NIOSH alert: Do more to protect health workers from chemo agents

Exposure continues despite PPE, precautions

Current work practices are not adequate to protect health care workers from chemotherapeutic agents and other dangerous drugs, and hospitals need to be more vigilant in their efforts to prevent exposure, according to a hazard alert from the National Institute for Occupational Safety and Health (NIOSH).

Health care workers are being exposed to possible reproductive and carcinogenic hazards despite the use of engineering controls and personal protective equipment, the alert cautioned. For example, residue may linger on contaminated surfaces, such as IV poles; may become aerosolized when bedpans are emptied or IV lines flushed; or may be absorbed through the skin when drugs spill on clothing.

In all, more than 5.5 million health care workers may be at risk from exposure to hazardous drugs, NIOSH said.

"People thought the problems were solved when [pharmacists and pharmacy technicians] started working with biological safety cabinets," says Thomas Connor, PhD, a research biologist with NIOSH in Cincinnati and an author of the alert. But in research studies, Connor and colleagues found evidence of drug residue on work surfaces. "Even with biological safety cabinets, there was contamination everywhere," he says.

Exposure may occur in these situations:

  • Drugs are reconstituted or diluted.
  • Nurses or others expel air from syringes or give injections, and small amounts are aerosolized.
  • Uncoated tablets are counted or dosed in a unit-dose machine.
  • Health care workers touch contaminated surfaces, patients’ body fluids, or contaminated clothing and linens.
  • Workers prime the IV with drug-containing solution or administer the drug with the IV.

"Every step along the way, you have the potential for release and exposing the workers," says Connor. "I don’t think people are aware of it. They can’t see it [because the drugs are colorless] and don’t think there can be a spill."

(The alert contains further information on exposure-prone activities. It is available at www. cdc.gov/niosh/docs/2004-HazDrugAlert/pdfs/ 2004-HazDrugAlert.pdf.)

The Oncology Nursing Society, (ONS) based in Pittsburgh, welcomed the alert, which reflected their longtime concerns. In fact, exposures are increasing as chemotherapy drugs are used to treat a wider range of conditions, such as rheumatoid arthritis, multiple sclerosis, and lupus, notes 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.

At the same time, nurses assume they are protected and become complacent, she says. "We still have people who don’t take it seriously." They don’t see bad things happening from exposures. [They think,] I’ve given chemo for 20 years. Nothing bad happened to me, so it must be OK.’"

Bill Borwegen, MPH, occupational safety and health director for the Service Employees Inter-national Union (SEIU), also lauded the extensive alert, which is 93 pages long. "If hospitals voluntarily started adhering to the recommendations in this document, everyone would be safer," he says.

As a first step, hospitals should conduct an analysis of the potential hazards and make a list of hazardous drugs, the alert says. The NIOSH alert provides a list of dangerous drugs, and the list will be placed on-line at http://www.cdc.gov/niosh/homepage.html (on the health care worker page) and updated periodically.

The list includes antineoplastic agents as well as some antivirals, antibiotics, hormonal agents, and bioengineered drugs.

The list is likely to grow — and so is the population at risk, says Connor. "The number of cancer patients is going to increase, so there’s going to be more need for more drugs," he explains. "Clinicians are able to use higher doses of drugs because there are ways to reduce the side effects, which means nurses and pharmacists will be exposed to higher doses. All of these [issues] are leading to the potential for more exposures."

As hospitals purchase new drugs, they should consider adding them to their own list of hazardous drugs. In fact, identifying and updating the list of drugs that pose occupational hazards is a requirement of the Hazard Communication Standard of the U.S. Occupational Safety and Health Administration (OSHA).

Employee health professionals and safety managers should conduct a walk-through to trace the use of the drugs and the potential hazards to a variety of employees. "Look at places where you may have problems with contamination or hazards: high-traffic areas where there’s preparation; proper storage; look at what type of gloves and gowns are being used," Connor advises. "Every step along the way [from the pharmacy to disposal], produces some waste material."

For example, vinyl gloves are not effective chemical barriers. Health care workers handling these drugs should use special gloves designed for that purpose, says Connor. NIOSH recommends double-gloving and nonpermeable gowns. The outer glove should cover the cuff of gown sleeve, he adds. "We don’t recommend lab coats because they just absorb the drug and press it against the skin."

The proper precautions often are not followed, according to a recent survey of oncology nurses.

The hazard alert is designed for both employers and employees. Educating workers to handle hazardous drugs or the related contaminated waste in a safe manner is a major emphasis.

"People need to realize that a lot of these drugs were chemical warfare agents in World War I," adds Borwegen, who was a member of the NIOSH working group. "A lot of people don’t realize how dangerous these agents can be."

Employees also need to understand the wide range of tasks that can lead to exposure, he says. "Even some of the more innocuous work tasks may be putting workers at risk — workers emptying the bedpan of the patient who was administered chemotherapeutic drugs. Just flushing the toilet can aerosolize the drugs."

The alert describes incidents that led to exposures, and even symptoms, in health care workers. Health care workers who are not aware of the potential for exposure in some tasks may fail to protect themselves, says Polovich, who was an author of the ONS chemotherapy and biotherapy guidelines and recommendations for practice. For example, they may touch a contaminated surface while not wearing gloves, she says.

"I hope people will stop and look at their practice and say, What are the opportunities for exposure in my workplace?’ Think about that seriously. What can be changed to make it a safer place?"

The NIOSH alert does not require medical surveillance of employees who work with hazardous drugs, which is a concern of ONS. There is no blood test that can test for exposure to hazardous drugs. Air sampling also is not recommended. "We’ve recommended an annual health questionnaire with a special focus on those systems that would be affected by hazardous drugs," Polovich says.

Connor acknowledges that the guidance is lacking on medical surveillance because there is no marker that can be detected in tests. He advises employees, "If you have any problems you think might be related to occupational exposure, talk to the occupational health physician or your personal physician."

The NIOSH hazard alert is a voluntary guideline. Hazard Communication is the only OSHA standard that addresses hazardous drugs in the workplace. But employers who fail to protect their workers from known, serious hazards can be cited under OSHA’s "general duty" clause, Connor notes.