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Chemo drug exposures put health workers at risk
NIOSH to issue new alert on hazards
Health care workers may be at risk for reproductive disorders and cancer due to improper handling of hazardous drugs in hospitals.
Many chemotherapeutic agents have similar toxicity profiles as benzene and other industrial chemicals, but often they aren’t being handled with the caution they require, says Melissa McDiarmid, MD, MPH, director of the occupational health program and professor in the School of Medicine at the University of Maryland in Baltimore.
An alert from the Washington, DC-based National Institute for Occupational Safety and Health (NIOSH) will be released this spring, urging better compliance with guidelines for handling hazardous drugs. In addition to the anti-cancer agents, the category of hazardous drugs includes antivirals and immunosuppressants.
"We know what to expect from overexposed, underprotected workers. We know precisely what the drug does even at what doses in treated patients," says McDiarmid, who co-chairs the NIOSH working group developing the alert. "Even though treated patients are at the high end of the dose-response curve, we know [health care worker] exposures are taking place. People handling these drugs have the drugs in their own urine."
In a recent study, researchers at a lab in Italy found cyclophosphamide in 13% of urine samples taken before, during, and after the work shifts of nine pharmacy technicians and seven nurses.1 University of Texas researchers found substantial contamination from three antineoplastic agents in the pharmacy drug preparation areas and drug administration areas in six cancer treatment centers in Canada and the United States.2 Another study found that 40% of hospital pharmacists reported a skin exposure to antineoplastics at least once a month.3
Even facilities that follow the hazardous drug guidelines from the U.S. Occupational Safety and Health Administration (OSHA) may find significant exposure, says Thomas Connor, PhD, senior service fellow at NIOSH in Cincinnati and associate professor of environmental and occupational health at the University of Texas School of Public Health in Houston. (For a copy of the guidelines, go to: www.osha.gov/SLTC/hazardousdrugs.)
Connor once specialized in hazards in the petrochemical industry. The dangers associated with preparing and administering antineoplastic agents are greater than those posed in oil refineries, he says.
"The patients get high doses [of antineoplastics] over a very short period of time, but pharmacists and nurses are exposed possibly for a lifetime. They’re exposed to 20, 30 different drugs in a day," he says. "We don’t know what the low doses will do. The potential is there.
"Health care is an unusual type of occupational setting. Usually, you have two or three hazardous agents [in a nonhealth care environment]. Here you have a whole host of them — very, very toxic, very hazardous. Many of [the drugs] themselves cause cancer," he says.
While the risk of chemotherapeutic agents may be obvious, the extent of the exposure isn’t. Currently there’s no method of monitoring individual exposure, such as badges or air sampling.
Connor and colleagues at NIOSH are launching a comprehensive study to look for blood markers or other methods of detecting exposure. They will conduct environmental and air sampling and will conduct urine tests. Nurses, pharmacy technicians, and pharmacists who handle the hazardous drugs will answer detailed questionnaires about their health, reproductive history, and work practices.
Meanwhile, following the current OSHA guidelines is imperative; but in visits to hospitals, Connor says he has seen a wide variation of adherence.
"We’ve seen people eating and drinking where they’re preparing chemotherapy and not wearing protective equipment," he says. "There are other places where people wear all the protective equipment and do everything they should. It varies considerably from hospital to hospital."
The OSHA guidelines call for "a systematic program of medical surveillance," with medical exams yearly or every two to three years. "The physical examination should be complete, but the skin, mucous membranes, cardiopulmonary and lymphatic systems, and liver should be emphasized," the guidelines state.
OSHA also stresses the importance of exposure assessment for health care workers who work with hazardous drugs. "A confidential database should be maintained with information regarding the individual’s medical and reproductive history, with linkage to exposure information to facilitate epidemiologic review," the guidelines state.
"The most important aspect of surveillance is knowing who in your institution is actually exposed and having record linkage," explains McDiarmid, who helped draft the hazardous drug guidelines when she served as chief medical officer at OSHA. "An annual questionnaire [about exposure] could easily serve the majority of the purpose of surveillance."
The upcoming NIOSH alert will remind hospitals what they need to do to monitor exposure and protect workers. Meanwhile, McDiarmid says she hopes eventually there will be a set of "universal precautions" to follow whenever handling hazardous drugs, similar to the approach used with bloodborne pathogens. This would involve using a combination of methods to control exposure, such as mixing in hoods, using safe work practices, and personal protective equipment.
That approach would include continual training about safe handling. Training should emphasize the risks involved with exposure to the drugs, McDiarmid says.
"Using Material Safety Data Sheets, as required by OSHA’s hazard communications standard goes a long way in this regard," she says. Many institutions do annual training to refresh knowledge of hazards and safe work practices, she says.
Some vendors provide products that allow workers to check their technique. For example, Kendall-LTP of Chicopee, MA, sells ChemoChek Training Kits that allow pharmacists, nurses, and technicians to see the potential exposure while handling antineoplastics. The kit uses a fluorescent dye that shows up under UV light.
"These drugs are very toxic," McDiarmid says. "That’s necessary for the patients but not necessary for the person who handles them. That’s the tension for health care workers — providing good care for the patient while not harming themselves."
[For information about the ChemoChek Training Kits, call (800) 669-1009. Web site: www.kendall-ltp.com/pdf/chemocheck.pdf.]
1. Turci R, Sottani C, Ronchi A, et al. Biological monitoring of hospital personnel occupationally exposed to antineoplastic agents. Toxicol Lett 2002; 134:57-64.
2. Connor TH, Anderson RW, Sessink PJ, et al. Surface contamination with antineoplastic agents in six cancer treatment centers in Canada and the United States. Am J Health Syst Pharm 1999; 56:1,427-1,432.
3. Christensen CJ, Lemasters GK, Wakeman MA. Work practices and policies of hospital pharmacists preparing antineoplastic agents. J Occup Med 1990; 32:508-512.