosols. Preprocedural rinsing with an antimicrobial mouthwash such as chlorhexidine is also recommended, although it is only effective for oral bacteria found in saliva and those adhering to mucous membranes. It does not penetrate subgingivally and likely has no effect on bacteria in the nasopharynx [5,6].

Diseases known to spread by aerosols or droplet include:

Procedures or equipment aimed at eliminating the means of transmission include [5,6]:

Devices can transmit pathogens if they are contaminated with blood or bodily fluids or are shared without cleaning, disinfecting, and sterilizing between patients; these are classified as fomites. Surgical instruments that are inadequately cleaned between patients or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial, fungal, and viral pathogens. Clothing, uniforms, laboratory coats, or gowns used as PPE may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent [5,6,10].

Dental water units and dental unit waterlines are both potential sources of transmission and potential reservoirs. Routine cleaning and sterilization and adherence to the CDC's recommended procedures for treating dental unit waterlines have been shown to be effective in eliminating transmission of infectious organisms via these devices. Infections known to be caused by dental-related water transmission include Pseudomonas aeruginosa, Mycobacterium avium, and Legionella pneumophila [5,7].

Despite the simplicity and effectiveness of hand hygiene in preventing the spread of infectious disease, adherence to hand hygiene practice remains low. Adherence varies among professional categories of healthcare workers but is usually estimated at less than 50%. Healthcare providers may be required to clean their hands as many as 100 times in a 12-hour shift, depending on the number of patients and intensity of care [14,17]. For dental healthcare workers, strict adherence to proper hand hygiene is the most important prevention strategy to protect both the patient and the worker. In one study, adherence rates to hand hygiene among postgraduate-year dentists found that overall handwashing compliance rate was 34.7%, with higher rates of compliance noted in oral surgery services (92.8%) than during work in general clinical practice (34.2%) [13]. The World Health Organization has designed the guidelines 5 Moments for Hand Hygiene as a reminder of when proper hand hygiene should be completed [11]:

In general, perform hand hygiene [14]:

A number of conditions restrict DHCP from participating in direct patient care. These include weeping dermatitis, exudative lesions, or any hand condition that increases the risk of disease transmission [9].

Good handwashing is difficult to practice, is rarely known or taught, and is one of the single most effective ways to prevent transmission of many diseases, including influenza. Everyone knows to wash their hands before eating and after using the restroom. However, few do little more than remove obvious dirt. Good handwashing involves removing the skin oils where organisms can remain even when the hands look clean. A quick pass under the water faucet and fast dry with a towel may remove visible dirt, but the oils and organisms remain.

To effectively remove the oils and organisms, the process should take at least 20 seconds, or the amount of time it takes to sing "Twinkle, Twinkle Little Star." The hands should be soaped and rubbed vigorously for 15 seconds to create a good lather and to assure that all parts of each hand are soaped and rubbed well. Then, the hands should be rinsed thoroughly and dried, preferably with a paper towel. The towel should be used to turn off the water faucet and then properly thrown away. However, 20 seconds is a long time in the busy life of a healthcare provider, and this 20 seconds has been identified as a major barrier to handwashing, particularly among those who consider themselves "too busy" to wash their hands. If there is no visible dirt or contamination, a waterless hand sanitizer with at least 60% alcohol can be used between patients. However, nothing is as good as washing well with soap and water. Further, some organisms are not eliminated through the use of hand sanitizers alone (e.g., Clostridioides difficile spores). Hands should be thoroughly dried before donning gloves and washed again immediately after glove removal [9].

Some mistakenly think that hot water must be used to kill the organisms. Water hot enough to kill organisms would be too hot to touch. Warm water softens oils but mainly adds to comfort and encourages better washing technique (i.e., longer duration). Careful attention to handwashing and cleansing may result in chapped skin, so the dental professional must find effective lotions to care for his/her hands [14,17].

Certain soaps contain stronger antiseptic compounds, such as chlorhexidine, and these soaps may be considered in cases in which exposure to potentially infectious material is likely. Antiseptic soaps or surgical preparation liquids have been found more effective than plain soap in removing bacteria from healthcare workers hands both pre- and postprocedure. In addition, antiseptics may be added to alcohol-based handrubs in order to achieve persistent germicidal activity. Possible side effects associated with frequent use of antiseptic hand scrubs include skin irritation, dermatitis, allergic reactions, and potential development of microbial resistances. Chlorhexidine products are considered safe for regular use in dental practice; however, if associated side effects are bothersome, they may result in decreased hand hygiene compliance [10,14].

In summary, start and end each work day using an antibacterial soap. Gloves provide a breeding ground for microbial growth, and washing before and after use is encouraged. If hands are not visibly soiled, a waterless hand sanitizer (at least 60% alcohol) may be used. For surgical procedures, wash hands with antimicrobial soap prior to gowning and gloving [5].

PPE is defined as special coverings designed to protect healthcare personnel from exposure to or contact with infectious agents [18]. Cal/OSHA regulations require use of PPE in dental care settings to protect personnel from exposure to bloodborne pathogens and other OPIM [9]. Under OSHA's General Duty Clause, PPE is also required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure its proper disposal. If reusable, it must be properly cleaned or laundered, repaired, and stored after use [19]. PPE must fit the individual user, and it is up to the employer to ensure that PPE is available in sizes appropriate for all their workers. Employees are prohibited from taking PPE home to launder.

In addition to the familiar gloves, masks, and gowns, PPE includes a variety of barriers and respirators used alone or in combination to protect skin, mucous membranes, and airways from contact with infectious agents. The selection of PPE is based on the nature of the patient/provider interaction and the likely mode of transmission. Primary PPE used in oral healthcare settings includes gloves, surgical masks, respiratory devices, protective eyewear, face shields, and protective shoes and clothing.

Procedures that can generate splashes or sprays of blood, bodily fluids, secretions, excretions, or chemical agents require either a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection, and face shields in specified circumstances (when blood or OPIM exposures are likely to occur) is mandated by the OSHA Bloodborne Pathogens Standard. Sterile barriers for invasive procedures and masks or respirators for the prevention of droplet contamination are also required [2].

The use of PPE is not a substitute for safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting equipment. PPE is a potential means of transmission if not changed between patients. All PPE should be removed when leaving patient care areas.

If dental clinics and offices comply with state regulations for screening of patients with ATDs, they are not required to comply with the new standards for prevention of transmission of ATDs [4]. However, because no screening process is universally effective, dental personnel should be aware of the potential dangers associated with transmission of pathogens via the airborne and droplet routes.

Respiratory droplets can transmit infection when they travel directly from the respiratory tract of the infected individual to the mucosal surfaces of the recipient, generally over short distances (i.e., 6 feet or less). Airborne transmission occurs with only a few organisms that can survive the drying of respiratory droplets. When the droplets evaporate, they leave behind droplet nuclei, which are so small they remain suspended in the air and can travel over longer distances. Respiratory droplets and droplet nuclei are generated when an infected person coughs, sneezes, or talks during procedures. Facial masks or shields generally provide direct protection from droplet transmission. Some pathogens transmitted via the airborne route (e.g., TB) require the use of an N95 respirator or better (e.g., N99, N100) due to the small particle size [5].

Measures to contain respiratory secretions in symptomatic patients and accompanying adults may include [5,18]:

Most percutaneous injuries among DHCP involve scalers, burs, needles, wires, and sharp instruments. In 2000, the Federal Needlestick Safety and Prevention Act authorized OSHA to revise its Bloodborne Pathogens Standard to require the use of safety-engineered sharp devices in healthcare settings [2,3,16]. Guidelines on the design, implementation, and evaluation of a sharps injury prevention program have been developed by the CDC, and outline engineering controls and work practice controls as primary methods to prevent such occurrences. Engineering controls, such as sharps disposal containers, self-sheathing needles, and safer medical devices (e.g., sharps with engineered sharps injury protections and needleless systems) isolate or remove the bloodborne pathogens hazard from the workplace. On the other hand, work practice controls reduce the likelihood of exposure by specifying the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Engineering and work practice controls are intended to work synergistically to eliminate or minimize employee exposure. These controls must be examined and maintained or replaced on a regular basis to ensure their effectiveness. To maintain a safe workplace, employers must provide handwashing facilities that are readily accessible to employees.

Contaminated needles and other contaminated sharps should not be bent, recapped, or removed unless the employer can demonstrate that there is no alternative or that such action is required by a specific procedure. Necessary bending, recapping, or needle removal must be accomplished through the use of a mechanical device or a one-handed scoop technique. Shearing or breaking of contaminated needles is prohibited. Immediately, or as soon as possible after use, contaminated reusable sharps (e.g., scalpels, dental knives) must be placed in appropriate containers until properly reprocessed. These containers must be [9,10]:

Safe injection practices are designed to prevent disease transmission within the healthcare setting. The absence of visible blood or other signs of contamination in a used syringe does not mean the item is free from potentially infectious agents. Bacteria and other microbes can be present without any visible evidence of contamination. All used injection supplies and materials should be considered potentially contaminated and should be discarded.

To ensure safe injection practices, use aseptic technique throughout all aspects of injection preparation and administration. Aseptic technique involves the handling, preparation, and storage of medications in a manner that prevents microbial contamination. It also applies to the handling of all supplies used for injections and infusions. To avoid contamination, medications should be drawn in a clean medication preparation area. Any item that may have come in contact with blood or OPIM should be kept separate from medications. In addition, eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink should not be kept in refrigerators, freezers, shelves, or cabinets or on countertops where blood or OPIM is present.

A new, sterile syringe and needle should be used to draw up medications while preventing contact between the injection materials and the nonsterile environment. Practice proper hand hygiene before handling medications, and discard medication vials upon expiration or any time there are concerns regarding the sterility of the medication [5].

Never leave a needle or other device inserted into a vial or bottle for multiple uses. This provides a direct route for micro-organisms to enter the vial and contaminate the fluid. Medications should never be combined between vials or administered from the same syringe to more than one patient, even if the needle is changed. Multidose vials should be used on a single patient whenever possible and should never enter the immediate patient treatment area [5].

Dental personnel should follow proper technique when using and handling needles, cannulae, and syringes. Whenever possible, use sharps with engineered sharps injury protections (e.g., non-needle or needle devices with built-in safety features or mechanisms that effectively reduce the risk of an exposure incident). Do not disable or circumvent the safety feature on devices [5].

Cases of bloodborne pathogen transmission as a result of improper injection practices have common themes. Often, aseptic technique and Standard Precautions were not carefully followed. Infection control programs may be lacking or responsibilities unclear. In several instances, failure to recognize an infection control breach has led to prolonged transmission and a growing number of infected patients. In all cases, investigations were time-consuming and costly and required the notification, testing, and counseling of hundreds and sometimes thousands of patients [5,16].

Application of accepted infection control principles helps maintain a safe environment for both patients and dental care workers. This includes proper use of Standard Precautions and application of approved techniques for cleaning, disinfection, sterilization, and reprocessing of dental equipment. Healthcare policies must identify—primarily on the basis of an item's intended use—whether cleaning and disinfection or sterilization is indicated (Table 2) [9,10,21].

Cleaning is defined as the removal of visible soil (organic and inorganic material) debris and OPIM from objects and surfaces; normally, it is accomplished manually or mechanically using water with detergents or enzymatic products [9]. Cleaning must precede any disinfection or sterilization process.

Decontamination reduces the number of pathogenic micro-organisms on objects, usually with a 0.5% chlorine solution [21]. Thorough cleaning and decontamination are essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

Disinfection is a process that eliminates many or all pathogenic micro-organisms, except bacterial spores, on inanimate objects. In healthcare settings, objects are usually disinfected using liquid chemicals or wet pasteurization (i.e., the use of hot water to destroy micro-organisms). There are three levels of disinfection [9,10]:

Surface disinfection is an important part of environmental cleaning. Most bacteria and mycobacteria (e.g., TB) survive for several months on dry surfaces [20]. Respiratory viruses, such as coxsackie or influenza, can persist on surfaces for a few days. Hepatitis viruses and HIV can persist for more than one week, and herpes viruses have been shown to persist from only a few hours up to seven days [20]. All surfaces in patient care areas should be cleaned then disinfected according to the manufacturer's instructions and allowed to dry completely.

Sterilization is a process that destroys or eliminates all forms of microbial life and is carried out in healthcare facilities by physical or chemical methods. Sterile and nonsterile are absolute concepts. If a sterile item is touched by anything nonsterile, the formerly sterile item is contaminated.

The sterilization area should be separate from any patient care or staff break areas. The sterilization section of the processing area should include the sterilizers and related supplies, with adequate space for loading, unloading, and cool down [10]. The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and single-use items. Manufacturer and local building code specifications will determine placement and room ventilation requirements.

According to the CDC guideline, heat-tolerant dental instruments usually are sterilized by steam under pressure (autoclaving), dry heat, or unsaturated chemical vapor [10]. All sterilization should be performed by using medical sterilization equipment cleared by the FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed [10]. Sterilization most often fails due to overloading.

Devices being sterilized should first be cleaned, as debris interferes with the sterilization process. If an ultrasonic unit is utilized, it should be covered while actively in use. Instruments should be fully dry prior to packaging and storage.

Storage practices for wrapped sterilized instruments can be either date- or event-related. Packages containing sterile supplies should be inspected before use to verify barrier integrity and dryness. Although some facilities continue to date every sterilized package and use shelf-life practices, other facilities have switched to event-related practices [10]. This approach recognizes that the product should remain sterile indefinitely, unless an event causes it to become contaminated (e.g., torn or wet packaging). Even for event-related packaging, the date of sterilization should be placed on the package, and if multiple sterilizers are used in the facility, the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure [10]. If packaging is compromised, the instruments should be re-cleaned, sterilized again, and packaged in new wrap.

As discussed, contaminated surfaces and objects can serve as the means of transmission for potential pathogens. The transfer of a micro-organism from an environmental surface to a patient is largely via hand contact with the surface. Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of infections [10].

All work areas, including contact surfaces and barriers, must be maintained in a clean and sanitary condition. Employers are required to determine and implement a written schedule for cleaning and disinfection based on the location, type of surface to be cleaned, type of soil present, and tasks or procedures being performed. All equipment and environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM.

If non-critical items or surfaces likely to be contaminated are manufactured in a manner preventing cleaning and disinfection, they should be protected with disposable impervious barriers. Disposable barriers should be changed when visibly soiled or damaged and between patients. Products used to clean items or surfaces prior to disinfection procedures shall be clearly labeled and follow all material safety data sheet (MSDS) handling and storage instructions. Clean and disinfect all clinical contact surfaces that are not protected by impervious barriers using a CalEPA-registered, hospital grade low- to intermediate-level disinfectant after each patient. The low-level disinfectants used must be labeled effective against hepatitis B virus and HIV. Use disinfectants in accordance with the manufacturer's instructions. Clean all housekeeping surfaces (e.g., floors, walls, sinks) with a detergent and water or a CalEPA-registered, hospital-grade disinfectant. Chemical-resistant utility gloves should be worn when handling hazardous chemicals [9].

Contact Precautions are utilized for patients with known or suspected infections that represent an increased risk for contact transmission. Contact Precautions require that practitioners [24]:

Use Droplet Precautions for patients that are known or suspected to be infected with pathogens transmitted by respiratory droplets. Droplet Precautions requires that one [24]:

Airborne Precautions are used when patients are known or suspected to be infected with pathogens transmitted by airborne or aerosol route. Airborne pathogens include TB, measles, chickenpox, and herpes zoster. Airborne Precautions require [24]:

An occupational exposure is defined as a percutaneous injury or contact of mucous membrane or nonintact skin with blood, tissue, or OPIM, most commonly a needlestick injury. The risk of infection depends on several factors, including [27]:

If a sharps injury occurs, wash the exposed area with soap and water. Do not "milk" or squeeze the wound. There is no evidence that using antiseptics will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is extremely rare. There are no documented cases of a dental healthcare professional contracting HIV from an occupational exposure.

OSHA requires dental employers of an individual with an occupational exposure to a bloodborne pathogen to arrange a confidential medical evaluation and follow-up for any employee reporting an exposure incident [3]. An exposure incident is any eye, mouth, mucous membrane, nonintact skin, or other parenteral contact with blood or OPIM. Saliva in dental procedures is treated as potentially infectious material.

Following an exposure, the dental employer must refer the exposed employee to a licensed healthcare professional who can provide information and counseling and discuss how to prevent further spread of a potential infection. The exposed employee is entitled to appropriate follow-up and evaluation of any reported illness to determine if the symptoms may be related to HIV or hepatitis B or C infection [27].

Prompt response is necessary whenever an occupational exposure occurs. If possible, the patient should be interviewed to determine if any risk factors or bloodborne pathogens not previously disclosed are present. The patient may be tested along with the employee, if he or she agrees, in order to obtain the most information possible. Testing and postexposure prophylaxis may be conducted at an occupational injury clinic. All events leading up to and after the exposure should be documented in a written report [27].

California has one of the highest incidence rates of TB in the country, primarily because of its large population of persons born outside of the United States [31]. In 2023, the TB infection rate in California was 13 times higher among non-U.S.-born individuals than among those born in the United States. The rates of TB among Asian and Black individuals born outside the United States were 43 and 28 times higher, respectively, than that of U.S.-born White persons [31].

To prevent the transmission of Mycobacterium tuberculosis in dental care settings, infection-control policies should be developed based on the community TB risk assessment and reviewed annually. The policies should include appropriate screening for latent or active TB disease in dental care providers, education about the risk for TB transmission, and provisions for detection and management of patients who have suspected or confirmed TB disease.

The CDC recommends that all dental care providers be screened for TB upon hire, using either a tuberculin skin test or blood test [10]. The California Department of Public Health recommends an initial skin or blood test; positive reactions or results should be followed up by chest x-ray. Annual testing thereafter is recommended for dental personnel, although local and/or employer policies and methods of testing (e.g., questionnaire or skin or blood test) may differ [32].

Patients with symptoms of TB should be identified by screening; dental treatment should be deferred until active TB has been ruled out or the patient is no longer infectious following treatment. The potentially active TB patient should be promptly referred to an appropriate medical setting for evaluation of possible infectiousness and should be kept in the dental care setting only long enough to arrange for referral. Standard Precautions are not sufficient to prevent transmission of active TB [24].

A diagnosis of active respiratory TB should be considered for any patient with the following symptoms:

A person with latent TB (positive skin test and no symptoms) can be treated in a dental office using standard infection control precautions [26]. This person has no symptoms and cannot transmit TB to others as there are no spores in his or her sputum.

The American Dental Association recommends that all patients be asked about any history of TB or exposure to TB, including signs and symptoms and medical conditions that increase their risk for TB disease. The Health History Form, developed by the U.S. Department of Health and Human Services, can be used to ask these questions.

If a patient with suspected or confirmed infectious TB disease requires urgent dental care, that care should be provided in a setting that meets the requirements for California ATD standards and airborne infection isolation. Respiratory protection (with a fitted N95 disposable respirator) should be used while performing procedures on such patients. Standard surgical masks are not designed to protect against TB transmission [4,26].

Due to increased risk of occupational exposure, the CDC strongly recommends that all healthcare workers, including dental care providers, receive immunizations as a preventive measure. While these are the recommendations from the CDC, state and local legislation and workplace regulations may or may not require these immunizations.

Dental personnel should also fulfill all federal and state requirements for infection control training. New employees, or employees being transferred into jobs involving tasks or activities with potential exposure to blood or OPIM, must receive bloodborne pathogen training before assignment to tasks in which an occupational exposure may occur. Retraining is required annually or when changes in procedures or tasks affecting occupational exposure occur. Employees should be provided access to a qualified trainer to answer questions during the training session [9,10].