Evidence of antineoplastic drug exposure—agents themselves and genotoxicity biomarkers—was identified in the urine of nurses who prepared and administered antineoplastic drugs in 1979, and nurses in oncology care settings were alerted to the potential risks associated with exposure to these agents.1 Since then, data support the adverse effects of exposure to antineoplastic drugs (cytotoxicity, genotoxicity, terotogenicity, and carcinogenicity), reproductive health risks among health care workers, and congenital malformations among infants born to exposed personnel.2,3 US guidelines for safe handling of antineoplastic drugs were devised more than three decades ago (Table 1). With the exception of suggested inclusion of closed system transfer devices (CSTDs or closed systems), recommended safe handling procedures and personal protective equipment (PPE) have not been significantly revised since their introduction.4-7
TABLE 1. PPE for health care workers who work with hazardous drugs.
|Policies for PPE use and worker compliance with PPE use and policies|
|Availability and use of appropriate PPE
• Double gloves tested for use with hazardous drugs
• Nonpermeable gowns
• Respiratory protection
• Class II biological safety cabinets/compounding aseptic containment isolators
• Closed IV systems
• Closed system drug transfer devices
• Robotic systems
|Conduct environmental sampling when analytical methods are available|
|Compare performance of controls against recommended standards|
| Key: PPE, personal protective equipment.
Source: National Institute for Occupational Safety and Health, US Department of Health and Human Services Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs. Cincinnati, OH: Department of Health and Human Services; 2009. DHHS (NIOSH) publication 2009-106. http://www.cdc.gov/niosh/docs/wp-solutions/2009-106/pdfs/2009-106.pdf. Accessed September 2, 2015.
EFFICACY OF CURRENT CONTROL PRACTICES
Despite adherence to safety guidelines and use of PPE in health care settings, occupational exposure and absorption of antineoplastic drugs continues to be detected at disturbing levels.8-10 Evidence of contamination in multiple and varied health care settings, recognition of exposures beyond pharmacy and nursing/patient care areas, and demonstrated health risks to more than eight million health care workers—just in the United States—coalesce as an issue that will not go away.11
In a statewide survey, 16.9% of Michigan oncology nurses working outside of hospital in-patient units self-reported chemotherapy exposure to skin or eyes.12 In a more recent multisite report, Friese and colleagues found evidence of exposure to antineoplastic drugs, not surprisingly, after acute spills but, perhaps surprisingly, as a result of routine drug handling.10 Such data underscore the need to increase adherence to safe handling procedures among potentially exposed health care workers, and highlight the need to implement more effective protection of potentially exposed workers.
In its most recent recommendations relating to medical surveillance of health care personnel, the National Institute of Occupational Safety and Health (NIOSH) expanded the list of jobs that may involve exposure to hazardous drugs13,14 (Table 2).
TABLE 2. Jobs with potential workplace exposure to hazardous drugs
|Environmental service workers (housekeeping, laundry, maintenance workers)|
|Home health care workers|
|Nurses (RNs, ARNPs, LPNs)|
|Operating room personnel|
|Pharmacists and pharmacy technicians|
|Physicians and physician assistants|
|Veterinarians and veterinary technicians|
|Workers who ship, transport, or receive hazardous jobs|
A project conducted in British Columbia identifies challenges to reducing inadvertent exposure to antineoplastic agents, concluding that control practices do not appear effective in eliminating surface contamination and/or occupational exposure to antineoplastic drugs.15 Polovich and Clark examined relationships among factors affecting oncology nurses’ use of hazardous drug safe-handling precautions.16 Their findings indicate that “exposure knowledge, self-efficacy for using personal protective equipment, and perceived risk of harm from exposure was high; total precaution use was low.”16 The authors’ suggested interventions include fostering a positive workplace safety climate and reducing barriers. Similarly, Friese and colleagues report collegial relations with physicians were poorer among workers who reported spills.10