Reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: a review of the evidence

Environmental assessment of cytotoxic drugs in healthcare settings: protocol for a systematic review and meta-analysis

BACKGROUND

Occupational exposure to cytotoxic drugs is associated with various unfavorable health outcomes. This protocol reports a methodology for a systematic review and meta-analysis that aims to systematically review the published literature and quantify the level of environmental contamination of healthcare settings with cytotoxic drugs.

METHODS

This protocol is developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol-2015 (PRISMA-P) guidelines. Six electronic databases (PubMed, Web of Science, Scopus, Cochrane Library, CINAHL, and EMBASE) will be searched with no restrictions on publication period. Eligible studies will be identified and data will be extracted using a predefined data extraction form by at least two independent reviewers following best practice. Eligible studies should report calculated or calculable estimates on the proportion of positive samples tested for cytotoxic drugs and/or estimates on the concentration of the cytotoxic drug(s) in the tested samples. Risk of bias (RoB) will be assessed by using the RoB in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool, which developed by the World Health Organization (WHO) and International Labour Organization (ILO) for environmental and occupational health systematic reviews. The random-effects model will be used to perform meta-analyses.

DISCUSSION

Occupational exposure to cytotoxic drugs is associated with short- and long-term adverse health outcomes. Following this protocol, the review to be carried out will be the first to fill an evidence gap on the environmental contamination of healthcare settings with cytotoxic drugs. The findings of this review will help in the understanding of the risk of occupational exposure of healthcare workers to cytotoxic drugs and facilitate the identification of priority areas for specific interventions.

ETHICS AND DISSEMINATION

The systematic review methodology does not require ethics approval due to the nature of the study design. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020162780 , dated July 14, 2020.

Occupational exposure of platinum-based anti-cancer drugs: five-year monitoring of hair and environmental samples in a single hospital

Background

Occupational exposure to chemotherapeutic agents in hospitals is a critical issue. Here, we focused on occupational exposure to platinum-based anti-cancer drugs (PDs) by evaluating platinum concentrations in hair and environmental workplace samples to monitor the risk among workers.

Methods

Hospital workers who dealt with or without PDs, patients treated with PDs, and non-medical office workers outside the hospital donated hair samples and completed a questionnaire regarding their history of handling PDs, including any incidents. Hair samples were collected and surface wipe sampling was performed in July 2010 and April 2015, before and after moving to a new building and introducing a revised safety program in August 2010. Samples were analyzed by inductively coupled plasma-mass spectrometry.

Results

Platinum concentrations in hair from PDs-handling workers was significantly higher than in non-PDs-handling workers (P = 0.045), although 50 times lower than that from PDs-treated patients. Platinum concentrations in the hospital environment had decreased at the second survey 5 years later but had not changed significantly in the hair samples from hospital workers.

Conclusion

Platinum concentrations in hair are likely dependent on the frequency of handling PDs. Reduced environmental contamination from PDs did not influence platinum levels in hospital workers’ hair. Continuous monitoring by measuring platinum concentrations in the environment and in hair would provide information regarding these issues.

Efficiency of four solutions in removing 23 conventional antineoplastic drugs from contaminated surfaces

BACKGROUND

Residual contamination by intravenous conventional antineoplastic drugs (ICAD) is still a daily issue in hospital facilities. This study aimed to compare the efficiency (EffQ) of 4 different solutions to remove 23 widely used ICADs from surfaces.

METHOD AND FINDINGS

A solution containing 23 ICADs (4 alkylating agents, 8 antimetabolites, 2 topo-I inhibitors, 6 topo-II inhibitors and 3 spindle poisons) was spread over 100 cm2 stainless steel. After drying, decontamination was carried out using 10×10 cm wipes moistened with 300 μL of one of the following solutions: 70% isopropanol (S1); ethanol-hydrogen peroxide 91.6-50.0 mg/g (S2); 10-2 M sodium dodecyl sulphate/isopropanol 80/20 (S3) or 0.5% sodium hypochlorite (S4). Six tests were performed for each decontamination solution. Two modalities were tested: a single wipe motion from top to bottom or vigorous wiping (n = 6 for each modality). Residual contamination was measured with a validated liquid chromatography with tandem mass spectrometry detection method. Solution efficiency (in %) was computed as follows: EffQ = 1-(quantity after decontamination/quantity before decontamination), as median (min-max) for the 23 ICADs. The overall decontamination efficiency (EffQ) of the 4 solutions was compared by a Kruskall-Wallis test. Decontamination modalities were compared for each solution and per ICAD with a Mann-Whitney test (p<0.05). EffQ were significantly different from one solution to the next for single wipe motion decontamination: 79.9% (69.3-100), 86.5% (13.0-100), 85.4% (56.5-100) and 100% (52.9-100) for S1, S2, S3 and S4 (p<0.0001), respectively. Differences were also significant for vigorous decontamination: EffQ of 84.3% (66.0-100), 92.3% (68.7-100), 99.6% (84.8-100) and 100% (82.9-100) for S1, S2, S3 and S4, respectively (p<0.0001). Generally, vigorous decontamination increased EffQ for all tested solutions and more significantly for the surfactant.

CONCLUSION

Decontamination efficiency depended on the solution used but also on the application modality. An SDS admixture seems to be a good alternative to sodium hypochlorite, notably after vigorous chemical decontamination with no hazard either to materials or workers.

Measures to prevent the risks associated with exposure to cytostatic drugs in glaucoma filtering surgery

INTRODUCTION

The use of cytostatic drugs such as Mitomycin C and 5-Fluorouracil is well-known in glaucoma filtering surgery, as well as the management of its complications. However, there is a lack of information regarding the preventive measures to be taken by the professional that handles these types of substances.

OBJECTIVE

Raise awareness among professionals of the risks associated with the use of cytostatic drugs without adequate prevention measures.

RESULTS

Review of the available literature and legislation on preventive measures in the management of cytostatic drugs in the medical and ophthalmological field.

CONCLUSIONS

The prevention and awareness of the risks of the qualified professionals that handle these substances is the most important measure to prevent the possible risks. Coordination is necessary with the Occupational Health teams of the Hospital, as well as the professionals and staff involved in the different phases of the process, from the preparation in Hospital Pharmacy to its elimination.

Occupational health and safety hazards faced by healthcare professionals in Taiwan: A systematic review of risk factors and control strategies

Background

Healthcare professionals in Taiwan are exposed to a myriad of occupational health and safety hazards, including physical, biological, chemical, ergonomic, and psychosocial hazards. Healthcare professionals working in hospitals and healthcare facilities are more likely to be subjected to these hazards than their counterparts working in other areas.

Objectives

This review aims to assess current research literature regarding this situation with a view to informing policy makers and practitioners about the risks of exposure and offer evidence-based recommendations on how to eliminate or reduce such risks.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses review strategy, we conducted a systematic review of studies related to occupational health and safety conducted between January 2000 and January 2019 using MEDLINE (Ovid), PubMed, PMC, TOXLINE, CINAHL, PLOS One, and Access Pharmacy databases.

Results

The review detected 490 studies addressing the issue of occupational health and safety hazards; of these, 30 articles were included in this systematic review. These articles reported a variety of exposures faced by healthcare professionals. This review also revealed a number of strategies that can be adopted to control, eliminate, or reduce hazards to healthcare professionals in Taiwan.

Conclusion

Hospitals and healthcare facilities have many unique occupational health and safety hazards that can potentially affect the health and performance of healthcare professionals. The impact of such hazards on healthcare professionals poses a serious public health issue in Taiwan; therefore, controlling, eliminating, or reducing exposure can contribute to a stronger healthcare workforce with great potential to improve patient care and the healthcare system in Taiwan. Eliminating or reducing hazards can best be achieved through engineering measures, administrative policy, and the use of personal protective equipment.

Implications

This review has research, policy, and practice implications and provides future students and researchers with information on systematic review methodologies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. It also identifies occupational health and safety risks and provides insights and strategies to address them.

USP General Chapter <800>: Considerations for Oncology Nursing Practice

OBJECTIVES

To describe the nurse leader's role in implementing the hazardous drug safe-handling standards from USP General Chapter <800> that are most relevant to oncology nursing practice, and to provide strategies for reducing nurses' exposure to hazardous drugs.

DATA SOURCES

Published literature indexed in PubMed, CINAHL, textbooks, and clinical expertise.

CONCLUSION

Nurse leaders are essential to promoting a safe environment for nurses handling hazardous cancer drugs.

IMPLICATIONS FOR NURSING PRACTICE

Several barriers and challenges to handling hazardous drugs exist and must be overcome before oncology nurses' exposure can be reduced.

Environmental assessment of cytotoxic drugs in the Oncology Center of Cyprus

Background

Cytotoxic drugs constitute an important workplace hazard in the hospital environment. Our aim was to conduct an environmental assessment of hazardous drugs in the Oncology Center of Cyprus.

Methods

Wipe samples were obtained from 42 workplace areas of the Oncology Center including two pairs of gloves in an initial assessment, while 10 samples were obtained at follow-up 3 years later. Potential contamination with cyclophosphamide (CP), ifosphamide (IF) and 5-fluorouracil (5-FU) and other cytotoxic medications was examined using the GC-MSMS system (CP, IF) and the HPLC system with UV detection (5-FU) method, respectively.

Results

Wipe sample contamination was detected at 11.9% and 15% in the initial and follow-up assessment, respectively. Both pairs of gloves assessed were free from contamination. The results showed contamination with cyclophosphamide on the work space inside the isolator, on a day-care office phone and on the central pharmacy bench. Ifosphamide was only detected on the floor of a patient’s room. Contamination with 5-fluorouracil was found only on the surface of a prepared IV infusion bag. The levels of contamination in the positive samples ranged from 0.05 to 10.12 ng/cm².

Conclusions

The overall percentage of sample contamination at the Oncology Center was very low compared to other centers around the world. In addition, the detected levels of contamination with cytotoxic drugs were relatively low with the exception of the workspace inside the biological safety cabinet. These results in both assessments may reflect the implementation of comprehensive control measures including employee training, technological equipment and effective cleaning procedures.

A Protocol for the Safe Use of Hazardous Drugs in the OR

Hazardous drug (HD) use in the perioperative environment poses unique challenges and risks for exposure that can have adverse consequences for perioperative personnel. The United States Pharmacopeial Convention has implemented new standards to address the safe handling and administration of HDs by health care workers. To comply with these standards and minimize perioperative personnel's occupational exposure to HDs, a multidisciplinary team at an academic medical center in Boston that was performing an increased number and variety of operative and other invasive procedures using antineoplastic agents updated their protocol for the safe use of HDs in the OR. This article discusses HDs and the risks they pose to health care workers and outlines the new HD safety protocol for the OR that was part of a performance improvement plan to ensure compliance with new standards and staff member safety in the perioperative setting.

Enteral tube administration of oral chemotherapy drugs

Objective

Patients receiving oral chemotherapies face treatment interruptions if they require placement of an enteral tube for nutrition, potentially leading to adverse outcomes in cancer treatment. Enteral tube medication administration can provide a suitable alternative. The purpose of this review is to compile available data that describe enteral tube administration of oral chemotherapy agents. Data sources: A systematic evaluation of all Food and Drug Administration-approved oral chemotherapy agents through 31 July 2019 was conducted. Information on crushing or opening of the tablet or capsule, enteral tube administration, and extemporaneous formulations was compiled from the prescribing information, tertiary resources, and primary literature. Drug manufacturers were contacted for additional information. Data summary: A total of 87 oral chemotherapy agents were evaluated. Of the 87 drugs, 33 agents (37.9%) had information regarding enteral tube administration with only four drugs with nasogastric or gastric tube administration instructions in their prescribing information. The strength of evidence varied from non-peer reviewed data to complete evaluations of efficacy and safety. The majority of chemotherapies (62%) had no available data on enteral tube administration.

Conclusions

The results of this review suggest that there is limited data surrounding enteral tube administration of most oral chemotherapies, demonstrating the need for more studies to be conducted to provide more guidance to healthcare providers when administration via an enteral tube is needed in their patients.

Maternal cumulative exposure to extremely low frequency electromagnetic fields, prematurity and small for gestational age: a pooled analysis of two birth cohorts

Background

Data on the effects of extremely low frequency electromagnetic fields (ELF-EMF) on pregnancy outcomes are inconclusive.

Objective

To study the relation between maternal cumulative exposure to ELF-EMF during pregnancy and the risk of prematurity or small for gestational age (SGA) in a pooled analysis of two French birth cohorts.

Methods

Elfe and Epipage2 are both population-based birth cohorts initiated in 2011 and included 18 329 and 8400 births, respectively. Health data and household, mother and child characteristics were obtained from medical records and questionnaires at maternity and during follow-up. A job exposure matrix was used to assess cumulative exposure to ELF-EMF during three periods: (1) until 15 weeks of gestation, (2) until 28 weeks of gestation and (3) until 32 weeks of gestation. Analyses were restricted to single live births in mainland France and to mothers with documented jobs (N=19 894). Adjusted logistic regression models were used.

Results

According to the period studied, 3.2%–4% of mothers were classified as highly exposed. Results were heterogeneous. Increased risks of prematurity were found among low exposed mothers for the three periods, and no association was observed among the most exposed (OR1=0.92 (95% CI 0.74 to 1.15); OR2=0.98 (95% CI 0.80 to 1.21); OR3=1.14 (95% CI 0.92 to 1.41)). For SGA, no association was observed with the exception of increased risk among the low exposed mothers in period 2 and the most exposed in period 3 (OR=1.25 (95% CI 1.02 to 1.53)).

Conclusion

Some heterogeneous associations between ELF-EMF exposure and prematurity and SGA were observed. However, due to heterogeneity (ie, their independence regarding the level of exposure), associations cannot be definitely explained by ELF-EMF exposure.

Nursing Assistants' Use of Personal Protective Equipment Regarding Contact With Excreta Contaminated With Antineoplastic Drugs

PURPOSE

To examine the feasibility of observing and interviewing nursing assistants about handling of antineoplastic drugs contaminated with excreta, acceptability of a measure of personal protective equipment (PPE) use with nursing assistants, and predictors of PPE use.

PARTICIPANTS & SETTING

27 nursing assistants in an inpatient hematology-oncology unit at an academic medical center in the southeastern United States.

METHODOLOGIC APPROACH

This was an exploratory, multimethod study using observation, verbally administered questionnaires, and interviews. Research variables included recruitment rates, acceptability of observation, and understandability of a safe-handling instrument.

FINDINGS

Observed use of double gloves, chemotherapy gowns, and face shields was low; use of plastic-backed pads when flushing excreta was high.

IMPLICATIONS FOR NURSING

Nursing assistants are willing to participate in research. Standardized training and education about PPE use are needed.

CE: Original Research: Antineoplastic Drug Administration by Pregnant and Nonpregnant Nurses: An Exploration of the Use of Protective Gloves and Gowns

: Background: Many antineoplastic (chemotherapeutic) drugs are known or probable human carcinogens, and many have been shown to be reproductive toxicants in cancer patients. Evidence from occupational exposure studies suggests that health care workers who have long-term, low-level occupational exposure to antineoplastic drugs have an increased risk of adverse reproductive outcomes. It's recommended that, at minimum, nurses who handle or administer such drugs should wear double gloves and a nonabsorbent gown to protect themselves. But it's unclear to what extent nurses do.

PURPOSE

This study assessed glove and gown use by female pregnant and nonpregnant nurses who administer antineoplastic drugs in the United States and Canada.

METHODS

We used data collected from more than 40,000 nurses participating in the Nurses' Health Study 3. The use of gloves and gowns and administration of antineoplastic drugs within the past month (among nonpregnant nurses) or within the first 20 weeks of pregnancy (among pregnant nurses) were self-reported via questionnaire.

RESULTS

Administration of antineoplastic drugs at any time during their career was reported by 36% of nonpregnant nurses, including 27% who reported administering these drugs within the past month. Seven percent of pregnant nurses reported administering antineoplastic drugs during the first 20 weeks of pregnancy. Twelve percent of nonpregnant nurses and 9% of pregnant nurses indicated that they never wore gloves when administering antineoplastic drugs, and 42% of nonpregnant nurses and 38% of pregnant nurses reported never using a gown. The percentage of nonpregnant nurses who reported not wearing gloves varied by type of administration: 32% of those who administered antineoplastic drugs only as crushed pills never wore gloves, compared with 5% of those who administered such drugs only via infusion.

CONCLUSION

Despite longstanding recommendations for the safe handling of antineoplastic and other hazardous drugs, many nurses-including those who are pregnant-reported not wearing protective gloves and gowns, which are considered the minimum protective equipment when administering such drugs. These findings underscore the need for further education and training to ensure that both employers and nurses understand the risks involved and know which precautionary measures will minimize such exposures.

Administration of antineoplastic drugs and fecundity in female nurses

BACKGROUND

We examined the association between the administration of antineoplastic drugs (AD) and fecundity among female nurses.

METHODS

AD administration and use of exposure controls (EC) such as gloves, gowns, and needleless systems were self-reported at baseline among 2649 participants of the Nurses' Health Study 3, who were actively attempting pregnancy. Every 6 months thereafter, the nurses reported the current duration of their pregnancy attempt. Multivariable accelerated failure time models were used to estimate time ratios (TR) and 95% confidence intervals (CI) adjusted for age, race, body mass index, smoking, marital status, hours of work, and other occupational risk factors.

RESULTS

Mean (standard deviation) age and BMI at baseline were 30.7 years (4.7) and 26.0 kg/m² (6.4). Forty-one percent of nurses reported ever administering AD; 30% only in the past and 11% currently. The former administration of AD (TR = 1.02, 95% CI, 0.93-1.12) was unrelated to the ongoing duration of pregnancy attempt. Among nurses currently administering AD, those who had administered AD for 6 years and above had a 27% (95% CI, 6%-53%) longer duration of pregnancy attempt than nurses who never handled ADs in unadjusted analyses. This difference disappeared in multivariable analyses (TR = 1.01, 95% CI, 0.85-1.21). 93% (n = 270) of the nurses currently administering ADs reported consistent use of EC. These nurses had a similar median duration of pregnancy attempt to those who never handled AD (TR = 1.00, 95% CI, 0.87-1.15).

CONCLUSIONS

Administration of ADs did not appear to have an impact on fecundity in a cohort of nurses planning for pregnancy with a high prevalence of consistent ECs. Our results may not be generalizable to women who are less compliant with PPE use or with less availability to ECs. Therefore, it is possible that we did not observe an association between occupational exposure to AD and reduced fecundity because of lower exposure due to the more prevalent use of effective ECs.

Psycho social risks noted by oncology workers related to their quality of life

ABSTRACT Objective: To analyze the relation between occupational psychosocial risks and quality of life related to health, felt by workers who work in oncology and palliative care units in a region of Chile. Method: Cross-sectional analytical study of quantitative approach, in which 110 health workers participated. Research met the ethical requirements of E. Emanuel. Results: Participants perceive greater exposure to psychosocial risks in the dimension of psychological demands and double presence. On the other hand, they see better results in the physical health component (��: 76.72; SD 9.75) versus the mental health component (��: 71.13; SD 6.38). In addition, there are relations with statistical significance, between psychosocial risks and quality of life related to Health (p≤0.05). Conclusions: This study shows that there the perception of psychosocial risks and quality of life are related, when considering the health of workers.

Evaluation of decontamination strategies for cyclophosphamide

Purpose

The main objective was to determine the efficacy of various types of cleaning equipment and products after deliberate contamination with cyclophosphamide. The secondary objective was to test various cleaning scenarios using these equipment and products.

Methods

The study had two phases: testing of cleaning equipment (wipe : woven microfibers – Hygen®, two layers of non-woven microfibres and an inner layer of highly absorbent viscose fibres – MicronSolo®, two layers of non-woven microfibres and an inner layer of highly absorbent viscose fibres – MicroMix®, simili-tissu (low filament production) – Tork® and, mop : woven microfibers – Hygen®, microfibre and viscose – MicroOne®) and products (disinfectant : quaternary ammonium – DR100®, chlorine 0.1% – Zochlor® – Brutab® – PCS® NPH, sodium hypochlorite 2%, cleaner : detergent – Nu- Action 3®, cleaner and disinfectant: sodium hypochlorite 0.6% + detergent – Aliflex® and water) in phase 1 and testing of various cleaning procedures in phase 2. Specific areas of a room with a laminar flow hood (class II/type B2) were contaminated with 10 mcg of cyclophosphamide. Different types of surfaces were cleaned with various scenarios and the remaining cyclophosphamide was measured by the Institut national de santé publique du Québec. All tests were performed in triplicate.

Results

A total of 189 samples were obtained: 42 negative controls and positive controls, 54 during phase 1 and 93 during phase 2. All products were more than 96.5% effective. The 0.1% chlorines were the most effective products. Cleaning procedures with two or three products had average cleaning efficacies of 99.94–99.99%. Efficacy increased with the number of successive cleanings. When two products were used, the average cleaning efficacy varied between 99.78% and 99.98%, depending on the surface.

Conclusion

All cleaning products tested reduced cyclophosphamide contamination by more than 96.58%. Cleaning efficacy increased with successive cleaning. No scenario was effective in removing 100% of traces. Additional studies with larger samples should be conducted to confirm these results.

Evaluating Antineoplastic Agents and Occupational Exposures Among Italian Workers Using SIREP Surveillance System

OBJECTIVE

The aim of the study is to evaluate exposures to antineoplastic agents at workplaces in healthcare and manufacturing in Italy.

METHODS

Data on antineoplastic agents were collected from occupational exposure registries. Statistical analysis was carried out for exposure-related variables. The number of workers potentially exposed was estimated for selected industrial sectors. Concurrent exposures were investigated using cluster analysis.

RESULTS

Overall 15,763 exposure situations were analyzed during 1996 to 2016. Most exposures occurred in healthcare (66%). A total of 11,830 workers potentially exposed to antineoplastic agents was estimated. Concurrent exposures were frequently detected in the pharmaceutical industry and among healthcare workers.

CONCLUSIONS

Occupational exposure to antineoplastic agents currently represents a matter of concern both in the chemical industry and in the healthcare sector. The growing number of agents in use supports the need to constantly control exposures.

Evaluation of a safe handling and cytotoxic drug preparation training program for oncology pharmacy practitioners

BACKGROUND

Onkofar Health Devices Inc. offers solutions and service for safe and accurate preparation of anticancer agents. Due to the necessity of specific instructions for the drug preparation systems and the widespread use of services including personnel, the company has to train the personnel employed as oncology pharmacy practitioner technicians.

PURPOSE

This study aimed to investigate the contribution of the training program to the theoretical knowledge and the opinions of the participants about the training by retrospectively analyzing the related data.

METHODS

The training program consisted of a comprehensive theoretical part and an applied practical part. Participants took pre-tests and post-tests and filled out a standard training evaluation form. Between November 2014 and September 2018, 100 people participated in the training. This study included 71 participants' pre-test and post-test results and 72 participants' evaluation forms.

RESULTS

The test results showed that the post-test score was higher in all participants. There was a 34% increase between the average of scores. The improvement percentage was at least 9%, whereas the most considerable improvement was 61%. Overall, almost all of the participants conveyed their positive thoughts about the training. The participants' interest seemed to be mostly related to their applied practice.

CONCLUSIONS

Increased post-test scores showed an increase in theoretical knowledge level. The training was found to meet the expectations and needs to a great extent. Participants' opinions contributed to the shaping of the educational content for future training programs. This study showed that the training program provided improvement and value for participants.

Korean nurses' adherence to safety guidelines for chemotherapy administration

PURPOSE

Nurses are at risk from handling chemotherapeutic agents. This study aimed to determine adherence to safety guidelines for chemotherapy administration by Korean nurses and to examine the relationship between the hospital safety climate and nurses' adherence to safety guidelines.

METHOD

A descriptive, correlational design with a cross-sectional survey using data from the Korea Nurses' Health Study. For this study, participants included 872 female nurses who had administered chemotherapeutic agents to patients in the last 30 days.

RESULTS

Only a quarter of the participants had high adherence to the safety guidelines, while the majority had moderate to low adherence. The absence of job hindrances and feedback/training - two sub-factors of the hospital safety climate - enhanced the likeliness for nurses to comply with the safety guidelines by almost 1.3 and 1.7 times, respectively.

CONCLUSION

The results imply that the hospital safety climate, particularly feedback/training, and the absence of job hindrances are significantly correlated with adherence to the safety guidelines for chemotherapy administration. Therefore, organisational and policy support is needed to improve the hospital safety climate.

Validation of cleaning procedures used in an Italian Hospital Pharmacy for antineoplastic drug decontamination: a new tool for industrial hygiene

BACKGROUND

Current Italian regulations and procedures for surface decontamination of antineoplastic drugs (ADs) are not clear. Therefore, most hospital pharmacies follow internal procedures as an interpretation of the recommended handling guidelines.

OBJECTIVES

Our study compared 7 different cleaning procedures after controlled contamination of the work surface of a biological safety cabinet workbench in an Italian hospital oncology pharmacy (HOP) to determine which of them is more efficient and practical. Moreover, in order to approximate operative routine and improve risk awareness, cleaning procedures were carried out by the personnel that usually operate in the HOP.

METHODS

Measured quantities, i.e. a drop (100 μL) of 5-FluoroUracil, IPhosfamide, CycloPhosphamide and Gemcitabine, were deposited on the work surface within precisely delimited areas. Following the wipe-test analysis using UPLC-MS/MS, the cleaning efficacy was calculated based on the ratio of the residual concentration of the AD, after the cleaning procedure, to the concentration of each AD before the procedure.

RESULTS

Tested cleaning procedures were: 1) Hypo-Chlor®, hot water and Farmecol70®; 2) Hypo-Chlor® and hot water; 3) Farmecol70®; 4) Surfa'Safe SH® and hot water; 5) Amuchina® 10%, hot water and Farmecol70®; 6) Incidin® Oxyfoam and hot water; 7) liquid Marseille soap, hot water and Farmecol70®. Within the studied HOP, the Marseille soap was evaluated to be the optimal choice due to its efficacy, low cost, and the very short contact time needed before rinsing.

DISCUSSION

The application of the protocol for procedure validation suggested here could be used in every HOP as a reliable industrial hygiene tool to demonstrate the validity of the chosen cleaning procedure.

Efficiency of degradation or desorption methods in antineoplastic drug decontamination: A critical review

Although considerable efforts have been made over the last 40 years, occupational exposure to antineoplastic drugs is still a daily concern, since eradicating such contamination from workplaces seems unattainable. Considerable data are currently available on the risks associated with their use at work. Hospital facilities are often cleaned with marketed antimicrobials whose chemical decontamination efficacy certainly differs but remains unknown. To keep compounding facilities sterile, alcohol-based solutions are frequently used but with very limited efficiency. It would be particularly useful if a decontamination method could be added to the means already available so that all conventional antineoplastic drug contamination could be removed. Several degradation methods or desorption methods have previously been experimented, with varying success. They have never been compared or discussed in terms either of efficiency or usability. This review aims to analyse and discuss the results of each degradation or decontamination procedure and to compare them. This should facilitate selection of the method to be implemented in daily practice.

Efficacy of four cleaning solutions for the decontamination of selected cytotoxic drugs on the different surfaces of an automated compounding system

The automated aseptic preparation of ready-to-administer antineoplastic drug solutions with robotic systems reduces the risk of occupational exposure. However, the surfaces in the preparation area of the robot are to be cleaned by wiping with an appropriate cleaning solution. The aim of the study was to evaluate the cleaning efficacy of four cleaning solutions on four surface materials installed in the APOTECAchemo robot. Predefined amounts of cisplatin (Cis), 5-fluorouracil (5-FU), and cyclophosphamide (CP) were intentionally spread on test plates made of stainless steel, aluminium, polyoxymethylene, and polycarbonate just as installed in the robotic system APOTECAchemo. After drying, the plates were cleaned with 0.2% ethanolic NaOH, 0.23% isopropanolic sodium dodecylsulfate (SDS-2P), 0.5% sodium hypochlorite (NaOCl), and 0.1% benzalkonium chloride (BZK) solutions following a standardized wiping protocol. Residual contamination was recovered with wipe tests, Pt was quantified by voltammetry, and 5-FU and CP was quantified by gas chromatography-tandem mass spectrometry (GC-MSMS). The mean residual contamination after cleaning and the cleaning efficacy (CE) rates were calculated and aggregated on different levels. The CE rates varied between 81.5% and 100% and lay in the majority of cases above 90%. The lowest CE rates were registered for Pt contamination. Especially on aluminium surfaces the residual contamination was high. The overall CE rates of the three different drugs and four different surface types amounted to 98.3% for NaOCl, 97.9% for SDS-2P, 96.9% for ethanolic NaOH, and 96.5% for BZK. The tested cleaning solutions proved to be higher than 90% in most cases, but none of them was able to eliminate 100% of the intentional surface contamination of three antineoplastic drugs on the test plates. The cleaning efficacy varied according to the different surface types and antineoplastic drug. Results could be used in the daily clinical practice to develop and implement effective cleaning procedures.

A new, sensitive and versatile assay for quantitative determination of α-fluoro-β-alanine (AFBA) in human urine by using the reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) system

A method for the quantitation of α-fluoro-β-alanine (AFBA), the main metabolite of capecitabine (Cape) and 5-fluoruracil (5-FU), is described. Among antineoplastic drugs (ADs), 5-FU and Cape (the new oral prodrug) are the most commonly applied drugs in cancer therapy. The main objective of this study was to develop a reliable method that would be easy to run on a reversed-phase UHPLC system coupled to tandem mass spectrometry. AFBA was derivatized with Sanger's reagent to ensure complete yield of a stable 2,4 dinitrophenil-α-fluoro-β-alanine derivative. This method was based on the use of a mixed-mode anion exchange solid phase extraction enabling urinary extracts to be clear of endogenous interferences affecting quantitative results. The assay was validated in human urine according to FDA criteria with the use of a labeled internal standard (β-alanine-d4) to minimize experimental error. Good accuracy and precision were demonstrated by determining spiked urine QC samples in four consecutive days. The recovery of AFBA was between 70.0 and 82.6%, with a matrix effect that was 12.8%-18.5%. The lower limit of quantitation (LOQ) was 0.5 ng/mL with a coefficient of variation of 5.3%. This assay was successfully applied to determine the levels of this metabolite in a large number of urine samples taken from personnel who were occupationally exposed to ADs.

Medical Surveillance Programs for Workers Exposed to Hazardous Medications: A Survey of Current Practices in Health Care Institutions

OBJECTIVE

To assess current medical surveillance monitoring practices for health care workers who prepare, handle, or administer hazardous medications.

METHODS

A cross-sectional survey was distributed to members of the American College of Occupational and Environmental Medicine and the National Comprehensive Cancer Network.

RESULTS

Forty-six of the 91 survey respondents indicated that their institution had a hazardous medication surveillance program. We identified the most frequent laboratory (complete blood count) and physical (skin) examination components. A health history was frequently used. Statistical analysis did not suggest an association between institutions with greater resources and presence of a surveillance program.

CONCLUSIONS

A consensus standard for medical monitoring was not reported by the respondents. We recommend using a standardized surveillance questionnaire and applying uniform laboratory testing across institutions, in addition to establishing a national repository for surveillance data.

Occupational exposure to cytotoxic drugs: the importance of surface cleaning to prevent or minimise exposure

Healthcare workers who prepare or administer cytotoxic agents run the risk of exposure, and the risks for health are real even at doses lower than those applied in cancer patients, because, in theory, no dose is safe. The most common and problematic route of exposure is through the skin, especially as work surfaces can remain contaminated even after cleaning. This pilot study aimed to demonstrate the importance of having an effective surface decontamination protocol by determining surface contamination with cyclophosphamide, 5-fluorouracil, and paclitaxel as the most common cytotoxic drugs in an oncology day service. Samples were collected before and after drug handling and analysed with high performance liquid chromatography with diode array detection (HPLC-DAD). Of the 29 samples collected before drug handling 23 were contaminated, five of which with more than one drug. Of the 30 samples collected after drug handling 25 were contaminated, eight of which with more than one drug. The two time points did not significantly differ, which evidences a widespread contamination and ineffective cleaning. This calls for revising the cleaning protocol and handling procedure to place contamination under control as much as possible.

A decontamination process adding a tensioactive agent and isopropanol to a closed-system drug transfer device for better control of isolator contamination. A prospective, parallel study

Background

Despite the use of closed system drug transfer devices (CSTD), residual contamination from antineoplastic drugs is still detected inside isolators. The aim of this study was to compare the decontamination level obtained using a CSTD + standard cleaning procedure with a CSTD + standard cleaning procedure + specific decontamination procedure.

Methods and findings

A comparative and prospective study was carried out in a newly opened compounding unit. Compounding was performed with a CSTD (BD-Phaseal, Becton-Dickinson). In the Control isolator (C), the cleaning process was completed daily with a standard biocide solution (Anioxyspray^TM, Anios, France). In the Intervention isolator (I), weekly decontamination with a homemade admixture of sodium dodecyl sulfate 10⁻² M/70% isopropanol (80/20, v/v) was added. Monitoring was performed via a validated LC-MS/MS method. Eight drugs (cyclophosphamide, cytarabine, dacarbazine, fluorouracile, gemcitabine, ifosfamide, irinotecan and methotrexate) were monitored daily over 14 consecutive weeks on three sites inside the isolators: gloves, workbench and window. Results are presented as the odds-ratio (OR) of contamination and as overall decontamination efficiency (Eff_Q, %). The proportion of Eff_Q ≥ 90% was assessed by a Fisher’s exact test (p<0.05). Overall contamination rates (CR, %) were significantly different from one isolator to the other (CR_C = 25.3% vs. CR_I = 10.4%; OR = 0.341; p<0.0001). Overall Eff_Q values (median; 1^st and 3^rd quartiles) were higher in the intervention isolator (I: 78.3% [34.6%;92.6%] vs. C: 59.5% [-5.5%;72.6%]; p = 0.0015) as well as the proportion of days with an Eff_Q ≥ 90% (I: 42.9% vs. C: 7.1%; p = 0.077) but very variable depending on drugs.

Conclusion

Adding a decontamination protocol with a tensioactive agent to a CSTD leads to better control of chemical contamination inside isolators. Improving decontamination by increasing decontamination frequency or modifying the protocol will be further studied.

Monitoring Surface Contamination by Antineoplastic Drugs in Italian Hospitals: Performance-Based Hygienic Guidance Values (HGVs) Project

Antineoplastic drugs (ADs) will continue to represent a potential risk for personnel involved in the handling of these compounds and great concerns have been raised by the presence of ADs in many surveyed workplaces. Eight hospitals were investigated by means of wipe sampling for surface residue determination. Each wipe sample was tested for five ADs considered suitable exposure markers. Cyclophosphamide (CP), gemcitabine (GEM), 5-fluorouracil (5-FU), platinum-containing drugs (Pt), and epi-doxorubicin (EPI) contamination levels were measured in 85 per cent of the studied pharmacies and 93 per cent of outpatient care units (OpCUs). This study showed that 83 out of 349 samples were positive in Pharmacies, this proportion being statistically significant (χ2 = 42.9, p < 0.001). The positive samples provided evidence of at least one substance with levels greater than the limit of detection (LOD). The two most frequently detected substances were Pt (42%) and CP (30%). These accounted for 72 per cent of the whole dataset, followed by 5-FU and GEM. Based on the 90th percentile of wipe sampling data distribution, we suggest hygienic guidance values (HGVs) of 3.6, 1.0, 0.9, and 0.5 ng cm-2 for CP, 5-FU, GEM and Pt, respectively, as the best target levels of the surface contamination load in Italian pharmacies. The approach of proposing guidance values at the 90th percentile of results obtained from workplaces with good hygiene practice was found to be a simple and practical way of controlling occupational exposure. HGVs were challenged in this study as technical threshold limits to benchmark AD residual surface contamination at workplaces.

Environmental and Product Contamination during the Preparation of Antineoplastic Drugs with Robotic Systems

Background

Robotic systems are designed to minimize the exposure to antineoplastic drugs during automated preparation. However, contamination cannot be completely excluded. The aim of the study was to evaluate the contamination with antineoplastic drugs on the working surfaces and on the outer surface of the ready-to-use products (infusion bags and syringes) during automated preparation with different versions of a robot and manual preparation.

Methods

Surface contamination with platinum (Pt) and 5-fluorouracil (5-FU) was measured by wipe sampling and quantified by voltammetry for Pt and GC-MS for 5-FU. Sampling was performed on pre-defined locations in the working areas before and after preparation of standardized test products. The outer surfaces of Pt- or 5-FU-containing infusion bags and 5-FU-containing syringes were sampled without and after manual capping.

Results

Overall, the surface contamination in the working areas of the robotic system ranged from 0.4 to 114 pg/cm2 for Pt and from 1.3 to 1,250,000 pg/cm2 for 5-FU. The highest contamination levels were detected after preparation on the gripper of the robotic arm and on the surface beneath the dosing device. In most cases, measured concentrations were higher after preparation. Outer surfaces of infusion bags prepared with the robotic system were less contaminated than manually prepared bags. Contamination on the outer surface of syringes varied depending on the procedure adopted.

Conclusions

The risk of contamination is localised inside the working area of the robot. The outer surfaces of products were only marginally contaminated. Cleaning procedures of the working area are to be further investigated. An effective decontamination procedure for the working area of the robot and automated capping of filled syringes should be developed to further minimize the occupational risk.

Occupational exposure to cisplatin/oxaliplatin during Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)?

INTRODUCTION

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a new promising treatment for patients with peritoneal carcinomatosis. It is supposed to provide a higher local drug concentration and deeper penetrate into the tumor tissue compared to systemic chemotherapy or hyperthermic intraperitoneal chemotherapy perfusion (HIPEC). Due to the application of cytotoxic drug aerosols within the operating room (OR), concern has been raised regarding the occupational exposure risk of the involved OR staff.

MATERIALS AND METHODS

In this study, an OR workplace monitoring was performed during 14 PIPAC procedures in two hospitals by collecting air samples (n = 14) during PIPAC and wipe samples (n = 223) before and after PIPAC: 56 samples from the OR floor, 84 from the injector, 28 from trocars and 55 from gloves. All samples were analyzed for platinum (Pt).

RESULTS

While air Pt concentrations were below 3.1 pg/m³, surface contaminations widely varied between 0.01 pg/cm² and 1733 pg/cm² (median 1.04 pg/cm²), with substantial Pt concentrations on injector parts (i.e. syringe holder) and trocars. Floors and particularly injectors were often higher contaminated before compared to after PIPAC, probably due to inefficient cleaning or cross-contamination. Glove samples taken after different tasks ranged between 0.04 and 423 pg/cm² (median 0.58 pg/cm²).

CONCLUSION

Contamination on various OR surfaces widely ranged and can lead to a distribution of cytotoxic drug residues. However, the air contamination was very low. The results indicate that PIPAC performance seems to be possible with low occupational exposure risk, but adequate safety and cleaning standards for PIPAC must be developed and monitored.

Surface contamination with ten antineoplastic drugs in 83 Canadian centers

PURPOSE

The aim of this study was to monitor environmental contamination by 10 antineoplastic drugs in Canadian oncology pharmacy and patient care areas. The secondary objective was to explore the impact of factors that may explain contamination.

METHODS

Twelve standardized sites were sampled in each center (six in the pharmacy and six in patient care areas). Each sample was prepared to allow quantification of seven antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, cytarabine, gemcitabine, 5-fluorouracil, irinotecan) by UPLC-MS-MS. Docetaxel, paclitaxel and vinorelbine were also detected, but not quantified due to sensibility limitations. The impact of some factors was evaluated compared with a Kolmogorov-Smirnov test for independent samples.

RESULTS

Eighty-three Canadian centers were recruited in 2017. A total of 953 surfaces were sampled, 495 in pharmacy and 458 in patient care areas. Cyclophosphamide was most often found on surfaces (36% of samples positive, 75th percentile 0.0040 ng/cm²). The arm rest (81.7% of samples positive for at least one antineoplastic drug), the front grille inside the hood (78.3%) and the floor in front of the hood (61.4%) were more frequently contaminated. Centers who prepared more antineoplastic drugs per year had higher concentration on different surfaces ( p < 0.0001).

CONCLUSION

Despite growing awareness and implementation of new safe handling guidelines, healthcare centers' surfaces remain contaminated with traces of many antineoplastic drugs. The use of personal protective equipment remains indisputable. Performing an annual monitoring remains a good indicator to monitor trends over time and to compare with similar centers.

Closed-system drug-transfer devices plus safe handling of hazardous drugs versus safe handling alone for reducing exposure to infusional hazardous drugs in healthcare staff

BACKGROUND

Occupational exposure to hazardous drugs can decrease fertility and result in miscarriages, stillbirths, and cancers in healthcare staff. Several recommended practices aim to reduce this exposure, including protective clothing, gloves, and biological safety cabinets ('safe handling'). There is significant uncertainty as to whether using closed-system drug-transfer devices (CSTD) in addition to safe handling decreases the contamination and risk of staff exposure to infusional hazardous drugs compared to safe handling alone.

OBJECTIVES

To assess the effects of closed-system drug-transfer of infusional hazardous drugs plus safe handling versus safe handling alone for reducing staff exposure to infusional hazardous drugs and risk of staff contamination.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, OSH-UPDATE, CINAHL, Science Citation Index Expanded, economic evaluation databases, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to October 2017.

SELECTION CRITERIA

We included comparative studies of any study design (irrespective of language, blinding, or publication status) that compared CSTD plus safe handling versus safe handling alone for infusional hazardous drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models. We assessed risk of bias according to the risk of bias in non-randomised studies of interventions (ROBINS-I) tool, used an intracluster correlation coefficient of 0.10, and we assessed the quality of the evidence using GRADE.

MAIN RESULTS

We included 23 observational cluster studies (358 hospitals) in this review. We did not find any randomised controlled trials or formal economic evaluations. In 21 studies, the people who used the intervention (CSTD plus safe handling) and control (safe handling alone) were pharmacists or pharmacy technicians; in the other two studies, the people who used the intervention and control were nurses, pharmacists, or pharmacy technicians. The CSTD used in the studies were PhaSeal (13 studies), Tevadaptor (1 study), SpikeSwan (1 study), PhaSeal and Tevadaptor (1 study), varied (5 studies), and not stated (2 studies). The studies' descriptions of the control groups were varied. Twenty-one studies provide data on one or more outcomes for this systematic review. All the studies are at serious risk of bias. The quality of evidence is very low for all the outcomes.There is no evidence of differences in the proportion of people with positive urine tests for exposure between the CSTD and control groups for cyclophosphamide alone (RR 0.83, 95% CI 0.46 to 1.52; I² = 12%; 2 studies; 2 hospitals; 20 participants; CSTD: 76.1% versus control: 91.7%); cyclophosphamide or ifosfamide (RR 0.09, 95% CI 0.00 to 2.79; 1 study; 1 hospital; 14 participants; CSTD: 6.4% versus control: 71.4%); and cyclophosphamide, ifosfamide, or gemcitabine (RR not estimable; 1 study; 1 hospital; 36 participants; 0% in both groups).There is no evidence of a difference in the proportion of surface samples contaminated in the pharmacy areas or patient-care areas for any of the drugs except 5-fluorouracil, which was lower in the CSTD group than in the control (RR 0.65, 95% CI 0.43 to 0.97; 3 studies, 106 hospitals, 1008 samples; CSTD: 9% versus control: 13.9%).The amount of cyclophosphamide was lower in pharmacy areas in the CSTD group than in the control group (MD -49.34 pg/cm², 95% CI -84.11 to -14.56, I² = 0%, 7 studies; 282 hospitals, 1793 surface samples). Additionally, one interrupted time-series study (3 hospitals; 342 samples) demonstrated a change in the slope between pre-CSTD and CSTD (3.9439 pg/cm², 95% CI 1.2303 to 6.6576; P = 0.010), but not between CSTD and post-CSTD withdrawal (-1.9331 pg/cm², 95% CI -5.1260 to 1.2598; P = 0.20). There is no evidence of difference in the amount of the other drugs between CSTD and control groups in the pharmacy areas or patient-care areas.None of the studies report on atmospheric contamination, blood tests, or other measures of exposure to infusional hazardous drugs such as urine mutagenicity, chromosomal aberrations, sister chromatid exchanges, or micronuclei induction.None of the studies report short-term health benefits such as reduction in skin rashes, medium-term reproductive health benefits such as fertility and parity, or long-term health benefits related to the development of any type of cancer or adverse events.Five studies (six hospitals) report the potential cost savings through the use of CSTD. The studies used different methods of calculating the costs, and the results were not reported in a format that could be pooled via meta-analysis. There is significant variability between the studies in terms of whether CSTD resulted in cost savings (the point estimates of the average potential cost savings ranged from (2017) USD -642,656 to (2017) USD 221,818).

AUTHORS' CONCLUSIONS

There is currently no evidence to support or refute the routine use of closed-system drug transfer devices in addition to safe handling of infusional hazardous drugs, as there is no evidence of differences in exposure or financial benefits between CSTD plus safe handling versus safe handling alone (very low-quality evidence). None of the studies report health benefits.Well-designed multicentre randomised controlled trials may be feasible depending upon the proportion of people with exposure. The next best study design is interrupted time-series. This design is likely to provide a better estimate than uncontrolled before-after studies or cross-sectional studies. Future studies may involve other alternate ways of reducing exposure in addition to safe handling as one intervention group in a multi-arm parallel design or factorial design trial. Future studies should have designs that decrease the risk of bias and enable measurement of direct health benefits in addition to exposure. Studies using exposure should be tested for a relevant selection of hazardous drugs used in the hospital to provide an estimate of the exposure and health benefits of using CSTD. Steps should be undertaken to ensure that there are no other differences between CSTD and control groups, so that one can obtain a reasonable estimate of the health benefits of using CSTD.

A UHPLC-MS/MS-based method for the simultaneous monitoring of eight antiblastic drugs in plasma and urine of exposed healthcare workers

Exposure of healthcare workers to anticancer drugs requires the combined action of environmental and biological monitoring to assess the effective level of exposure to these chemicals, to improve awareness and to avoid adverse health effects on this category of workers. Cancer chemotherapeutic drugs show different mechanisms of action due to diverse chemical structures; consequently, they differ in hydrophobicity, pharmacokinetics and pharmacodynamics. Therefore, the appearance, accumulation and elimination of each of these molecules in body fluids and tissues might be extremely variable; this prompts the need for a rapid and versatile analytical protocol for the biological monitoring of possible exposure of workers involved in the manipulation, administration and disposal of cancer chemotherapeutic drugs. In this paper we describe the development, optimization and validation of a UHPLC-MS/MS method for the simultaneous quasi-quantitative analysis of eight widely used antineoplastic drugs, which can be used for the analysis of both urine and blood samples. This methodology was applied to the biological monitoring of healthcare workers exposed to different extents to antiblastic drugs at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy), and allowed to identify two subjects exposed to irinotecan out of a total of fifteen workers analyzed.

Pre and post intervention study of antiblastic drugs contamination surface levels at a Pharmacy Department Compounding Area using a closed system drug transfer device and a decontamination process

Assuring healthcare workers security on Hazardous Drugs (HD) compounding is critical in healthcare settings. Our study aims to demonstrate that the use of a Close System drug Transfer Device (CSTD) PhaSeal™ added to a decontamination process reduces antiblastic surface contamination levels in the Compounding Area (CA) of our Pharmacy Department (PD). We selected cyclophosphamide, 5-fluorouracil and iphosphamide to be evaluated. Testing was carried out with a wipe kit and quantified by an independent laboratory. We defined four sampling times: baseline; just after a decontamination procedure, which was repeated weekly during the study; four months after introduction of CSTD PhaSeal™ for cyclophosphamide and 5-fluorouracil compounding; and after eight months using CSTD PhaSeal™ for cyclophosphamide and 5-fluorouracil and one month for iphosphamide compounding. There was a decrease at the number of positive samples at the beginning/end of the study for all the drugs tested: 28/15 for cyclophosphide, 29/23 for iphosphamide and 7/1 for 5-fluorouracile. Comparing to the baseline, median cyclophosphamide levels significantly decreased (p-value <0.001) at 4 and 8 months sampling time (baseline: 1.01 ng/cm² to 0.06 ng/cm² and 0.01 ng/cm²), and median iphosphamide levels significantly decreased (p < 0.001) at 8 months sampling time (baseline: 3.02 ng/cm² to 0.06 ng/cm²). 5-Fluorouracil did not show significant differences between the sampling times (baseline: 0.09 ng/cm² to 0.09 ng/cm²). We saw a significant increase at iphosphamide levels at 4 months sampling point, contrary to cyclophosphamide, which levels had decreased. The use of CSTD PhaSeal™ for iphosphamide compounding the last month was implemented for ethical reasons after this intermediate results review. Our study suggests that the use of CSTD PhaSeal™, adding to decontaminating procedures, significantly reduces antiblastic drug surface levels at the CA of our PD.

Genotoxicity assessment of a selected cytostatic drug mixture in human lymphocytes: A study based on concentrations relevant for occupational exposure

Cytostatic drugs are highly cytotoxic agents used in cancer treatment and although their benefit is unquestionable, they have been recognized as hazardous to healthcare professionals in occupational settings. In a working environment, simultaneous exposure to cytostatics may occur creating a higher risk than that of a single substance. Hence, the present study evaluated the combined cyto/genotoxicity of a mixture of selected cytostatics with different mechanisms of action (MoA; 5-fluorouracil, cyclophosphamide and paclitaxel) towards human lymphocytes in vitro at a concentration range relevant for occupational as well as environmental exposure. The results suggest that the selected cytostatic drug mixture is potentially cyto/genotoxic and that it can induce cell and genome damage even at low concentrations. This indicates not only that such mixture may pose a risk to cell and genome integrity, but also that single compound toxicity data are not sufficient for the prediction of toxicity in a complex working environment. The presence of drugs in different amounts and with different MoA suggests the need to study the relationship between the presence of genotoxic components in the mixture and the resulting effects, taking into account the MoA of each component by itself. Therefore, this study provides new data sets necessary for scientifically-based risk assessments of cytostatic drug mixtures in occupational as well as environmental settings.

Biomonitoring of occupational exposure to 5-FU by assaying α-fluoro-β-alanine in urine with a highly sensitive UHPLC-MS/MS method

5-Fluorouracil (5-FU) is one of the most widely antineoplastic drugs handled by healthcare professionals.

Biological Monitoring of Healthcare Workers Exposed to Antineoplastic Drugs: Urinary Assessment of Cyclophosphamide and Ifosfamide

Exposure of health care workers to antineoplastic drugs and subsequent adverse health effects is still an open issue. Very little has been studied on the extent of occupational exposure and handling conditions of antineoplastic drugs in Iran. We aimed to determine cyclophosphamide and ifosfamide concentrations in the urine samples of oncology healthcare workers. In addition, we assessed workplace safety controls that are important to decrease occupational exposure. Urinary samples of subject and control groups were collected to measure pre and post-shift cyclophosphamide and ifosfamide concentrations. Prior to sample collection, an occupational toxicologist observed and recorded working safety conditions for the healthcare workers during an eight-week period. Heath care workers were also asked about occurrence of acute adverse health effects. A total number of 425 chemotherapeutic drugs (389.83 g) were prepared during the study. Cyclophosphamide was detected in five pre-shift and nine post-shift urine samples. One pre-shift and four post-shift urine samples were positive for Ifosfamide. The urine samples of control group had no detectable concentrations of cyclophosphamide and ifosfamide. Personal protective equipment usage was not adequate for handling activities. Some adverse health effects reported by oncology personnel confirmed exposure to antineoplastic drugs. High percentage of oncology personnel was exposed to antineoplastic drugs that could be related to the large amount of drug preparations and inadequate safety controls. We recommend training of oncology personnel, implementation of safety controls, and periodic surveillance in order to minimize workplace contamination and occupational exposure to antineoplastic drugs.

PVP capped silver nanocubes assisted removal of glyphosate from water-A photoluminescence study

Glyphosate [N-phosphono-methylglycine (PMG)] is the most used herbicide worldwide and it has been reported very recently that Glyphosate is very harmful and can produce lots of diseases such as alzheimer and parkinson's disease, depression, cancer, infertility including genotoxic effects. As it is mostly present in stable water body and ground water system, its detection and removal is very important. Here, we have shown a fluorescence technique for the removal of glyphosate from water using chemically synthesized polyvinylpyrrolidone (PVP) silver nanocrystals. Transmission Electron Microscopy (TEM) study shows the average size of silver nanocrystals of 100nm approximately with a morphology of cubic shape. Glyphosate does not show absorption in the visible region. But both glyphosate and silver nanocrystals show strong fluorescence in the visible region. So, photoluminescence study has been successfully utilized to detect the glyphosate in water samples and on treating the glyphosate contaminated water sample with silver nanocrystals, the sample shows no emission peak of glyphosate at 458nm. Thus, this approach is a promising and very rapid method for the detection and removal of glyphosate from water samples on treatment with silver nanocubes. NMR spectra further confirms that the silver nanocrystals treated contaminated water samples are glyphosate free.

Survey of guidelines and current practices for safe handling of antineoplastic and other hazardous drugs used in 24 countries

PURPOSE

A survey of guidelines and current practices was conducted to examine the safe handling procedures for antineoplastic and other hazardous drugs that are used in 24 countries including the Americas, Europe, the Mideast, Far East, and Australia.

METHODS

Subject experts were asked to complete a brief survey regarding safe handling guidelines and practices for hazardous drugs in their countries. Questions addressed practices for handling monoclonal antibodies, the use of closed-system transfer devices, medical surveillance practices, and measurements of compliance with existing guidelines.

RESULTS

Responses from 37 subject experts representing 24 countries revealed considerable variation in the content and scope of safe handling guidelines and pharmacy practices among the participating countries. Guidelines in the majority of countries used the term "cytotoxics," while others referred to "hazardous" or "antineoplastic" drugs. The International Society of Oncology Pharmacy Practice standard was cited by six countries, and five cited the National Institute for Occupational Safety and Health Alert. Others cited international guidelines other than International Society of Oncology Pharmacy Practice, or they have created their own guidelines. Approximately half reported that their guidelines were mandatory under federal, state, or provincial legislation. Only 11 countries reported that monoclonal antibodies were covered in their guidelines. Closed-system drug-transfer devices are widely used, but were not specifically recommended in four countries, while one country required their use. Medical surveillance programs are in place in 20 countries, but only in The Netherlands is surveillance mandatory. Nine countries reported that they have completed recent updates or revisions of guidelines, and the measures for their adoption have been initiated.

CONCLUSIONS

Although the overall goals in the participating countries were similar, the approaches taken to assure safe handling of hazardous drugs varied considerably in some cases.

Meta-analysis of chromosomal aberrations as a biomarker of exposure in healthcare workers occupationally exposed to antineoplastic drugs

Many antineoplastic drugs used to treat cancer, particularly alkylating agents and topoisomerase inhibitors, are known to induce genetic damage in patients. Elevated levels of chromosomal aberrations, micronuclei, and DNA damage have been documented in cancer patients. Elevations in these same biomarkers of genetic damage have been reported in numerous studies of healthcare workers, such as nurses and pharmacists, who routinely handle these drugs, but results vary across studies. To obtain an overall assessment of the exposure effect, we performed a meta-analysis on data obtained from peer-reviewed publications reporting chromosomal aberration levels in healthcare workers exposed to antineoplastic drugs. A literature search identified 39 studies reporting on occupational exposure to antineoplastic drugs and measurement of chromosomal aberrations in healthcare workers. After applying strict inclusion criteria for data quality and presentation, data from 17 studies included in 16 publications underwent meta-analysis using Hedges' bias-corrected g and a random-effects model. Results showed the level of chromosomal aberrations in healthcare workers exposed to antineoplastic drugs was significantly higher than in controls. The standardized mean differences (difference of means divided by within sd) from all studies were pooled, yielding a value 1.006 (unitless) with p<0.001. Thus, in addition to the documented genotoxic effects of antineoplastic drugs in cancer patients, this meta-analysis confirmed a significant association between occupational exposure to antineoplastics during the course of a normal work day and increases in chromosomal aberrations in healthcare workers. Based on the studies reviewed, we were unable to accurately assess whether appropriate use of protective measures might reduce the incidence of genetic damage in healthcare workers. However, given the potential for increased cancer risk linked to increases in chromosomal aberrations, the results of this study support the need to limit occupational exposure of healthcare workers to antineoplastic drugs as much as possible.

Multicenter study of environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in 66 Canadian hospitals: A 2016 follow-up study

PURPOSE

Oncology workers are occupationally exposed to antineoplastic drugs. This exposure can induce adverse health effects. To reduce their exposure, contamination on surfaces should be kept as low as possible. The main objective of this study was to monitor environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in oncology pharmacy and patient care areas in Canadian centers. The secondary objective was to describe the impact of some factors that may limit contamination.

METHODS

This is a descriptive study. Twelve standardized sites were sampled in each participating center (six in the pharmacy and six in patient care areas). Samples were analyzed for the presence of cyclophosphamide, ifosfamide, and methotrexate by ultra-performance liquid chromatography-tandem mass spectrometry technology. Descriptive statistical analyses were done and results were compared with a Kolmogorov-Smirnov test for independent samples.

RESULTS

In 2016, 66 centers participated in this study (66/202, 32.7%). Overall, 43.4% (326/752) of the samples were positive for cyclophosphamide, 13.2% (99/752) for ifosfamide and 6.9% (52/752) for methotrexate. The 75th percentile value of cyclophosphamide surface concentration was 6.8 pg/cm² and lower than the limit of detection for ifosfamide and methotrexate. Centers who prepared more antineoplastic drugs per year (p < 0.0001), who used more cyclophosphamide per year (p < 0.0001) and who primed antineoplastic IV tubing in patient care unit by nurses (p = 0.004) showed significantly higher surface contamination to cyclophosphamide.

CONCLUSION

Environmental surveillance is one part of a comprehensive approach for minimizing hazardous exposures in healthcare. This study highlights a low level of contamination of three hazardous drugs amongst 66 Canadian centers. Regular environmental monitoring is a good practice to maintain contamination as low as reasonably achievable.

Estimating National-Level Exposure to Antineoplastic Agents in the Workplace: CAREX Canada Findings and Future Research Needs

OBJECTIVES

Occupational exposure to antineoplastic agents occurs in various environments and is associated with increased cancer risk and adverse reproductive outcomes. National-level information describing the location and extent of occupational exposure to antineoplastic agents is unavailable in Canada and most other countries. CAREX Canada aimed to estimate the prevalence and relative levels of occupational exposures to antineoplastic agents across work setting, occupation, and sex.

METHODS

'Exposure' was defined as any potential for worker contact with antineoplastic agents. Baseline numbers of licensed workers were obtained from their respective professional bodies. For unlicensed workers, Census data or data extrapolated from human resources reports (e.g., staffing ratios) were used. Prevalence was estimated by combining population estimates with exposure proportions from peer-reviewed and grey literature. Exposure levels (classified as low, moderate, and high) by occupation and work setting were estimated qualitatively by combining estimates of contact frequency and exposure control practices.

RESULTS

Approximately 75000 Canadians (0.42% of the total workforce) are estimated as occupationally exposed to antineoplastic agents; over 75% are female. The largest occupational group exposed to antineoplastic agents is community pharmacy workers, with 30200 exposed. By work setting, 39000 workers (52% of all exposed) are located in non-hospital settings; the remaining 48% are exposed in hospitals. The majority (75%) of workers are in the moderate exposure category.

CONCLUSIONS

These estimates of the prevalence and location of occupational exposures to antineoplastic agents could be used to identify high-risk groups, estimate disease burden, and target new research and prevention activities. The limited secondary data available for developing these estimates highlights the need for increased quantitative measurement and documentation of antineoplastic agent contamination and exposure, particularly in work environments where use is emerging.

Effects of organizational safety practices and perceived safety climate on PPE usage, engineering controls, and adverse events involving liquid antineoplastic drugs among nurses

Antineoplastic drugs pose risks to the healthcare workers who handle them. This fact notwithstanding, adherence to safe handling guidelines remains inconsistent and often poor. This study examined the effects of pertinent organizational safety practices and perceived safety climate on the use of personal protective equipment, engineering controls, and adverse events (spill/leak or skin contact) involving liquid antineoplastic drugs. Data for this study came from the 2011 National Institute for Occupational Safety and Health (NIOSH) Health and Safety Practices Survey of Healthcare Workers which included a sample of approximately 1,800 nurses who had administered liquid antineoplastic drugs during the past seven days. Regression modeling was used to examine predictors of personal protective equipment use, engineering controls, and adverse events involving antineoplastic drugs. Approximately 14% of nurses reported experiencing an adverse event while administering antineoplastic drugs during the previous week. Usage of recommended engineering controls and personal protective equipment was quite variable. Usage of both was better in non-profit and government settings, when workers were more familiar with safe handling guidelines, and when perceived management commitment to safety was higher. Usage was poorer in the absence of specific safety handling procedures. The odds of adverse events increased with number of antineoplastic drugs treatments and when antineoplastic drugs were administered more days of the week. The odds of such events were significantly lower when the use of engineering controls and personal protective equipment was greater and when more precautionary measures were in place. Greater levels of management commitment to safety and perceived risk were also related to lower odds of adverse events. These results point to the value of implementing a comprehensive health and safety program that utilizes available hazard controls and effectively communicates and demonstrates the importance of safe handling practices. Such actions also contribute to creating a positive safety climate.

Minimizing Occupational Exposure to Antineoplastic Agents

The inherent toxicity of antineoplastic drugs used for the treatment of cancer makes them harmful to healthy cells as well as to cancer cells. Nurses who prepare and/or administer the agents potentially are exposed to the drugs and their negative effects. Knowledge about these drugs and the precautions aimed at reducing exposure are essential aspects of infusion nursing practice. This article briefly reviews the mechanisms of action of common antineoplastic drugs, the adverse outcomes associated with exposure, the potential for occupational exposure from preparation and administration, and recommended strategies for minimizing occupational exposure.

Why regulatory indifference towards pharmaceutical pollution of the environment could be a missed opportunity in public health protection. a holistic view

The last generation has witnessed bludgeoning of the world's population, a spike in disease burden, and unprecedented levels of pharmaceutical consumption and production. Unfortunately, pharmaceuticals have left their industrial and household confines and leaked into the environment. Pharmaceuticals are now major environmental pollutants, and are ubiquitous in waters and soils. Unlike other environmental contaminants, pharmaceutical pollutants are not yet regulated globally, simply because acute risk assessments show insignificant human health hazard. But the pitfalls of pharmaceutical pollutants extend beyond acute effects to delayed effects from bioaccumulation, amplified effects from drug-drug interactions, exacerbation of drug resistance, and reduction in aquatic and terrestrial food production. Therefore, ignoring pharmaceutical pollutants deprives society of holistic public health protection.