NIOSH: No lab tests in chemo monitoring

Use annual questionnaires to detect effects

Hospitals should provide medical monitoring of employees who work with hazardous drugs, but they don't need to conduct periodic blood tests or urinalysis, according to new recommendations from the National Institute for Occupational Safety and Health (NIOSH).

At press time, NIOSH was preparing to release updated recommendations on medical surveillance of employees handling chemotherapeutic agents. They take into account new technology, a large body of recent research, and an expanded range of hazardous drugs. Currently, NIOSH lists about 150 hazardous drugs.

"I don't know of any industry where there's anything close to this number of potentially hazardous [chemicals]," says Thomas H. Connor, PhD, research biologist with NIOSH's Division of Applied Research and Technology and an expert on hazardous drugs and occupational safety.

Medical surveillance of those handling hazardous drugs has been a particularly difficult issue because it's not clear what biologic changes to look for. "No one is able to come up with a universal marker. Because there are so many drugs, there is never going to be a universal marker," says Connor.

However, medical surveillance remains important for all employees who handle chemotherapy agents and other hazardous drugs, he says. Employees should complete an annual questionnaire that asks about possible acute symptoms, such as rash and headache, as well as adverse effects such as reproductive problems, he says.

As chemotherapy agents gain wider use beyond health care, it's important to conduct a thorough hazard assessment, Connor says. You also should consider the range of employees with the potential for exposure, from the person who unpacks vials (which could be contaminated on the outside) to housekeeping workers who clean the patient's room, he says. Many hazardous drugs also may be used outside of oncology units and those employees also need training and monitoring, Connor says.

Cleaning didn't remove residue

Residue from chemotherapy agents can linger in unexpected places — the outside of vials, surfaces in a patient's room, even trailed on the floor by someone's shoes. A recent Health Hazard Evaluation at a Florida oncology clinic found chemotherapy residue at the checkout counter.

In fact, 80% of wipe samples were positive for chemotherapy residue in a 2010 evaluation, even more than the 69% positive that were found in a 2009 visit. A comparison of morning and evening wipe samples found that overnight cleaning reduced but did not eliminate the residue.1

"This speaks to the difficulty of controlling these drug exposures," says NIOSH industrial hygienist James Couch, CIH, MS, REHS/RS.

Surface wipe sampling kits are now commercially available and can be used to monitor contamination. NIOSH is validating a process for obtaining, storing and analyzing the samples, says Couch.

In 2010, Couch was able to sample for cyclophosphamide, ifosfamide, and doxorubicin, common chemotherapy agents, in addition to the platinum-containing drugs that were detected in samples in 2009.

The highest level of cyclophosphamide was found under an IV pole, which may have indicated an unreported or undetected leak. It took a couple of days of cleaning for the level to drop to a level consistent with other minor surface contamination, an indication that "housekeeping procedures were not effectively removing this chemotherapy drug in one cleaning," Couch said.

Employees should be aware that surfaces are likely to be contaminated in treatment areas, says Connor. "I think you can go into any facility that handles these and find similar results," he says. "Every facility has some level of contamination."

No recommended levels

Does exposure at low levels cause harm to employees? NIOSH has no recommended exposure limits and acknowledges that the health effects of the myriad of chemotherapy drugs are difficult to discern. Drugs are often used in combination. Acute symptoms, such as headache or rash, could have other, non-occupational causes. The drugs are associated with an increased risk of cancer and reproductive problems, but those effects may take years to develop.

"We know the effects from high doses in patients over short periods of time. We don't know, for the most part, the long-term effects at low doses," says Connor.

A 2010 study found an increased risk of chromosomal abnormality among nurses and pharmacists who handled chemotherapeutic drugs.2 An analysis of data in the Nurses' Health Study also found a significantly higher risk of spontaneous abortion in the first trimester among nurses who handled antineoplastic drugs.3 (See HEH, April 2012, p. 41.)

NIOSH now recommends looking for health effects with annual questionnaires and following up with blood testing and urinalysis if there are any concerns, such as multiple spontaneous abortions.

The agency moved away from a recommendation for routine blood and urine testing because slightly elevated results often occur as part of the normal variability, making it difficult to interpret the results as related to possible work exposures, Connor says.

Team assesses employee risk

Monitoring employees who work with hazardous drugs is part of a comprehensive safety program. Henry Ford Hospital and Health Network in Detroit brought together an interdisciplinary team to look at hazards in inpatient, outpatient and home health care. The team included employee health, pharmacy, environmental services, the safety officer and an oncology fellow.

"We wanted to make sure we didn't miss anyone," says Karen Karwowski, RN, MSN, Ed, CHSP, nurse manager of employee health services, who described her program at the recent conference of the Association of Healthcare Professionals in Healthcare (AOHP).

The committee identified the risk levels of different employees and developed an extensive health questionnaire. Those who voluntarily participate in the program complete the questionnaire every two years and have some blood work and urinalysis. Participation varies from 20% to 80%, Karwowski says. Employees also view an online educational program.

So far, no adverse effects have been detected, but Karwowski notes, "we're providing some comfort to our employees."


1. National Institute for Occupational Safety and Health. Health hazard evaluation report: Chemotherapy drug exposures at an oncology clinic – Florida. By Couch J, West C. Cincinnati, OH, 2012. NIOSH HETA No. 2009-0148-3158. Available at

2. McDiarmid MA, Oliver MS, Roth TS, et al. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med 2010;52:1028-1034.

3. Lawson CC, Rocheleau CM, Whelan, EA, et al. Occupational exposures among nurses and risk of spontaneous abortion, Amer Jrl Obstet Gyn 2011;206:327.e1-327.e8.