Chemo quandary: No good way to monitor exposure

NIOSH hopes to find markers for health changes

Chemotherapeutic agents are colorless, odorless, and hazardous. How do you know if your employees have been exposed as they prepare or administer the drugs or clean in contaminated areas?

Medical surveillance may be one of the most difficult aspects of protecting employees from exposure to chemical hazards.

The National Institute for Occupational Safety and Health (NIOSH) is encouraging hospitals to use annual questionnaires to check for health changes related to chemotherapeutic agents. Meanwhile, in a research study of health care workers handling the drugs, researchers are seeking biological markers or reports of health changes that could be used for surveillance.

"It’s a tough issue. You’re dealing with so many different drugs. Right now there are about 80-plus chemotherapy drugs, and the number is increasing all the time," explains Thomas Connor, PhD, a research biologist with NIOSH in Cincinnati who focuses on occupational exposure to hazardous drugs.

In March, NIOSH issued an alert, Preventing Occupational Exposures to Antineoplastic and other Hazardous Drugs in Healthcare Settings. The agency is sponsoring a conference on the alert, Converting Theory to Practice, in October. (For more information, see editor’s note at the end of this article.)

There are no badges that employees can wear to monitor exposure, and there’s no product available in the United States to wipe surfaces and test for hazardous drugs. Wipe kits that can measure cyclophosphamide, ifosfamide, 5-fluorouracil and etoposide, as well as mitomycin C, and the platinum compounds (cisplatin and carboplatin), are available from Exposure Control, a company in the Netherlands. The company also produces a urine kit to test for cyclophosphamide, ifosfamide and 5-fluorouracil.

The samples must then be frozen and shipped to the Netherlands for analysis. "Unfortunately, there’s no one in the U.S. doing it right now," says Connor, an author of the NIOSH alert.

Meanwhile, NIOSH recommends that hospitals monitor employees with medical questionnaires that ask about exposure to hazardous drugs, general health, and reproductive health. (See questionnaire.) The alert also suggests "baseline and periodic laboratory tests," including a complete blood count and a reticulocyte count to check for bone marrow reserve. "Because several antineoplastic agents are known to cause bladder damage and hematuria in treated patients, the urine of workers who handle these drugs should be monitored by means of a urine dipstick or a microscopic examination of the urine for blood," the alert says.

NIOSH doesn’t specify how often employees should receive the questionnaires or the lab tests. More specific recommendations may come from the pending study, Connor says.

The uncertainty makes it difficult for hospitals. "How do you measure and what do you measure for? If you get an abnormal result, what does it mean?" asks Bruce E. Cunha, RN, MS, COHN-S, manager of Employee Health and Safety at the Marshfield (WI) Clinic.

In fact, recent studies have not shown reproductive effects from working with chemotherapeutic agents, says Cunha, which may mean that the protective measures are preventing exposure. "Without the ability to actually monitor if surfaces are being contaminated, it is impossible to truly monitor if safety measures are working," he says.

In oncology units, nurses and pharmacists often feel anxious about the potential for exposure, says Martha Polovich, MN, RN, AOCN, an oncology clinical nurse specialist at Southern Regional Medical Center in Riverdale, GA, and a member of the NIOSH working group on antineoplastic and other hazardous drugs. She was also an author of the Oncology Nursing Society’s guidelines, Safe Handling of Hazardous Drugs.

"There are a lot of people who are worried because their organizations are not doing any kind of regular monitoring . . . but actually, what are they going to be monitoring other than general health?" she says. "You don’t expect to see health changes. If you do, something’s wrong with your safe-handling program."

Hospitals need to monitor employees after an acute exposure to hazardous drugs, stresses Polovich. (See box.) And hospitals should focus on engineering controls, worker training, and personal protective equipment, she says.

For example, Baxa Corp. of Englewood, CO, produces the only closed system that allows hazardous drugs to be transferred from a vial to syringe and syringe to an IV system.

Cunha is conducting a trial of the enclosed system. The vendor first conducts wipe samples, brings in the product for six months, then conducts wipes samples again. The initial wipe samples showed some contamination, though not a lot, Cunha explains. "We’re going to have to go to administration to say, This is really the best thing we can put in place right now to protect the safety of our employees,’" he says.

Hospitals can use a fluorescent dye in training exercises to help pharmacists and nurses test their techniques and observe whether there is leakage or other exposure. And employee health professionals can be alert for symptoms among employees that could indicate a pattern of exposure, Connor adds. "The approach we’re aiming toward is similar to radiation. Keep the exposure as low as you possibly can."

Here is some other advice for monitoring exposure to chemotherapeutic agents:

Know who’s at risk.

NIOSH recommends that hospitals "identify the work population that has the potential to be exposed to the drugs — from shipping and receiving to waste handling and everyone in between," Connor notes.

"Often, an institution is not aware of who might be exposed. They most commonly think of nurses and pharmacists. But there are other populations who could be exposed," he explains.

Be aware of new uses of the drugs.

Chemotherapeutic drugs now are being used for diseases other than cancer, or even in the operating room. Those health care workers may not have the training and experience of working with the drugs that the oncology staff have.

Consider the drugs’ usual effects.

In your health questionnaire, ask about symptoms that would be associated with the drug’s use in patients, such as hair loss, skin irritation, mucous membrane irritation, and eye irritation, Connor adds.

Editor’s note: The NIOSH conference will be held Oct. 3-4 in San Antonio. More information is available from the NIOSH web site at www.cdc.gov/niosh/topics/hazdrug/ or from Barbara MacKenzie at (513) 533-8132. A copy of the alert is available at www.cdc.gov/niosh/topics/hazdrug/conference.html. For more information on Exposure Control wipe sampling kits, contact Exposure Control, P.O. Box 467, 6600 Al Wijchen, The Netherlands. Telephone: (+31) 24 6452745. Fax: (+31) 24 6452746. E-mail: exposure.control@wxs.nl. Web site: www.exposurecontrol.nl.