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Even the best safety program can’t eliminate the risk to employees handling hazardous drugs, so workers who are pregnant, trying to conceive or breastfeeding should be offered alternative duty, the National Institute for Occupational Safety and Health concluded in a draft guidance document.
This is the first such recommendation from NIOSH, and although it is voluntary guidance, it represents a strong endorsement of alternative duty for those with reproductive risks related to working with chemotherapy agents and other hazardous drugs.
“I really think it’s essential that nurses take this risk seriously, be aware that you can’t prevent all exposures, and consider alternative duty,” says Martha Polovich, PhD, RN, clinical associate professor at the Georgia State University School of Nursing and Health Professions and a co-author of the Current Intelligence Bulletin.
Polovich, who is a liaison to NIOSH from the Oncology Nursing Society, calls the bulletin “an important step to improve the safety for health care workers handling chemotherapy.”
The document stems from a progression of research. There are now multiple studies showing a dose-response association between occupational exposure to chemotherapy agents and chromosomal damage in workers1 and the persistent contamination of surfaces in patient rooms, nurses’ stations and hospital or clinic pharmacies.2
“There are dozens of studies still being published in the literature that show it’s really impossible to have a clean workplace,” says Thomas H. Connor, PhD, research biologist with NIOSH’s Division of Applied Research and Technology, an expert on occupational exposure to hazardous drugs and a co-author of the bulletin. “You can have a pretty good workplace with low levels [of contamination], but there’s always going to be some present.”
NIOSH was accepting comments on the draft bulletin through March 24. (See editor’s note at end more information.)
Is it necessary to have a special policy for pregnant workers if the goal is to protect all workers from exposure to chemotherapy agents and other hazardous drugs?
With a predominantly female workforce, hospitals have a large population of employees of childbearing age who could be impacted by a reassignment policy, notes William Buchta, MD, MPH, assistant professor of occupational medicine at the Mayo Clinic Medical College in Rochester, MN.
Mayo provides safety evaluations of the worksite of any concerned employee and urges employees to be diligent in reporting accidental exposures, he says. Mayo employees working with chemotherapy agents are offered annual medical monitoring, including tests of liver and kidney function and complete blood counts.
Those at higher risk of miscarriage receive temporary reassignment, and other pregnant employees who request alternative duty are typically accommodated after a consultation with employee health, Buchta says. But Mayo doesn’t have a blanket policy of offering reassignment to women who become pregnant, and Buchta notes that many women prefer not to tell their employers and co-workers about a pregnancy until after the first trimester.
“I don’t think we should be outing women on their pregnancies early to scare them about the potential exposures in the workplace,” he says. “I think we should reassure them that we’ve done everything to minimize the risk.”
Connor acknowledges that employers have an obligation to create a safe workplace for every worker. But there is no way to completely eliminate the risk of exposure — and the fetus is especially vulnerable to antineoplastic agents, which are chemicals designed to kill rapidly developing cells, he says.
“No one should have exposures or illness or injury when they’re just doing their job. But there are certain risks that are greater during pregnancy,” he says.
A review of studies found an increased risk of reproductive problems such as miscarriage and stillbirth among health care workers with long-term, low-level occupational exposure to hazardous drugs,3 he notes.
Federal law prohibits employers from requiring pregnant workers to accept alternative duty. The Occupational Safety and Health Administration’s Hazard Communications standard requires employers to train workers about the hazards of chemicals they work with and how to protect themselves.
To varying degrees, professional organizations have endorsed alternative duty related to reproductive risks. The American Nurses Association, Oncology Nursing Society and the American Society of Health-System Pharmacists state that employers should offer alternative duty to employees handling hazardous drugs if they are pregnant, actively trying to conceive or breastfeeding.
The American College of Occupational and Environmental Medicine (ACOEM) is less prescriptive, stating that “temporary reassignment should be recommended if the conclusion of the risk assessment is that there is exposure to a reproductive or developmental toxicant that cannot be adequately controlled through engineering or work practice controls alone.”
Marian Condon, RN, MS, research associate with the Division of Occupational and Environmental Health at the University of Maryland School of Medicine, previously worked with the Maryland Nurses Association to develop the ANA policy statement. NIOSH’s pending guidance adds validation, she says.
“It provides a precautionary approach to protecting the breastfeeding infants and unborn offspring of hazardous drug handlers,” she says.
An alternative duty policy should include a risk assessment of hazardous drugs used in the facility, identification of jobs or tasks that have the potential for exposure, and identification of safe jobs or tasks that could be an option for alternative duty, NIOSH says. The guidance also applies to men who are trying to conceive.
The agency maintains an updated list of hazardous drugs, many of which are used outside of oncology units.
The NIOSH guidance may encourage facilities to create a written policy for alternative duty, rather than relying on ad hoc decision-making, Polovich says. “That’s the only way that you guarantee that a worker who requests alternative duty will get it,” she says.
[Editor’s note: The draft Current Intelligence Bulletin is available at www.regulations.gov under CDC-2015-0003-0002. Comments can be submitted on the site for Docket Number NIOSH-279.]