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NIOSH: Workplace Safety and Health

Hazardous Drugs in Healthcare

Thomas H. Connor, PhD

Posted: 03/07/2011

 

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Occupational Risk of Antineoplastic Drugs

The toxicity of antineoplastic drugs in patients has been well-known since their introduction in the 1940s and 1950s.[1] Because most antineoplastic medications have nonselective mechanisms of action, these agents affect noncancerous cells as well as cancerous cells, resulting in numerous adverse effects. When secondary cancers began to develop in patients treated with these drugs, concern was raised that healthcare workers also could be at risk for harmful effects from antineoplastic agents as a result of occupational exposure.[2]

In addition to the capability of many of the antineoplastic drugs of causing cancer, acute illnesses, and organ toxicity, evidence points to teratogenic and adverse reproductive outcomes in patients exposed to these agents. In current practice, antineoplastic medications are administered under controlled regimens that are designed to optimize benefits to patients while minimizing the risk for adverse effects. The safety of the patient is the primary focus. However, these procedures may result in job-related exposure of healthcare workers who are involved in patient treatment and related activities, such as storage, transportation, and disposal of the drugs.

Safe Handling Guidelines

Awareness of the possible adverse health effects in workers during the 1980s prompted several organizations, including the Occupational Safety and Health Administration (OSHA),[3] the Oncology Nursing Society (ONS),[4] and the American Society of Hospital Pharmacists (ASHP, now the American Society of Health-System Pharmacists)[5] to issue safe handling guidelines for antineoplastic drugs. Despite these improvements in guidance and recommendations, more recent studies have shown that workers continue to be exposed to these toxic agents.[6-8]

In 1995, OSHA updated its recommendations and included some non-antineoplastic medications in its list of hazardous drugs.[9] The National Institute for Occupational Safety and Health (NIOSH) issued an alert in 2004 reviewing literature on hazardous drug exposure and recommending a program of safe drug handling.[6] This alert incorporated a comprehensive list of hazardous drugs that require special handling by healthcare workers. Although most of the drugs are antineoplastic agents, approximately one third are used to treat other diseases. This list was updated and expanded in 2010 to include newly-approved drugs and existing drugs with new health warnings.[10]

 
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References

  1. Ladik CF, Stoehr GP, Maurer MA. Precautionary measures in the preparation of antineoplastics. Am J Hosp Pharm. 1980;37:1184-1185. Abstract
  2. Theiss JC. Hospital personnel who handle anticancer drugs may face risks. JAMA. 1982;247:11-12. Abstract
  3. US Department of Labor. Guidelines for cytotoxic (antineoplastic) drugs. OSHA, Office of Occupational Medicine. Pub 8-1.1, January 1986. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p;_id=1702 Accessed January 15, 2011.
  4. Oncology Nursing Society. Standards for Cancer Nursing Practice. 1982.
  5. American Society of Hospital Pharmacists. Technical assistance bulletin on handling cytotoxic drugs in hospitals. Am J Hosp Pharm. 1985;42:131-137.
  6. NIOSH Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. DHHS (NIOSH) Pub no. 2004-165, September 2004. Available at: http://www.cdc.gov/niosh/docs/2004-165 Accessed January 15, 2011.
  7. Connor TH, McDiarmid MA. Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin. 2006;56:354-365. Abstract
  8. Connor TH, DeBord DG, Pretty J, et al. Evaluation of antineoplastic drug exposure in healthcare workers at three U.S. cancer centers. J Occup Environ Med. 2010;52:1019-1027. Abstract
  9. OSHA Instruction TED 1.15. Directorate of technical support. Controlling occupational exposure to hazardous drugs. Sept, 1995.
  10. NIOSH List of antineoplastic and other hazardous drugs in healthcare settings 2010. DHHS (NIOSH) Pub No. 2010-167, September 2010. Available at: http://www.cdc.gov/niosh/docs/2010-167/pdfs/2010-167.pdf Accessed January 15, 2010.
  11. Connor TH, Sessink PJM, Harrison BR, et al. Surface contamination of chemotherapy drug vials and evaluation of new vial-cleaning techniques: results of three studies. Am J Health-Syst Pharm. 2005;62:475-484.
  12. Schierl R, Herwig A, Pfaller A, Groebmair S, Fischer E. Surface contamination of antineoplastic drug vials: comparison of unprotected and protected vials. Am J Health-Syst Pharm. 2010;67:428-429.
  13. Fransman W, Vermeulen R, Kromhout H. Dermal exposure to cyclophosphamide in hospitals during preparation, nursing and cleaning activities. Int Arch Occup Health. 2005;78:403-412.
  14. Fransman W, Huizer D, Tuerk J, Kromhout H. Inhalation and dermal exposure to eight antineoplastic drugs in an industrial laundry facility. Int Arch Occup Environ Health. 2007;80:396-403. Abstract
  15. Connor TH, Anderson RW, Sessink PJ, Broadfield L, Power LA. Surface contamination with antineoplastic agents in six cancer treatment centers in the United States and Canada. Am J Health Syst Pharm. 1999;56:1427-1432. Abstract
  16. US Pharmacopeia (USP) Revised General Chapter 797 Guidebook to Pharmaceutical Compounding -- Sterile Preparations. June 1, 2008.
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Authors and Disclosures

Author

Thomas H. Connor, PhD

Research Biologist, Division of Applied Research and Technology, National Institute for Occupational Safety and Health, Cincinnati, Ohio

Disclosure: Thomas H. Connor, PhD, has disclosed no relevant financial relationships.

 
 
 
 
 
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