Bloodborne Pathogens and Needlestick Prevention

Bloodborne Pathogens and Needlestick Prevention

Introduction

Needlestick injuries and other sharps-related injuries which expose workers to bloodborne pathogens continues to be an important public health concern. Workers in many different occupations are at risk of exposure to bloodborne pathogens, including Hepatitis B, Hepatitis C, and HIV/AIDS. First aid team members, housekeeping personnel in some settings, nurses and other healthcare providers are examples of workers who may be at risk of exposure.

Bloodborne Pathogens is addressed in standards specifically for the general industry.

OSHA Standards

This section highlights the OSHA standard requirements, preambles to final rules (background to final rules), directives (instructions for compliance officers), and standard interpretations (official letters of interpretation of the standards) related to bloodborne pathogens and needlestick prevention.

Note: Twenty-five states, Puerto Rico and the Virgin Islands have OSHA-approved State Plans and have adopted their own standards and enforcement policies. For the most part, these States adopt standards that are identical to Federal OSHA. However, some States have adopted different standards applicable to this topic or may have different enforcement policies.

• 1910.1030, Bloodborne pathogens.
  • Revisions to 1910.1030 as a result of the Needlestick Safety and Prevention Act:
    • Paragraph 1910.1030(d)(2)(i) requires the use of engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens.
    • Employers must keep a Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps [1910.1030(h)(5)(i)].
    • The Exposure Control Plan (1910.1030(c)(1)(i)) shall:
      • Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens [1910.1030(c)(1)(iv)(A)].
      • Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure [1910.1030(c)(1)(iv)(B)].
      • Solicit input from non-managerial employees responsible for direct patient care, who are potentially exposed to injuries from contaminated sharps, in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan [1910.1030(c)(1)(v)].
  • Appendix A, Hepatitis B vaccine declination (Mandatory).

The following information provides discussion on the revised standard.

• Revision to OSHA's Bloodborne Pathogens Standard - Technical Backgr.... OSHA, (2001, April). Includes revised information regarding the identification, evaluation, and selection of effective engineering controls, including safer medical devices.
• Most frequently asked questions concerning the bloodborne pathogens.... OSHA Standard Interpretation, (1993, February 1; corrected 2003, August 13). Responses to common questions about the bloodborne pathogens standard.
• Frequently Asked Questions. OSHA. Provides questions and answers to some commonly asked questions regarding needlestick hazards and prevention.
• Frequently Asked Questions: Bloodborne Pathogens. OSHA. Provides answers and additional information to frequently asked questions regarding bloodborne pathogen hazards.
• Frequently Asked Questions: OSHA's Occupational Exposure to Bloodbo.... OSHA. Provides answers to questions concerning the safe administration of vaccines.
• Occupational Exposure to Bloodborne Pathogens; Needlestick and Othe.... OSHA Federal Register Final Rules 66:5317-5325, (2001, January 18). Also available as a 450 KB PDF, 9 pages. OSHA revised the Bloodborne Pathogens standard in conformance with the requirements of the Needlestick Safety and Prevention Act.
• OSHA's Bloodborne Pathogens Standard [63 KB PDF^*, 2 pages]. OSHA Fact Sheet, (2011, January).

Needlestick Legislation

• Overview of State Needle Safety Legislation. National Institute for Occupational Safety and Health (NIOSH). As of June 2002, twenty-two states have enacted legislation related to needle safety.
• Needlestick Prevention and Safety Act. 106th Congress - Public Law 106-430, (2000). The Needlestick Safety and Prevention Act became Public Law 106-430 on November 6, 2000.

Preambles to Final Rules

• Occupational Exposure to Bloodborne Pathogens. (1991)
• Search all available preambles to final rules.

Directives

• Enforcement Procedures for the Occupational Exposure to Bloodborne .... CPL 02-02-069 [CPL 2-2.69], (2001, November 27). Includes revisions mandated by the Needlestick Safety and Prevention Act.
  • Appendix D, Model Exposure Control Plan. Includes a model exposure control plan that meets the requirements of OSHA's Bloodborne Pathogens Standard and can be tailored to meet the specific requirements of an establishment.
  • Updated U.S. Public Health Service Guidelines for the Management of.... Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) 50(RR11);1-42, (2001, June 29). Also available as a 333 KB PDF, 67 pages. Updates and consolidates recommendations for the management of health-care personnel (HCP). Serves as Appendix E for CPL 02-02-069.
  • Updated U.S. Public Health Service Guidelines for the Management of.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 54(RR09);1-17, (2005, September 30). Updates US Public Health Service recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain human immunodeficiency virus (HIV).
• Rules of agency practice and procedure concerning OSHA access to em.... CPL 02-02-072, (2007, August 22). Provides guidance concerning application of the rules of agency practice and procedure when accessing personally identifible employee medical records.
• Multi-Employer Citation Policy. CPL 02-00-124 [CPL 2-0.124], (1999, December 10).
• Search all available directives.

Standard Interpretations

• Clarification of the use and selection of BBP safety devices. (2008, May 5).
• Applicability of OSHA's bloodborne pathogens standard to the contai.... (2008, January 2).
• Clarification of PPE requirements for phlebotomists performing veni.... (2007, October 26).
• The applicability of OSHA's bloodborne pathogens standards to the u.... (2007, June 14).
• Application of OSHA's Bloodborne Pathogens standard to contractors .... (2007, May 22).
• Requirements for safety-engineered sharps for stockpiled pandemic i.... (2007, March 2).
• The use of safety-engineered devices and work practice controls in .... (2007, January 18).
• Use of rapid HIV antibody testing on a source individual after an e.... (2007, January 8).
• Periodic serologic testing to monitor antibody concentrations after.... (2005, November 9).
• Safety precautions, PPE, and immunizations for workers in waste wat.... (2005, September 13).
• Containment and disposal requirements for disposable razors used in.... (2005, March 28).
• Needle removal procedures for situations where other methods of dis.... (2004, December 9).
• Limiting factors for implementing the use of engineering controls, .... (2004, September 1).
• Bloodborne Pathogens Standard application to bifurcated needles; ac.... (2004, May 27).
• Employer's responsibility to re-evaluate engineering controls, i.e..... (2004, January 20).
• Acceptable use of antiseptic-hand cleansers for bloodborne pathogen.... (2003, March 31).
• Needlestick Safety and Prevention Act and the requirement to includ.... (2003, February 20).
• Evaluation of sutureless catheter securement devices to prevent nee.... (2003, January 23).
• Safer medical devices must be selected based on employee feedback a.... (2002, November 21).
• Application of the bloodborne pathogens standard to veterinary clinics. (2002, October 15).
• Re-use of blood-tube holders. (2002, June 12).
• Search all available standard interpretations.

Hazard Recognition

OSHA estimates that 5.6 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) place workers at risk for infection with bloodborne pathogens. OSHA defines blood to mean human blood, human blood components, and products made from human blood. Other potentially infectious materials (OPIM) means: (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. The following references aid in recognizing workplace hazards associated with bloodborne pathogens.

Bloodborne Pathogens

• Hospital. OSHA eTool.
  • Bloodborne Pathogens
• Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B Virus, and He.... National Institute for Occupational Safety and Health (NIOSH) Safety and Health Topic.
• National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. US Department of Health and Human Services (DHHS), Centers for Disease Control and Prevention (CDC).
  • Viral Hepatitis B
  • Viral Hepatitis C
  • HIV/AIDS
• Healthcare-associated Infections (HAIs). Centers for Disease Control and Prevention (CDC).
• Exposure to Blood: What Healthcare Personnel Need to Know [363 KB PDF, 10 pages]. Centers for Disease Control and Prevention (CDC), National Center for Infectious Diseases, (2003, July).
• EPINet Data Reports. University of Virginia, International Health Care Worker Safety Center. The Center has used the Exposure Prevention Information Network (EPINet) since 1992 to collect data from approximately 70 hospitals on sharp object injury and blood and body fluid exposure patterns in the health care setting.

Needlestick

• Sharps Injuries among Hospital Workers in Massachusetts, 2008 --- F... [213 KB PDF, 32 pages]. Massachusetts Department of Public Health, (2010, March).
• Medical & Dental Offices: A Guide to Compliance with OSHA Stand.... OSHA Publication 3187-09R, (2003). Also available as a 787 KB PDF, 2 pages. Provides a glimpse of the most frequently found hazards in medical and dental offices.
• Disposal of Contaminated Needles and Blood Tube Holders Used for Ph.... OSHA Safety and Health Information Bulletin (SHIB), (2003, October 15). Also available as a 37 KB PDF, 4 pages. OSHA has concluded that the best practice for prevention of needlestick injuries following phlebotomy procedures is the use of a sharp with engineered sharps injury protection (SESIP), (e.g., safety needle), attached to the blood tube holder and the immediate disposal of the entire unit after each patient's blood is drawn.
• Potential for Occupational Exposure to Bloodborne Pathogens From Cl.... OSHA Health Information Bulletin (HIB), (1995, September 21).
• Securing Medical Catheters [353 KB PDF^*, 2 pages]. OSHA Fact Sheet.
• Job Safety and Health Quarterly (JSHQ) [4 MB PDF^*, 44 pages]. (2001, Summer).
  • Fleming, Susan. "Preventing Needlesticks [4 MB PDF^*, 44 pages]." New rules affirm the need for safer devices to protect workers.
  • "Highlights of OSHA's Bloodborne Pathogens Standard Revision [4 MB PDF^*, 44 pages]." A toolbox discussion of the revision to OSHA's bloodborne pathogens standard.
• Preventing Needlestick Injuries in Health Care Settings. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2000-108 (Alert), (1999, November). NIOSH warns that health care workers who use or may be exposed to needles are at increased risk of needlestick injury.
• Selecting, Evaluating, and Using Sharps Disposal Containers. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 97-111, (1998, January). Presents a comprehensive framework for selecting sharps disposal containers and evaluating their efficacy as part of an overall needlestick injury prevention plan, reviews the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard and recommends containers on the basis of a site-specific hazard analysis, and establishes criteria and provides tools for evaluating the performance of sharps disposal containers.
• What Every Worker Should Know: How to Protect Yourself From Needles.... US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2000-135, (1997, July). Discusses pathogens that pose the most serious health risks.

Possible Solutions

Studies show that nurses sustain the most needlestick injuries and that as many as one-third of all sharps injuries occur during disposal. The Centers for Disease Control and Prevention (CDC) estimates that 62 to 88 percent of sharps injuries can be prevented simply by using safer medical devices. The following references provide information regarding possible solutions for bloodborne pathogens and needlestick hazards.

Please Note: Articles/references that are dated before April 18, 2001 may not reflect the changes of the new Bloodborne Pathogens Standard but still provide relevant, general information.

Control Programs

• Model Plans and Programs for the OSHA Bloodborne Pathogens and Haza.... OSHA Publication 3186-06N, (2003). Also available as a 521 KB PDF, 29 pages. Includes a model exposure control plan that meets the requirements of the OSHA Bloodborne Pathogens Standard and can be tailored to meet the specific requirements for an establishment.
• Preventing Exposures to Bloodborne Pathogens among Paramedics. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2010-113, (2010, April).
• Information for Employers Complying with OSHA's Bloodborne Pathogen.... US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2009-111, (2009, March).
• Workbook for Designing, Implementing, and Evaluating a Sharps Injur... [2 MB PDF, 168 pages]. Centers for Disease Control and Prevention (CDC), (2008).
• Preventing Occupational HIV Transmission to Healthcare Personnel. Centers for Disease Control and Prevention (CDC), (2002, February). Offers recommendations to prevent transmission of HIV to healthcare personnel in the workplace.
• Checklist for Sharps Injury Prevention [21 KB PDF, 2 pages]. The University of Virginia, International Health Care Worker Safety Center. Provides a checklist intended to help facilities comply with the sharps safety requirements of OSHA's Bloodborne Pathogens Standard.
• A Best Practices Approach for Reducing Bloodborne Pathogens Exposure [3 MB PDF, 100 pages]. Cal/OSHA Consultation Service, Department of Industrial Relations, (2001).

Safer Needle Devices

• Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries t.... OSHA and the National Institute for Occupational Safety and Health (NIOSH) Publication No. 2008-101, (2007, October). Supersedes NIOSH Publication 2007–132.
• Evaluation of Blunt Suture Needles in Preventing Percutaneous Injur.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 46(02);25-29, (1997, January 17). Identifies the effectiveness of blunt needles in reducing percutaneous injuries (PIs) and suggests that they should be considered for more widespread use in surgical procedures.
• List of Safety-Engineered Sharp Devices -- and other products desig.... The University of Virginia Health System, International Health Care Worker Safety Center, (2003). Provides a list of devices designed to prevent percutaneous injury and exposure to bloodborne pathogens in the health care setting.
• Sharps Disposal Containers with Needle Removal Features. OSHA Hazard Information Bulletin (HIB), (1993, March 12). Alerts field personnel to the risk of possible safety and health hazards that may arise with the use of some sharps disposal containers that incorporate an "unwinder" mechanism to accomplish needle removal.
• Safer Medical Device Implementation in Health Care Facilities - Sha.... National Institute for Occupational Safety and Health (NIOSH). NIOSH developed this forum to assist health care facilities that are working through the process of implementing safer needle devices in their workplaces.
• Evaluation of Safety Devices for Preventing Percutaneous Injuries A.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 46(02);21-25, (1997, January 17). Indicates that the use of phlebotomy safety devices significantly reduces phlebotomy-related percutaneous injury (PI) rates.
• Needlestick and Other Risks from Hypodermic Needles on Secondary I.... Food and Drug Administration (FDA) Safety Alert, (1992, April 16). Urges the use of needleless systems or recessed needle systems to reduce the risk of needlestick injuries.

Decontamination

• Selected EPA-registered Disinfectants. Environmental Protection Agency (EPA), (2009, January 9). Includes lists of EPA registered anti-microbial products to assist in choosing the appropriate decontaminant.

Post-exposure Evaluation

According to the NIOSH Alert Preventing Needlestick Injuries in Health Care Settings, it is estimated that 600,000 to 800,000 needlestick injuries (NSIs) and other percutaneous injuries (PIs) occur annually among health care workers. PIs are caused by sharp objects such as hypodermic needles, scalpels, suture needles, wires, trochanters, surgical pins, and saws. Additional exposure incidents include splashes and other contact with mucous membranes or non-intact skin. Post-exposure management is an integral part of a complete program for preventing infection following exposure incidents.

The following references provide useful information about the management of occupational exposure incidents to blood or other potentially infectious materials.

• Rapid HIV Testing. Centers for Disease Control and Prevention (CDC). These pages include descriptions of the rapid HIV tests approved by the FDA, how the tests can be implemented in different settings and research on the effectiveness and possible uses of the tests.
• A Comprehensive Immunization Strategy to Eliminate Transmission of .... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 55(RR16);1-25, (2006, December 8).
• Updated U.S. Public Health Service Guidelines for the Management of.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 54(RR09);1-17, (2005, September 30). Updates US Public Health Service recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain human immunodeficiency virus (HIV).
• Updated U.S. Public Health Service Guidelines for the Management of.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 50(RR11);1-42, (2001, June 29). Updates and consolidates recommendations for the management of health-care personnel (HCP).
• Immunization of Health-Care Workers: Recommendations of the Advisor.... Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) 46(RR-18);1-42, (1997, December 26). Summarizes recommendations of the ACIP concerning the use of certain immunizing agents in health-care workers (HCWs), and assists workers and administrators, in optimizing infection prevention and control programs.
• EPINet. The University of Virginia, International Health Care Worker Safety Center. The Exposure Prevention Information Network (EPINet) system provides standardized methods for recording and tracking percutaneous injuries and blood and body fluid contacts. EPINet consists of a Needlestick and Sharp Injury Report, a Blood and Body Fluid Exposure Report, and software for entering, accessing, and analyzing the data from the forms.
• National HIV/AIDS Clinicians' Consultation Center. The University of California - San Francisco. Offers a post-exposure prophylaxis hotline called PEPline. PEPline offers health care providers around-the-clock advice about managing occupational exposures to HIV and Hepatitis B and C.

Additional Information

Related Safety and Health Topics Pages

• Dentistry
• Healthcare Facilities
• Medical and First Aid
• Nursing Homes and Personal Care Facilities

Training

• Training Resources. OSHA. Contains training and reference materials related to bloodborne pathogens.
• OSHA's Revised Bloodborne Pathogens Standard. OSHA, (2001), 34 slides. Covers safe needle devices and provides new definitions from the revised standard.
• Bloodborne Pathogens [1 MB ZIP^*]. OSHA, (2001, December 17). Assists trainers conducting OSHA 10-hour general industry outreach training for workers. Since workers are the target audience, the material emphasizes hazard identification, avoidance, and control — not standards.
• Public Health Training Network Catalog. Centers for Disease Control and Prevention (CDC), Public Health Training Network (PHTN). Browse for distance learning courses and resources.

OSHA Resources

• Regional & Area Offices. Each Regional Office has a Bloodborne Pathogens Coordinator available to answer questions.
• Small Business. OSHA.
  • On-site Consultation
    • Program Information and Benefits
• Compliance Assistance Specialists (CASs). Provides general information about OSHA standards and compliance assistance resources.
• Record Summary of the Request for Information on Occupational Expos.... (1999, May). Summarizes nearly 400 comments from health care facilities, workers and others who responded to OSHA's request for information on engineering and work practice controls used to eliminate or minimize the risk of occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Publications

• Model Plans and Programs for the OSHA Bloodborne Pathogens and Haza.... Publication 3186-06N, (2003). Also available as a 521 KB PDF, 29 pages. Includes a model exposure control plan to meet the requirements of the OSHA bloodborne pathogens standard and a model hazard communication plan to meet the requirements of the hazard communication standard.
• Access to Medical and Exposure Records. Publication 3110, (2001). Also available as a 1 MB PDF, 8 pages. Provides information for employees who have had possible exposure to or use toxic substances or harmful physical agents at their work site or employers who have employees who may be exposed.
• Medical & Dental Offices: A Guide to Compliance with OSHA Stand.... Publication 3187-09R, (2003). Also available as a 787 KB PDF, 2 pages. Provides a glimpse of the most frequently found hazards in medical and dental offices.
• OSHA Forms for Recording Work-Related Injuries and Illnesses. Forms 300, 300A, and 301.
• Personal Protective Equipment. Publication 3151-12R, (2003). Also available as a 629 KB PDF, 46 pages. Helps both employers and employees understand the types of PPE, know the basics of conducting a "hazard assessment" of the workplace, select appropriate PPE for a variety of circumstances, and understand what kind of training is needed in the proper use and care of PPE.
• RECORDKEEPING - It's new, it's improved, and it's easier... Publication 3169, (2001). Also available as a 2 MB PDF, 7 pages. Provides information on the new rule.
• Publications, Posters, and Online Order Forms

OSHA Alliances

• American Biological Safety Association (ABSA). Signed September 23, 2002; renewed October 13, 2004; renewed January 29, 2007; renewed March 3, 2009).
• Association of periOperative Registered Nurses (AORN). Signed December 15, 2006; renewed April 1, 2009.
• Association of Occupational Health Professionals in Healthcare (AOHP). Signed February 19, 2004; renewed August 27, 2006; renewed April 28, 2008.
• The Joint Commission and Joint Commission Resources (JCR). Signed July 27, 2004; renewed November 8, 2006; renewed January 14, 2009.

Other Resources

• Information for Employers Complying with OSHA's Bloodborne Pathogen.... US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2009-111, (2009, March).
• Worker Health Chartbook 2004. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2004-146, (2004, September).
  • Fatal and Nonfatal Injuries, and Selected Illnesses and Conditions
• First Responders: Protect Your Employees with an Exposure Control Plan. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2008-115, (2008, July). First Responders face unique scenarios due to uncontrolled settings and the possible presence of large volumes of blood at the scene. A comprehensive bloodborne pathogens exposure prevention program will help protect your employees.
• First Responders: Encourage Your Workers to Report Bloodborne Patho.... US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2008-118, (2008, July). Encourage your employees to report all exposures. This way, you can carry out your responsibility to take appropriate post-exposure actions to protect your workers, their families, and the public against infection from bloodborne pathogens.
• First Responders: Informational Poster on Bloodborne Pathogen Expos.... US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2008-116, (2008, July).
• Protect Your Employees with an Exposure Control Plan. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2007-158, (2007, September). NIOSH researches visited a number of prisons and jails to learn more about current practices and procedures being used to protect health care workers from bloodborne diseases. This brochure provides information to medical service administrators and supervisors about common problems with facility Exposure Control Plans.
• 2007 Guideline for Isolation Precautions: Preventing Transmission o.... Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion (DHQP). Provides an outline of a single set of standard precautions to be used for the care of all patients in hospitals regardless of their presumed infection status.
• The CDC Prevention Guidelines Database. Centers for Disease Control and Prevention (CDC). Provides a comprehensive compendium of all of the official guidelines and recommendations published by the Centers for Disease Control and Prevention (CDC) prior to October 1998 for the prevention of diseases, injuries, and disabilities.
• Cardo, Denise M., et al. "." The New England Journal of Medicine (NEJM) 337(1997, November 20): 1485-1490. Abstract only.

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