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Bouchfaa M, Vasseur M, Courtin J, Pinturaud M, Beauval N, Allorge D, Odou P, Simon N. Assessment of chemical contamination by cancer drugs during use of the RIVA TM compounding robot: A pilot study. J Oncol Pharm Pract 2024:10781552241276530. [PMID: 39183571 DOI: 10.1177/10781552241276530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Many hospitals are now investing in robotic compounding system for the preparation of cytotoxic agents. The objective of the present study was to describe contamination by cytotoxics inside and outside the RIVATM robot (ARxIUM, Winnipeg, Canada). MATERIAL & METHODS We applied a risk analysis to determine which locations inside and outside the compounding robot should be monitored. Samples were collected by swabbing with a wet swab (using 0.1 mL of sterile water) before the robots was cleaned. Ten cytotoxics compounded with the robot were screened for using LC-MS/MS. We determined the percentage contamination rates inside (CRin) and outside (CRout) the robot and the amounts of each contaminant (in ng/cm²). If a sample was found to be positive, a corrective action was implemented. RESULTS Our risk analysis highlighted 10 locations inside the robot and 7 outside. Ten sampling campaigns (10 samples per campaign) were performed. The mean CRin (40%) was significantly higher than the mean CRout (2%; p < 10-4). Gemcitabine and cyclophosphamide were the main contaminants. After the implementation of corrective measures (such as daily cleaning with SDS/isopropyl alcohol), the CRin fell from 60% to 10%. DISCUSSION/CONCLUSION The frequency of contamination was lower for robotic compounding than for manual compounding in an isolator. However, robotic compounding tended to generated larger mean amounts of contaminant; this was related to incidents such as splashing when syringes were disposed of after the compounding. The implementation of corrective actions effectively reduced the CRs. Further longer-term studies are required to confirm these results.
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Affiliation(s)
- Myriam Bouchfaa
- Institut de Pharmacie, CHU Lille, Lille, France
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Michèle Vasseur
- Institut de Pharmacie, CHU Lille, Lille, France
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | | | - Marine Pinturaud
- Institut de Pharmacie, CHU Lille, Lille, France
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Nicolas Beauval
- Univ. Lille, ULR 4483-IMPECS-IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Delphine Allorge
- Univ. Lille, ULR 4483-IMPECS-IMPact de l'Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Pascal Odou
- Institut de Pharmacie, CHU Lille, Lille, France
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Nicolas Simon
- Institut de Pharmacie, CHU Lille, Lille, France
- Univ. Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
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Cheng J, Yuan M, Zhang S, Xiao Q, Zhou Q, Huang X. Latent class analysis of healthcare workers' knowledge, attitudes, and practice levels, and risk factors regarding associated with occupational exposure to antineoplastic drugs: A multicenter cross-sectional study. Medicine (Baltimore) 2024; 103:e38400. [PMID: 38996165 PMCID: PMC11245233 DOI: 10.1097/md.0000000000038400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/08/2024] [Indexed: 07/14/2024] Open
Abstract
The study investigated the health care workers' knowledge, attitudes, and practice levels regarding occupational protection against antineoplastic drugs (ADs) via analysis of latent classes and their influencing factors. A convenience sampling method was used to select healthcare workers from 7 hospitals in southern China between April and August 2023. A questionnaire based on literature analysis, brainstorming, and Delphi method was used to investigate the knowledge, practice, and attitudes of healthcare workers exposed to ADs for appropriate occupational protection intervention, followed by latent class analysis. The factors influencing latent classes were identified via single-factor analysis and multiple logistic regression. A total of 322 healthcare workers from departments using ADs were surveyed. The knowledge score associated with occupational protection against ADs was 31.95 ± 7.38. The attitude score was 21.08 ± 2.729, while the practice score was 36.54 ± 9.485. The overall score was 89.57 ± 15.497. The healthcare workers were divided into 4 latent classes based on their knowledge, attitude, and practice associated with occupational protection measures against ADs. Healthcare workers in the 4 categories showed significance differences based on professional title, marital status, educational background, and frequency of exposure to ADs (P < .05). The knowledge, attitude, and practice levels of healthcare workers engaged in ADs at work can be divided into 4 latent classes. Despite their increased awareness of the hazards associated with ADs and their attitudes toward protection, the healthcare workers displayed poor knowledge and implementation of occupational protection measures.
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Affiliation(s)
- Jintao Cheng
- Zunyi Medical University, Zunyi, China
- Department of Nursing, Longgang Central Hospital of Shenzhen, Shenzhen, China
| | - Meng Yuan
- Zunyi Medical University, Zunyi, China
| | | | | | - Qian Zhou
- Zunyi Medical University, Zunyi, China
| | - Xiaohong Huang
- Zunyi Medical University, Zunyi, China
- Department of Nursing, Longgang Central Hospital of Shenzhen, Shenzhen, China
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Campos D, Silva I, Rego M, Correia P, Moreira F. Characterization of education, technical practices and attitudes of Portuguese pharmacy technicians towards manipulation of cytotoxic drugs. J Oncol Pharm Pract 2024; 30:893-901. [PMID: 37489259 PMCID: PMC11179318 DOI: 10.1177/10781552231190025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
Pharmacy professionals that manipulate cytotoxic drugs need to undergo educational programs, adopt the most convenient practices, and use appropriate equipment to avoid, as far as possible, occupational exposure to cytotoxic drugs. The main goal of this work is to characterize the education, technical practices, and attitudes towards cytotoxic drugs, of Portuguese pharmacy technicians. A questionnaire comprising eleven questions deemed pertinent was elaborated and subsequently validated by a pilot test. The anonymous, web-based survey was conducted between December 2022 and January 2023, by graduated pharmacy technicians that had manipulated cytotoxic drugs between 2017 and 2022. A total of 77 pharmacy technicians responded to the survey. Although sixty-six pharmacy technicians (86%) had been trained before beginning to manipulate cytotoxic drugs, the promotion of regular post-admission training by the institutions is sparse - only assumed by 53% of the pharmacy technicians (n = 41). All participants reported using gloves and gown during manipulation and the use of double gloves was common (99%; n = 76). Compliances with the recommended limit time for uninterrupted manipulation activity (82%; n = 63) and systematic double-checking (86%; n = 66) were high, but the regular use of sterile gauze around syringe connection sites 58% (n = 45), was less frequent. None of the surveyed pharmacy technicians used closed-system transfer devices (CSTD) and 41 (53%) of those who used spikes did not thoughtfully use these devices. The implementation of regular training programs in manipulating cytotoxic drugs should be fostered, to promote the more judicious use of engineering controls and transversal adoption of the safest technical practices.
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Affiliation(s)
- Daniela Campos
- Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
| | - Inês Silva
- Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
| | - Mariana Rego
- Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
| | - Patrícia Correia
- Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
- Centro de Investigação em Saúde e Ambiente, Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
| | - Fernando Moreira
- Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
- Centro de Investigação em Saúde e Ambiente, Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr António Bernardino de Almeida, Porto, Portugal
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Leeman M, Wetterling M, Kåredal M, Hedmer M. Development and validation of a quantitative wipe sampling method to determine platinum contamination from antineoplastic drugs on surfaces in workplaces at Swedish hospitals. J Oncol Pharm Pract 2024:10781552241259405. [PMID: 38835271 DOI: 10.1177/10781552241259405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Antineoplastic drugs (ADs) are frequently used pharmaceuticals in the healthcare, and healthcare workers can be occupationally exposed to ADs. Monitoring of surface contamination is a common way to assess occupational exposure to ADs. The objective was to develop and validate a sensitive and quantitative monitoring method to determine surface contaminations of Pt as a marker for Pt-containing ADs. The surface contaminations of Pt-containing ADs were monitored at four Swedish hospital workplaces. METHODS An analytical method was developed based on inductively coupled plasma mass spectrometry. The wipe sampling procedure was validated regarding different surface materials. The stability of collected wipe samples was investigated. Workplace surfaces were monitored by wipe sampling to determine contaminations of Pt-containing ADs. RESULTS A wipe sampling and analytical method with a limit of detection of 0.1 pg Pt/cm2 was developed. Pt was detected in 67% of the wipe samples collected from four workplaces, and the concentrations ranged from <0.10 to 21100 pg/cm2. In 4% of samples, the detected surface contaminations of Pt in three hospital wards were above proposed hygienic guidance value (HGV) of Pt. In the hospital pharmacy, 9% of the detected surface contaminations of Pt were above lowest proposed HGV. CONCLUSIONS A user-friendly, specific, and sensitive method for determination of surface contaminations of Pt from ADs in work environments was developed and validated. A large variation of contaminations was observed between detected surface contaminations of Pt in samples collected in wards, and it likely reflects differences in amounts handled and work practices between the wards.
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Affiliation(s)
- Mats Leeman
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Maria Wetterling
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Monica Kåredal
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Maria Hedmer
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
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Kåredal M, Özdemir J, Tinnert A, Wetterling M, Hedmer M. Pilot study: External surface contamination of gemcitabine and 5-fluorouracil on drug packaging. J Oncol Pharm Pract 2024; 30:9-14. [PMID: 36916178 DOI: 10.1177/10781552231163544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Antineoplastic drugs (ADs) are commonly used pharmaceuticals for anticancer treatments. It has previously been shown that the external surface of drug vials frequently is contaminated with ADs. More than a decade ago methods to prevent occupational exposure were introduced by using plastic coverage of the glass vials or packing vials in a secondary plastic container. The aim of the pilot study was to determine contamination levels of ADs on different parts of AD packaging of two different commercially available drug vials on the Swedish market and to investigate the occurrence of cross contamination of ADs. METHODS Packagings of gemcitabine (GEM) and 5-fluorouracil (5-FU) were tested by wipe sampling. Five ADs; GEM, 5-FU, cyclophosphamide (CP), ifosfamide and etoposide were quantified using liquid chromatography mass spectrometry. RESULTS AD contaminations were detected in 69% and 60% of the GEM and 5-FU packaging samples. Highest levels, up to approximately 5 µg/sample, were observed on the glass vials. The protective shrink-wrap of 5-FU vials and the plastic container of GEM were contaminated with low levels of 5-FU and GEM, respectively, and furthermore the 5-FU vials with shrink-wrap were cross-contaminated with GEM. Cross-contamination of CP and GEM was detected on 5-FU vials with plastic shrink-wrap removed. CONCLUSIONS External contamination of ADs are still present at primary drug packagings on the Swedish market. Protection of AD vials by plastic shrink-wrap or a secondary plastic container does not remove the external contamination levels completely. The presence of cross contamination of ADs on drug packagings was also observed.
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Affiliation(s)
- Monica Kåredal
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Jennie Özdemir
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Andreas Tinnert
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Wetterling
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Hedmer
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
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Saint-Lorant G, Vasseur M, Allorge D, Beauval N, Simon N, Odou P. Four-year follow-up of surface contamination by antineoplastic drugs in a compounding unit. Occup Environ Med 2023; 80:146-153. [PMID: 36717254 DOI: 10.1136/oemed-2022-108623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/21/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study aimed to monitor the contamination by antineoplastic drugs on work surfaces in a compounding unit 4 years after its implementation. METHODS This descriptive study was done in a unit performing on average 45 000 preparations per year. Surface sampling points (N=23) were monitored monthly in the frame of routine activity from the opening of an anticancer drug compounding unit. Contamination with nine antineoplastic drugs (cyclophosphamide, ifosfamide, dacarbazine, 5-fluorouracil, methotrexate, gemcitabine, cytarabine, irinotecan and doxorubicin) was assessed on wipes with a local liquid chromatography coupled with a tandem mass spectrometer analysis. The contamination rate (CR, %) was prospectively monitored every month during the entire study period. The occurrence of critical incidents was also registered. The effect of each safety measure implemented during this period was also analysed. RESULTS Based on the 1104 samples collected between March 2016 and March 2020, the CR was 18.5%. If three different critical incidents among a vial breakage that occurred were individually considered, this CR was slightly lower than that in the literature. Eight months after opening and taking different corrective actions, the overall CR dropped from 42.39% to 11.52% (p<0.001). Contamination was limited to the area that includes the compounding room and, more precisely, the welder and the QC-Prep+ sampling points. CONCLUSIONS From the beginning of the study and from month to month, surface contamination was limited to the nearest sampling points to the compounding unit. This 4-year monitoring study allowed us to determine the intravenous conventional antineoplastic drugs and sampling points to be focused on.
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Affiliation(s)
- Guillaume Saint-Lorant
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France .,Pharmacy, CHU Caen, Caen, France
| | - Michèle Vasseur
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Delphine Allorge
- ULR-4483-IMPECS-IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, Lille, France.,CHRU, Lille, France
| | | | - Nicolas Simon
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Pascal Odou
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
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Verscheure E, Creta M, Vanneste D, Vanoirbeek J, Zakia M, Abdesselam T, Lebegge R, Poels K, Ghosh M, Duca RC, Godderis L. Quantification of three antineoplastic agents in urine using the UniSpray ionisation source. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1205:123331. [PMID: 35752139 DOI: 10.1016/j.jchromb.2022.123331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many guidelines and safety measures led to a decrease in exposure to antineoplastic agents. Since healthcare workers are often exposed to lower concentrations than patients, a sensitive method is needed to quantify occupational exposure. OBJECTIVE The aim of this study was to develop and validate a sensitive method for simultaneous detection and quantification of cyclophosphamide, ifosfamide and paclitaxel in urine by use of UPLC-MS/MS with a UniSpray ionisation source. METHODS Compounds were extracted from urine using Novum simplified liquid extraction cartridges, separated on a C18 column, ionised by a UniSpray ionisation source and detected with MS/MS. In the second part of the study, a field study was performed to assess occupational exposure to antineoplastic agents. RESULTS Eighty-three samples from healthcare workers were analysed and resulted in seventeen samples containing quantifiable concentrations of at least one compound. In conclusion, a sensitive method for simultaneous detection and quantification of cyclophosphamide (LLOQ 0.05 ng/mL), ifosfamide (LLOQ 0.3 ng/mL) and paclitaxel (LLOQ 0.7 ng/mL) was developed and validated.
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Affiliation(s)
- Eline Verscheure
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Matteo Creta
- Unit Environmental Hygiene and Human Biological Monitoring, Department of Health Protection, Laboratoire National de Santé (LNS), Dudelange, Luxembourg
| | - Dorian Vanneste
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jeroen Vanoirbeek
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Meziane Zakia
- Centre Hospitalo-universitaire, Service Médicine du Travail, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria; Faculty of Medicine, TOXICOMED Research Laboratory, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria
| | - Taleb Abdesselam
- Centre Hospitalo-universitaire, Service Médicine du Travail, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria; Faculty of Medicine, TOXICOMED Research Laboratory, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria
| | - Robin Lebegge
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Katrien Poels
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Manosij Ghosh
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Radu-Corneliu Duca
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Unit Environmental Hygiene and Human Biological Monitoring, Department of Health Protection, Laboratoire National de Santé (LNS), Dudelange, Luxembourg
| | - Lode Godderis
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Idewe, External Service for Prevention and Protection at Work, Heverlee, Belgium.
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Simegn W, Dagnew B, Dagne H. Health professionals’ practice to care cytotoxic drug handling and associated factors: The case of university of gondar specialized hospital. J Oncol Pharm Pract 2022:10781552221090200. [DOI: 10.1177/10781552221090200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Health care professionals are potential to be in contact with cytotoxic drugs during their daily work activities. The study aimed to assess the practice of health professionals to care for cytotoxic drugs and associated factors in the University of Gondar Specialized Hospital. Methods Cross-sectional study design was employed. EPI Info 7 was used for data entry and then exported into SPSS 20 for statistical analysis. Frequencies and mean with standard deviation were computed. Logistic regression had been performed to find out associated factors. Crude’ and adjusted Odds’ ratio with 95% uncertainty interval was done. Variables with a p < 0.05 were declared as significant factors for practice of cytotoxic drug handling. Results The study used four-hundred and twelve health professionals took part in the study with 97.4% response rate. The mean age of study participants was 29.9 years ranging from 20–60 years and twenty (53.4%) participants were males. One hundred and fifty-five (37.6%) health professionals had good cytotoxic drug handling practice. Attending an average of 4–9 patients per day (AOR = 2.12, 95% CI: 1.05, 4.22), Medium work stress (AOR = 2.01, 95% CI: 1.04, 3.90), availability of cytotoxic drug handling manual (AOR = 2.51: 95% CI: 1.22, 5.12), and good knowledge (AOR = 4.09, 95% CI: 2.35, 7.11) were significantly associated with cytotoxic drug handling practice. Conclusion The practice of cytotoxic drug handling care was low. It demands the engagement of the health sector to avert such inadequate practice and has to focus on delivering knowledge and logistics for the practice of cytotoxic drug handling.
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Affiliation(s)
- Wudneh Simegn
- Department of Social and Administrative Pharmacy, School of pharmacy, University of Gondar, Gondar, Ethiopia
| | - Baye Dagnew
- Department of Human Physiology, School of Medicine, University of Gondar, Gondar, Ethiopia
| | - Henok Dagne
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of Gondar, Gondar, Ethiopia
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Kåredal M, Jönsson R, Wetterling M, Björk B, Hedmer M. A quantitative LC-MS method to determine surface contamination of antineoplastic drugs by wipe sampling. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2022; 19:50-66. [PMID: 34723774 DOI: 10.1080/15459624.2021.2000617] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The main objective was to develop a wipe sampling test to measure surface contamination of the most frequently used antineoplastic drugs (ADs) in Swedish healthcare and, furthermore, to develop an analysis method sensitive enough to assess low levels of contamination. Two wipe sampling tests with separate sample processing methods assessing (i) cyclophosphamide (CP), ifosfamide (IF), 5-fluorouracil (5-FU), etoposide (ETO), gemcitabine (GEM) and cytarabine (CYT) (Wipe Test 1); and (ii) GEM, CYT and methotrexate (MTX) (Wipe Test 2), respectively, were developed by optimization of absorption and extraction efficiencies using different wipe tissue materials, tissue wetting solution, and extraction solvents. A fast liquid chromatography tandem mass spectrometry method was developed for simultaneous detection of the studied ADs. The limit of quantification for the method was between 0.04 to 2.4 ng/wipe sample (0.10 to 6.1 pg/cm2 for an area of 400 cm2) and at 50 ng/sample the within-day precision was between 1.3 and 15%, and the accuracy between 102 and 127%. Wipe Test 1 was applied in an assessment of cleaning efficiency of five different cleaning solutions (formic acid, water, sodium hydroxide, ethanol, and sodium dodecyl sulfate (SDS) for removal of ADs from surfaces made of stainless steel or plastic. For CP, IF, 5-FU, GEM, and CYT 92% of the AD were removed regardless of surface and cleaning solution. In conclusion, a user-friendly assessment method to measure low levels of seven ADs in the work environment was developed and validated. Assessment of the decontamination efficiency of cleaning solutions concerning removal of ADs from stainless steel showed that efficiencies differed depending on the AD with water being the least effective cleaning agent. The results suggests that a combination of different cleaning agents including detergent and a solution with an organic component would be optimal to efficiently remove the measured ADs from surfaces in the workplace.
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Affiliation(s)
- Monica Kåredal
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Rebecca Jönsson
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Wetterling
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Birgitta Björk
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Hedmer
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
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Simegn W, Dagnew B, Dagne H, Weldegerima B. Health professionals' attitude and associated factors toward cytotoxic drug handling in University of Gondar specialized hospital: Institution-based cross-sectional study. J Oncol Pharm Pract 2021; 28:1731-1736. [PMID: 34590934 DOI: 10.1177/10781552211040490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies have shown that cytotoxic drugs are dangerous to health care workers. Health care professionals' attitude to cytotoxic drugs is vital to apply safety protocols in the prevention of cytotoxicity. The current study aimed to assess health professionals' desirable attitude and associated factors toward cytotoxic drugs handling in the University of Gondar Specialized Hospital. METHODS An institution-based cross-sectional study was conducted on 412 health professionals from June to August 2019. Simple random sampling was used to select participants and a self-administered questionnaire was used to collect data. Epi Info and SPSS 20 were used for data entry and analysis, respectively. Variables with a p value < 0.05 were declared as determinants. RESULTS The number of health professionals included was approximately 412. The mean age of participants was 29.9 ± 5.4 years. The proportion of participants with desirable attitude toward cytotoxic drugs handling was 224 (54.4%) (95% confidence interval: 51.95-56.85). Male (adjusted odds ratio = 1.69, 95% confidence interval:[1.08-2.65]), work experience of 5-8 years (adjusted odds ratio = 1.92, 95% confidence interval: [1.10-3.34]), weekly working hours of 44-55 (adjusted odds ratio = 2.25, 95% confidence interval: [1.02-4.96]), medium work stress (adjusted odds ratio = 1.67, 95% confidence interval: [1.01-2.69]), and good practice of cytotoxic drug handling (adjusted odds ratio = 1.67, 95% confidence interval: [1.04-2.67]) were significantly associated with the attitude of health professionals. CONCLUSION A significant proportion of health care workers did not have desirable attitude to handle cytotoxic drugs. Thus, strategies are suggested to improve the positive attitude of health professionals to cytotoxic drug handling. Female health professionals, those who had work experience of less than 2 years and those with higher work stress demand special attention.
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Affiliation(s)
- Wudneh Simegn
- Department of Social and Administrative Pharmacy, School of Pharmacy, 362057University of Gondar College of Medicine and Health Sciences, Ethiopia
| | - Baye Dagnew
- Department of Human Physiology, School of Medicine, University of Gondar College of Medicine and Health Sciences, Ethiopia
| | - Henok Dagne
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Ethiopia
| | - Berhanemeskel Weldegerima
- Department of Social and Administrative Pharmacy, School of Pharmacy, 362057University of Gondar College of Medicine and Health Sciences, Ethiopia
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Labrèche F, Ouellet C, Roberge B, Caron NJ, Yennek A, Bussières JF. Occupational exposure to antineoplastic drugs: what about hospital sanitation personnel? Int Arch Occup Environ Health 2021; 94:1877-1888. [PMID: 34410477 DOI: 10.1007/s00420-021-01731-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/19/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Occupational exposure to antineoplastic drugs (ANPs) occurs mainly through dermal contact. Our study was set up to assess the potential exposure of hospital sanitation (HS) personnel, for whom almost no data are available, through contamination of surfaces they regularly touch. METHODS In the oncology departments of two hospitals around Montreal, surface wipe samples of 120-2000 cm2 were taken at 10 sites cleaned by the HS personnel and five other sites frequently touched by nursing and pharmacy personnel. A few hand wipe samples were collected to explore skin contamination. Wipes were analyzed by ultra-performance liquid chromatography tandem-mass spectrometry for 10 ANPs. RESULTS Overall, 60.9% of 212 surface samples presented at least one ANP above the limits of detection (LOD). Cyclophosphamide and gemcitabine were most often detected (52% and 31% of samples respectively), followed by 5-fluorouracil and irinotecan (15% each). Highest concentrations of five ANPs were found in outpatient clinics on toilet floors (5-fluorouracil, 49 ng/cm2; irinotecan, 3.6 ng/cm2), a perfusion pump (cyclophosphamide, 19.6 ng/cm2) and on a cytotoxic waste bin cover (gemcitabine, 4.97 ng/cm2). Floors in patient rooms had highest levels of cytarabine (0.12 ng/cm2) and methotrexate (6.38 ng/cm2). Hand wipes were positive for two of 12 samples taken on HS personnel, seven of 18 samples on nurses, and two of 14 samples on pharmacy personnel. CONCLUSIONS A notable proportion of surfaces showed measurable levels of ANPs, with highest concentrations found on surfaces cleaned by HS personnel, who would benefit from appropriate preventive training. As potential sources of worker exposure, several hospital surfaces need to be regularly monitored to evaluate environmental contamination and efficacy of cleaning.
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Affiliation(s)
- France Labrèche
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada. .,Service de santé au travail, Direction de santé publique de 1 Estrie, CIUSSE - CHUS de Sherbrooke, Sherbrooke, QC, Canada.
| | - Capucine Ouellet
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada
| | - Brigitte Roberge
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada
| | - Nicolas J Caron
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec, QC, Canada
| | - Ahmed Yennek
- Service de santé au travail, Direction de santé publique de 1 Estrie, CIUSSE - CHUS de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-François Bussières
- Département de pharmacie, Unité de recherche en pratique pharmaceutique, CHU Sainte-Justine, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
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13
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Cytostatics in Indoor Environment: An Update of Analytical Methods. Pharmaceuticals (Basel) 2021; 14:ph14060574. [PMID: 34204005 PMCID: PMC8232629 DOI: 10.3390/ph14060574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Abstract
Periodic and adequate environmental monitoring programs are crucial to assess and reduce the occupational exposure of healthcare workers to cytostatics. The analytical methods employed should be rapid, reliable, sensitive, standardized, and include multiple compounds. A critical overview of recent overall procedures for surface and air contamination with cytostatics in workplace settings is presented, with a focus on sampling, sample preparation, and instrumental considerations. Limitations are also addressed and some recommendations and advice are provided. Since dermal absorption is the main exposure route, surface contamination is the preferred indicator of biological uptake and its methods have significantly improved. In contrast, cytostatics’ inhalation is rare; thus, air contamination has been poorly studied, with little improvement. Still, some elements of the analytical methods have not been extensively explored, namely: the amount of wetting solution, the extraction procedure, surface chemistry and roughness, recovery studies from specific surfaces, and cytostatics stability (in surfaces and during shipping and storage). Furthermore, complete validation data (including precision, accuracy, and instrumental and method detection limits) and estimation of global uncertainty are still lacking in most studies, thus preventing method comparison and proposal of standardized procedures.
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14
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Nurses' internal contamination by antineoplastic drugs in hospital centers: a cross-sectional descriptive study. Int Arch Occup Environ Health 2021; 94:1839-1850. [PMID: 34021808 DOI: 10.1007/s00420-021-01706-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to assess internal antineoplastic drugs (ADs) contamination in the nursing staff in French hospital centers, using highly sensitive analytical methods. METHODS This cross-sectional study included nurses practicing in care departments where at least one of the five ADs studied was handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The nurses study participation lasted 24 h including collection of three urine samples and one self-questionnaire. All urine samples were assayed by ultra-high-performance liquid chromatography-tandem mass spectrometry methods with very low value of the lower limit of quantification (LLOQ). RESULTS 74 nurses were included, 222 urine samples and 74 self-questionnaires were collected; 1092 urine assays were performed. The percentage of nurses with internal AD contamination was 60.8% and low levels of urinary concentrations were measured. Regarding nurses with internal contamination (n = 45), 42.2% presented internal contamination by methotrexate, 37.8% by cyclophosphamide, 33.3% by ifosfamide, 17.8% by 5-fluorouracil metabolite and 6.7% by doxorubicine. Among the positive assays, 17.9% (n = 26/145) were not explained by exposure data from the self-questionnaire but this could be due to the skin contact of nurses with contaminated work surfaces. CONCLUSIONS This study reported high percentage of nurses with internal ADs contamination. The low LLOQ values of the used analytical methods, allowed the detection of ADs that would not have been detected with the current published methods: the percentage of contamination would have been 17.6% instead of the 60.8% reported here. Pending toxicological reference values, urine ADs concentrations should be reduced as low as reasonably achievable (ALARA principle).
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15
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Simon N, Odou P, Decaudin B, Bonnabry P, Fleury-Souverain S. Chemical Decontamination of Hazardous Drugs: A Comparison of Solution Performances. Ann Work Expo Health 2021; 64:114-124. [PMID: 31848570 DOI: 10.1093/annweh/wxz093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/15/2019] [Accepted: 11/29/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Over the past 40 years, numerous actions have been undertaken to decrease the contamination of hospital facilities by intravenous conventional antineoplastic drugs (ICADs) such as centralizing compounding in pharmacies, using personal protective equipment, specific compounding, or infusion devices. As recently proposed in the <USP800> monograph, an additional specific decontamination step must be envisaged. A recent literature review analysed and discussed the different solutions tested in terms of decontamination efficacy. This article aims to discuss the performance of these solutions in the framework of aseptic compounding. METHODS The same dataset used in the previous literature review was reanalysed according to other parameters so as to select decontamination solutions: overall decontamination efficiency (EffQ), tested contaminants, and the risks of use in daily practice. RESULTS Using an EffQ threshold of 90% resulted in discarding 26 out of the 59 solutions. Solutions were tested differently: 8 on 1 contaminant, 11 on 2 contaminants, and 14 solutions on between 3 and 11 contaminants. Three risks were identified to help make choices in routine practice: the mutagenicity of degradation products, the safety of operators and facilities, and respect for the aseptic environment. CONCLUSIONS From the results, performance is discussed according to specific situations: a one-time incident or the basic chemical contamination due to daily practice. Accordingly, the decontamination solution selected then required a risk analysis and an evaluation before implementing it in the daily practice of a compounding unit.
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Affiliation(s)
- Nicolas Simon
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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16
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Halloush S, Reveles IA, Koeller J. Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH's 2015 Draft Vapor Protocol. Hosp Pharm 2020; 55:391-399. [PMID: 33245720 DOI: 10.1177/0018578719848730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: In 2015, the National Institute for Occupational Safety and Health (NIOSH) published a draft vapor containment protocol to quantitatively evaluate combined liquid, aerosol, and vapor containment performance of commercially available closed-system drug-transfer devices (CSTDs) that claim to be effective for gas/vapor containment within a controlled test environment. Until the release of this proposed protocol, no standard method for evaluating airtightness of CSTDs existed. The aim of this study was to evaluate six commercially available CSTDs utilizing NIOSH draft protocol methodology to evaluate vapor containment under a robust vapor challenge. Methods: In this study, six commercially available CSTDs were tested utilizing draft NIOSH vapor containment protocol methodology to simulate drug compounding and administration using 70% isopropyl alcohol (IPA) as the challenge agent. All device manipulations were carried out in an enclosed test chamber. A Miran sapphIRe gas analyzer was used to detect IPA vapor levels that escaped the device. Study test included the two tasks designated by the NIOSH protocol, with additional steps added to the evaluation. Tasks were repeated 10 times for each device. Results: Only three of the six tested CSTDs (Equashield®, HALO®, and PhaSealTM) had an average IPA vapor release below the quantifiable performance threshold (1.0 ppm) for all tasks performed. This value was selected by NIOSH to represent the performance threshold for successful containment. The remaining three CSTDs had vapor release above 1 ppm at various times during the IPA manipulation process. Conclusion: Equashield®, HALO®, and PhaSealTM devices tested met the 2015 NIOSH protocol quantifiable performance threshold, functioning as a truly closed system. Quantifiable effective data may be useful in product selection.
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Affiliation(s)
- Shiraz Halloush
- The University of Texas at Austin, USA.,UT Health San Antonio, USA
| | | | - Jim Koeller
- The University of Texas at Austin, USA.,UT Health San Antonio, USA
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17
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Astrakianakis G, Jeronimo M, Griffiths A, Colombo M, Kramer D, Demers PA, Hon CY. The application of novel field measurement and field evaluation protocols for assessing health care workers' exposure risk to antineoplastic drugs. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2020; 17:373-382. [PMID: 32615872 DOI: 10.1080/15459624.2020.1777296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Contamination of multiple antineoplastic drugs (ADs) on work surfaces presents an exposure concern for health care workers. Surface wipe sampling is a recognized method to evaluate the degree of contamination present. Our research team has previously reported on wipe sampling and analytical methods to simultaneously detect 10 commonly used ADs from a single wipe. Our objectives here were: to field test a protocol consisting of the wipe sampling method and an accompanying wipe sample collection tool kit and confirm this protocol can be effectively used by health care workers to assess drug contamination levels in their facilities; and, to confirm the potential for simultaneous exposure to multiple antineoplastic drugs. Three facilities within one health authority in British Columbia, Canada participated in this field study. In collaboration with the site health and safety advisors, up to 25 surfaces within each facility were considered for sampling. Collected wipe samples were analyzed using HPLC-MS/MS to quantify the 10 analyte, resulting in 750 potential analyses. Following the sampling, each of the three facilities' safety advisors provided feedback regarding the usability of the protocols. Among the 72 wipe samples actually collected (or 720 analyses conducted), detectable levels and simultaneous contamination of work surfaces of five of the 10 analytes were found at all three participating sites: 5-fluorouracil, cyclophosphamide, vincristine, paclitaxel, and methotrexate; (range < LoD to 33.0 ng/cm2) with 5-fluorouracil having the highest concentration in every instance. Drug contamination was found on a variety of different work surfaces in pharmacies and patient care areas among all three sites. Users of the sampling protocols were generally satisfied with the wipe sample collection toolkit with some minor suggestions for improvement. Our findings support the hypothesis that health care workers may be simultaneously at risk of exposure to several ADs. Our toolkit was found to be user-friendly and manageable by those who were not experienced in collecting wipe samples to monitor contamination of ADs on the work surfaces in their facilities.
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Affiliation(s)
- George Astrakianakis
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Griffiths
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Manuel Colombo
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Desré Kramer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Paul A Demers
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Chun-Yip Hon
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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18
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Verscheure E, Creta M, Vanoirbeek J, Zakia M, Abdesselam T, Lebegge R, Poels K, Duca RC, Godderis L. Environmental Contamination and Occupational Exposure of Algerian Hospital Workers. Front Public Health 2020; 8:374. [PMID: 32850596 PMCID: PMC7419462 DOI: 10.3389/fpubh.2020.00374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/29/2020] [Indexed: 11/13/2022] Open
Abstract
Guidelines are in place to assure limited occupational exposure to cytostatic drugs. Even though this has led to a reduction in exposure, several studies reported quantifiable concentrations of these compounds in healthcare workers. In this study, we evaluated occupational exposure to cytostatic drugs in hospital workers from the University Hospital in Tlemcen, Algeria. Monitoring was performed by collecting wipe samples from surfaces, objects, personal protective equipment (gloves and masks) and from the skin of employees at an Algerian university hospital. Wipe samples were analyzed with ultra-performance liquid chromatography coupled to a mass spectrometer. Concentrations ranged from below the limit of quantification up to 208.85, 23.45, 10.49, and 22.22 ng/cm2 for cyclophosphamide, ifosfamide, methotrexate and 5-fluorouracil, respectively. The highest values were observed in the oncology department. Nowadays, there are still no safe threshold limit values for occupational exposure to cytostatic agents. Therefore, contamination levels should be kept as low as reasonably achievable. Yet, healthcare workers in this hospital are still exposed to cytostatic agents, despite the numerous guidelines, and recommendations. Consequently, actions should be taken to reduce the presence of harmful agents in the work environment.
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Affiliation(s)
- Eline Verscheure
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium
| | - Matteo Creta
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium
| | - Jeroen Vanoirbeek
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium
| | - Meziane Zakia
- Centre Hospitalo-Universitaire, Service Médicine du Travail, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria.,TOXICOMED Research Laboratory, Faculty of Medicine, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria
| | - Taleb Abdesselam
- Centre Hospitalo-Universitaire, Service Médicine du Travail, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria.,TOXICOMED Research Laboratory, Faculty of Medicine, Université Abou Bekr Belkaid Tlemcen, Tlemcen, Algeria
| | - Robin Lebegge
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium
| | - Katrien Poels
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium
| | - Radu-Corneliu Duca
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium.,National Health Laboratory (LNS), Unit Environmental Hygiene and Human Biological Monitoring, Department of Health Protection, Dudelange, Luxembourg
| | - Lode Godderis
- Department of Public Health and Primary Care, Centre for Environment and Health, KU Leuven, Leuven, Belgium.,Idewe, External Service for Prevention and Protection at Work, Heverlee, Belgium
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19
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Crul M, Hilhorst S, Breukels O, Bouman-d'Onofrio JRC, Stubbs P, van Rooij JG. Occupational exposure of pharmacy technicians and cleaning staff to cytotoxic drugs in Dutch hospitals. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2020; 17:343-352. [PMID: 32633703 DOI: 10.1080/15459624.2020.1776299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Many studies into surface contamination of hospital environments have demonstrated that occupational exposure to cytotoxics through the dermal route remains a possible risk. In this study, we assess the actual dermal exposure of the hands of pharmacy technicians and cleaning personnel in a panel of hospitals performing tasks that pose a risk of exposure. We compare the dermal exposure to a tentative limit value for cyclophosphamide. Pharmacy technicians and cleaning personnel were asked for hand rinsing after performance of nine tasks previously identified as posing a risk of occupational exposure. All samples were analyzed for the presence and quantity of eight antineoplastic drugs. By using data on both the frequency of the performance of the tasks and the measured dermal contamination during these tasks, weekly exposure to the marker drug (cyclophosphamide) was calculated. In five Dutch hospitals, 70 hand rinse samples and 8 blanks were collected. These were analyzed and results were used to calculate weekly exposure. The tentative limit value used was 0.74 µg of cyclophosphamide. For cleaning personnel, all results remained below this threshold value. For pharmacy technicians, the compounding itself also remained well below the limit; however, the task involving preparatory work, as well as the checking of compounded drugs, had a 13% chance of exceeding the limit. All of the highest values were found when employees were not wearing gloves on these tasks. Cleaning personnel and pharmacy technicians compounding cytotoxic drugs in our study were sufficiently protected from occupational exposure. In contrast, pharmacy technicians who perform preparatory and finishing tasks (before and after the actual compounding) are not protected enough when they do not wear gloves.
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Affiliation(s)
- Mirjam Crul
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Simone Hilhorst
- Department of Human Resources, Occupational Health Services, Ziekenhuis de Gelderse Vallei, Ede, The Netherlands
| | - Oscar Breukels
- Department of Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Percival Stubbs
- Department of Human Resources, Healthteam, Haaglanden Medical Center, The Hague, The Netherlands
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20
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Simon N, Guichard N, Odou P, Decaudin B, Bonnabry P, Fleury-Souverain S. Efficiency of four solutions in removing 23 conventional antineoplastic drugs from contaminated surfaces. PLoS One 2020; 15:e0235131. [PMID: 32569333 PMCID: PMC7307753 DOI: 10.1371/journal.pone.0235131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/08/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Nicolas Simon
- Pharmacy, Geneva University Hospitals and Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Univ. Lille, CHU Lille, ULR 7365 –GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Nicolas Guichard
- Pharmacy, Geneva University Hospitals and Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Pascal Odou
- Univ. Lille, CHU Lille, ULR 7365 –GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, ULR 7365 –GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
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21
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Palamini M, Hilliquin D, Delisle JF, Chouinard A, Bussières JF. Surface Contamination by Antineoplastic Drugs in Two Oncology Inpatient Units. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2020. [DOI: 10.1515/pthp-2019-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractBackgroundHazardous drugs pose risks to health care workers. To reduce the risk of occupational exposure for all workers, several protective and monitoring measures have been recommended and implemented over the past two decades. This study was undertaken to describe traces contamination with ten antineoplastic drugs in the oncology care unit of two university hospitals.MethodsIn this descriptive interrupted time series study, data was collected in two hospitals (a pediatric hospital and an adult hospital) in two consecutive years (12 December 2017 and 27 March 2018, defined as Period 1; 17 April 2019 and 12 June 2019, defined as Period 2). In both Period 1 and Period 2, 36 sites were sampled in each inpatient care unit to explore the contamination of surfaces with hazardous drugs.ResultsA total of 144 samples from the oncology care unit of the two hospitals were obtained for measurement. Overall, 40 % (58/144) of the sampling sites were positive for at least one hazardous drug. In the pediatric centre, 50 % (18/36) and 36 % (13/36) of the sites sampled in Period 1 and Period 2, respectively, were positive for at least one hazardous drug, whereas in the adult hospital, the percentage of sites that were positive for at least one hazardous drug was 19 % (7/36) in Period 1 and 56 % (20/36) in Period 2.ConclusionThe surfaces of inpatient care units sampled in this study were contaminated with antineoplastic drugs, and contamination was present throughout the care units (including structures, furniture, medical equipment, and office equipment). Hospitals’ environmental surveillance programs should encompass inpatient care units.
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Affiliation(s)
- Marie Palamini
- Pharmacy Practice Research Unit, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, Montreal, QuebecH3T 1C5, Canada
| | - Delphine Hilliquin
- Pharmacy Practice Research Unit, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, Montreal, QuebecH3T 1C5, Canada
| | - Jean-François Delisle
- Pharmacy Practice Research Unit, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, Montreal, QuebecH3T 1C5, Canada
| | | | - Jean-François Bussières
- Pharmacy Practice Research Unit, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, Montreal, QuebecH3T 1C5, Canada
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22
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Occupational Exposure in Health Care Personnel to Antineoplastic Drugs and Initiation of Safe Handling in Hong Kong: A Literature Review. JOURNAL OF INFUSION NURSING 2020; 43:121-133. [PMID: 32287167 DOI: 10.1097/nan.0000000000000361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite the benefits for patients as cancer treatment, antineoplastic drugs may cause adverse effects not only in patients but also in health care personnel. Apart from minor symptoms, antineoplastic agents can cause serious health problems. However, protection from occupational exposures to antineoplastic drugs varies between pharmacy staff and nurses. While protection used for pharmacy staff are more advanced, personal protective equipment seems to be the only protection for most nurses around the world. Exposure can never be totally prevented, but it should be minimized at all costs. Guidelines and recommendations have been published; however, these guidelines do not have legal enforcement power. This article aims to provide a literature review on the occupational exposure of health care personnel to antineoplastic drugs and to reflect the current status in Hong Kong.
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Simegn W, Dagnew B, Dagne H. Knowledge and associated factors towards cytotoxic drug handling among University of Gondar Comprehensive Specialized Hospital health professionals, institutional-based cross-sectional study. Environ Health Prev Med 2020; 25:11. [PMID: 32284041 PMCID: PMC7155262 DOI: 10.1186/s12199-020-00850-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/02/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Currently, cancer is among the leading causes of morbidity and mortality in the world. Exposure to CDs may occur during drug preparation and mixing, during drug administration, during transport, and cleaning spills and waste disposal. Healthcare workers who prepare or administer antineoplastic drugs, or who work in areas where these drugs are used, can be exposed to these agents. This also affects the public around the exposed area if appropriate disposal system is not known. Several studies reported increased risks of leukemia and breast cancer among nurses handling CDs and not following safety guidelines. Because of the absence of studies in Ethiopia, the current study was conducted to determine the knowledge level of cytotoxic drug handling and associated factors among health professionals in the University of Gondar Comprehensive Specialized Hospital. METHODS The institutional-based cross-sectional study was conducted from June to August 2019. Epi info 7.1 was used for data entry and then exported into SPSS version 20 for computing, recording, and statistical analysis. Logistic regression was used to explain the relationship with independent variables. RESULTS Four hundred and twelve health professionals participated in the study with 53.4% males. The participants' mean age was 29.9 (± 5.43) years ranging from 20-60. Two hundred and twenty-three (54.1%) health professionals heard about cytotoxic drugs, and 52.7% (95% UI 47.8-57.8%) had good knowledge of cytotoxic drug handling. Being male sex (AOR = 1.84, 95% CI (1.13-3.00)), age of 29-31 (AOR = 1.99, 95% CI (1.03-3.84)), hearing information about cytotoxic drug handling (AOR = 2.53, 95% CI (1.43-4.47)), ever attended training on cytotoxic drug handling (AOR = 3.15, 95% CI (1.13-8.79)), ever taking courses related to cytotoxic drugs (AOR = 2.03, 95% CI (1.15-3.59)), and good practice (AOR = 3.24, 95% CI (1.95-5.37)) were significantly associated with knowledge towards cytotoxic drug handling. It is therefore imperative to train health professionals and to incorporate CDs handling related course contents while revising curricula to raise the knowledge of health professionals about proper cytotoxic drug handling. CONCLUSION Above half of the study participants scored higher than the median of the cytotoxic drug handling knowledge questions. Sex, age, information about cytotoxic drug handling, training, taking courses related to cytotoxic drugs, and good practice were significantly associated with knowledge towards cytotoxic drugs handling.
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Affiliation(s)
- Wudneh Simegn
- Department of Pharmaceutics, School of Pharmacy, University of Gondar, P.O.Box 196, Gondar, Ethiopia.
| | - Baye Dagnew
- Department of Human Physiology, School of Medicine, University of Gondar, P.O.Box 196, Gondar, Ethiopia
| | - Henok Dagne
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of Gondar, P.O.Box 196, Gondar, Ethiopia
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Rossignol E, Amiand MB, Sorrieul J, Bard JM, Bobin-Dubigeon C. A fully validated simple new method for environmental monitoring by surface sampling for cytotoxics. J Pharmacol Toxicol Methods 2019; 101:106652. [PMID: 31734280 DOI: 10.1016/j.vascn.2019.106652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/24/2019] [Accepted: 11/05/2019] [Indexed: 11/19/2022]
Abstract
A wipe sampling procedure followed by a simple ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) method was developed and validated for simultaneous quantification of six cytotoxic drugs: 5-fluorouracil (5FU), doxorubicin (DOXO), epirubicin (EPI), ifosfamide (IF), cyclophosphamide (CP) and gemcitabine (GEM), as surrogate markers for occupational exposure. After a solid-phase extraction of wiping filter on 10 × 10 cm surface, the separation was performed within 6.5 min, using a gradient mobile phase and the analytes were detected by mass spectrometry in the multiple reaction ion monitoring mode. The method was validated according to the recommendations of the US Food and Drug Administration. The method was linear (r2 > 0.9912) between 2.5 and 200 ng per wiping sample (25 to 2000 pg/cm2) for 5FU, doxorubicin and epirubicin and between 0.2 and 40 ng per wiping sample (2 to 400 pg/cm2) for cyclophosphamide, ifosfamide and gemcitabine. The lower limits of quantification were 2.5 ng (25 pg/ cm2) for 5FU, doxorubicin and epirubicin, and 0.2 ng (2 pg/cm2) for CP, IF and GEM. Within-day and between-day imprecisions were <14.0, 10.6, 11.1, 8.7, 11.2 and 10.9% for 5-fluorouracil, doxorubicin, epirubicin, ifosfamide cyclophosphamide and gemcitabine, respectively. The inaccuracies did not exceed 2.7, 10.9, 1.1, 4.5, 1.6 and 2.9% for the studied molecules, respectively. This new sensitive validated method for surface contamination studies of cytotoxics was successfully applied on different localizations in hospital. This approach is particularly suitable to assess occupational exposure risk to cytotoxic drugs.
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Affiliation(s)
- E Rossignol
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - M B Amiand
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - J Sorrieul
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - J M Bard
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France; Université de Nantes Faculté de Pharmacie, EA 2160 MMS, IUML FR3473 CNRS, 1 rue Gaston Veil, 44000 Nantes, France
| | - C Bobin-Dubigeon
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France; Université de Nantes Faculté de Pharmacie, EA 2160 MMS, IUML FR3473 CNRS, 1 rue Gaston Veil, 44000 Nantes, France.
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Villa A, Molimard M, Bignon E, Martinez B, Rouyer M, Mathoulin-Pelissier S, Baldi I, Verdun-Esquer C, Canal-Raffin M. Study protocol for the assessment of nurses internal contamination by antineoplastic drugs in hospital centres: a cross-sectional multicentre descriptive study. BMJ Open 2019; 9:e033040. [PMID: 31712349 PMCID: PMC6858204 DOI: 10.1136/bmjopen-2019-033040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/18/2019] [Accepted: 10/07/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Antineoplastic drugs (AD) are potentially carcinogenic and/or reprotoxic molecules. Healthcare professionals are increasingly exposed to these drugs and can be potentially contaminated by them. Internal contamination of professionals is a key concern for occupational physicians in the assessment and management of occupational risks in healthcare settings. Objectives of this study are to report AD internal contamination rate in nursing staff and to identify factors associated with internal contamination. METHODS AND ANALYSIS This trial will be conducted in two French hospital centres: University Hospital of Bordeaux and IUCT-Oncopole of Toulouse. The target population is nurses practicing in one of the fifteen selected care departments where at least one of the five studied AD is handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The trial will be conducted with the following steps: (1) development of analytical methods to quantify AD urine biomarkers, (2) study of the workplace and organization around AD in each care department (transport and handling, professional practices, personal and collective protection equipments available) (3) development of a self-questionnaire detailing professional activities during the day of inclusion, (4) nurses inclusion (urine samples and self-questionnaire collection), (5) urine assays, (6) data analysis. ETHICS AND DISSEMINATION The study protocol has been approved by the French Advisory Committee on the Treatment of Information in Health Research (CCTIRS) and by the French Data Protection Authority (CNIL). Following the opinion of the Regional Committee for the Protection of Persons, this study is outside the scope of the provisions governing biomedical research and routine care (n°2014/87). The results will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBER NCT03137641.
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Affiliation(s)
- Antoine Villa
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Consultation de Pathologie Professionnelle et de I'environnement, CHU Timone, AP-HM, Marseille, France
- Univ. of Bordeaux, Bordeaux, France
| | - Mathieu Molimard
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU de Bordeaux, Bordeaux, France
| | - Emmanuelle Bignon
- Bordeaux PharmacoEpi (BPE, CIC 1401), Université de Bordeaux, Talence, France
| | - Béatrice Martinez
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
| | - Magali Rouyer
- Bordeaux PharmacoEpi (BPE, CIC 1401), Université de Bordeaux, Talence, France
| | - Simone Mathoulin-Pelissier
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
| | - Isabelle Baldi
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- GH Pellegrin, Pôle de Santé Publique, Service de Médecine du Travail et Pathologies professionnelles, CHU de Bordeaux, Bordeaux, France
| | - Catherine Verdun-Esquer
- GH Pellegrin, Pôle de Santé Publique, Service de Médecine du Travail et Pathologies professionnelles, CHU de Bordeaux, Bordeaux, France
| | - Mireille Canal-Raffin
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU de Bordeaux, Bordeaux, France
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Shu P, Zhao T, Wen B, Mendelsohn-Victor K, Sun D, Friese CR, Pai MP. Application of an innovative high-throughput liquid chromatography-tandem mass spectrometry method for simultaneous analysis of 18 hazardous drugs to rule out accidental acute chemotherapy exposures in health care workers. J Oncol Pharm Pract 2019; 26:794-802. [PMID: 31483750 DOI: 10.1177/1078155219870591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Despite safe handling guidelines published by several groups, health care worker exposure to hazardous drugs continues to occur due to suboptimal engineering controls and low use of protective equipment. Simple, multi-target and specific analytical methods are needed so that acute exposures to these drugs in the workplace can be assessed rapidly. Our aim was to develop an analytical method for simultaneous detection and quantification of widely used cancer drugs to rule out accidental acute chemotherapy exposures in health care workers. METHODS We examined the feasibility of alternate high-performance liquid chromatographic-tandem mass spectrometry methods to simultaneously detect eighteen chemotherapy analytes in plasma and urine. The linear concentration ranges tested during assay development were 0.1-50 ng/mL. After development of a multi-analyte assay protocol, plasma samples (n = 743) from a multi-center cluster-randomized clinical trial (n = 12 sites) of an hazardous drug educational intervention were assayed. Confirmatory assays were performed based on the individual acute-spill case-histories. RESULTS An innovative HPLC-multiple reaction monitoring-information dependent acquisition-enhanced production ion (MRM-IDA-EPI) analytical method was developed to simultaneously detect: cytarabine, gemcitabine, dacarbazine, methotrexate, topotecan, mitomycin, pemetrexed, irinotecan, doxorubicin, vincristine, vinblastine, ifosamide, cyclophosphamide, vinorelbine, bendamustine, etoposide, docetaxel, and paclitaxel. The retention times ranged from 4 min to 13 min for the analytical run. The limit of detection (MRM-IDA-EPI) and limit of quantitation (MRM) was 0.25 ng/mL and 0.1 ng/mL, respectively for most analytes. No detectable plasma concentrations were measured at baseline, post-intervention and in cases of documented acute spills. Use of a secondary tandem mass spectrometry approach was able to successfully rule out false positive results. CONCLUSIONS Development of a sensitive high-throughput multi-analyte cancer chemotherapy assay is feasible using an MRM-IDA-EPI method. This method can be used to rapidly rule out systemic exposure to accidental acute chemotherapy spills in health care workers.
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Affiliation(s)
- Pan Shu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Ting Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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Simon N, Odou P, Decaudin B, Bonnabry P, Fleury-Souverain S. Efficiency of degradation or desorption methods in antineoplastic drug decontamination: A critical review. J Oncol Pharm Pract 2019; 25:929-946. [DOI: 10.1177/1078155219831427] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Nicolas Simon
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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Vasseur M, Simon N, Picher C, Richeval C, Soichot M, Humbert L, Barthélémy C, Fleury-Souverain S, Bonnabry P, Décaudin B, Allorge D, Odou P. 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. PLoS One 2018; 13:e0201335. [PMID: 30089139 PMCID: PMC6082556 DOI: 10.1371/journal.pone.0201335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/13/2018] [Indexed: 11/29/2022] Open
Abstract
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 (AnioxysprayTM, 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 (EffQ, %). The proportion of EffQ ≥ 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 (CRC = 25.3% vs. CRI = 10.4%; OR = 0.341; p<0.0001). Overall EffQ values (median; 1st and 3rd 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 EffQ ≥ 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.
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Affiliation(s)
- Michèle Vasseur
- Univ. Lille, EA 7365—GRITA—Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
- CHU Lille, Institut de Pharmacie, Lille, France
| | - Nicolas Simon
- Univ. Lille, EA 7365—GRITA—Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
- CHU Lille, Institut de Pharmacie, Lille, France
- * E-mail:
| | - Chloé Picher
- Univ. Lille, EA 4483 –IMPECS–IMPact de l’Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle de Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Camille Richeval
- Univ. Lille, EA 4483 –IMPECS–IMPact de l’Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle de Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Marion Soichot
- Laboratoire de Toxicologie, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Luc Humbert
- Univ. Lille, EA 4483 –IMPECS–IMPact de l’Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle de Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Christine Barthélémy
- Univ. Lille, EA 7365—GRITA—Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Bertrand Décaudin
- Univ. Lille, EA 7365—GRITA—Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
- CHU Lille, Institut de Pharmacie, Lille, France
| | - Delphine Allorge
- Univ. Lille, EA 4483 –IMPECS–IMPact de l’Environnement Chimique sur la Santé humaine, Lille, France
- CHU Lille, Pôle de Biologie-Pathologie-Génétique, Unité Fonctionnelle de Toxicologie, Lille, France
| | - Pascal Odou
- Univ. Lille, EA 7365—GRITA—Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
- CHU Lille, Institut de Pharmacie, Lille, France
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Unda-Urzaiz M, Alonso-Herreros JM, Fernandez-Gomez JM, Gaspar-Carreño M, Cozar-Olmos JM, Lleti ACC. Review of the evidence on handling drugs and hazardous products in Urology Departments. Consensus document between the Spanish Urological Association and the Spanish Society of Hospital Pharmacy. Actas Urol Esp 2018; 42:375-380. [PMID: 29685610 DOI: 10.1016/j.acuro.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The intravesical administration of hazardous drug products is a standard practice in the urology setting, which potentially exposing medical personnel to these drug products. It was deemed necessary to have a consensus document among the scientific societies involved (the Spanish Urological Association and the Spanish Society of Hospital Pharmacy) that collects the best available evidence on the safest handling possible of dangerous drug products in the setting of urology departments. METHODS We reviewed the legislation and recommendations on the handling of dangerous drug products, both at the national and international level. RESULTS There is national legislation and regulations for protecting workers who handle dangerous drugs and products, as well as recommendations for handling to protect both the product and workers. DISCUSSION Following the strategic lines of the European Parliament for 2014-2020 in the chapter on occupational safety and health, the Spanish Urological Association and the Spanish Society of Hospital Pharmacy proposed a series of actions that decrease the risks of exposure for practitioners and caregivers involved in the handling of these products. CONCLUSIONS After this review, 19 recommendations were established for handling dangerous drug products, which can be summarised as the need to train all individuals involved (from management teams to patients and caregivers), adopt systems that prevent contaminating leaks, implement exposure surveillance programmes and optimise available resources.
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Affiliation(s)
- M Unda-Urzaiz
- Hospital Universitario Basurto, Bilbao, Vizcaya, España.
| | | | | | | | - J M Cozar-Olmos
- Hospital Universitario Virgen de las Nieves, Granada, España
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Gajski G, Ladeira C, Gerić M, Garaj-Vrhovac V, Viegas S. Genotoxicity assessment of a selected cytostatic drug mixture in human lymphocytes: A study based on concentrations relevant for occupational exposure. ENVIRONMENTAL RESEARCH 2018; 161:26-34. [PMID: 29100207 DOI: 10.1016/j.envres.2017.10.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Goran Gajski
- Mutagenesis Unit, Institute for Medical Research and Occupational Health, Zagreb, Croatia.
| | - Carina Ladeira
- Grupo de Investigação em Ambiente e Saúde, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Lisbon, Portugal; Grupo de Investigação em Genética e Metabolismo, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Lisbon, Portugal.
| | - Marko Gerić
- Mutagenesis Unit, Institute for Medical Research and Occupational Health, Zagreb, Croatia.
| | - Vera Garaj-Vrhovac
- Mutagenesis Unit, Institute for Medical Research and Occupational Health, Zagreb, Croatia.
| | - Susana Viegas
- Grupo de Investigação em Ambiente e Saúde, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Lisbon, Portugal; Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
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Verdun-Esquer C, Atge B, Videau N, Delva F, Leclerc I, Goujon Y, Canal-Raffin M. Exposition du personnel des établissements de soin aux médicaments anticancéreux : de l’évaluation à la prévention. ARCH MAL PROF ENVIRO 2017. [DOI: 10.1016/j.admp.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cruickshank S, Henry R. Foreword. ACTA ACUST UNITED AC 2017; 26:S3-S4. [PMID: 28981321 DOI: 10.12968/bjon.2017.26.sup16b.s3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is a significant body of evidence describing the benefits of using systemic anti-cancer therapy (SACT) agents, such as chemotherapy, biological, hormone and antibiotics, to treat people diagnosed with cancer (Cancer Research UK, 2017). However, the potential improvements in survival outcomes must be regularly weighed against the risk of adverse health effects associated with exposure to them. For patients, the risks are balanced against the need to treat the cancer. For health professionals, the risks simply result from the occupational exposure that can occur when caring for patients receiving these drugs. Collectively referred to as cytotoxic agents, SACTs are known to be toxic; they are considered carcinogenic to humans, and are classified as hazardous (National Institute for Occupational Safety and Health (NIOSH), 2010).
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Affiliation(s)
- Susanne Cruickshank
- Associate Professor of Cancer Nursing, Faculty of Health Sciences and Sport, University of Stirling, and Chair, Royal College of Nursing (RCN) Cancer and Breast Care Forum
| | - Richard Henry
- President, UK Oncology Nursing Society (UKONS) and Lecturer in Cancer Nursing, Queen's University, Belfast
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Field A, Hughes G, Rowland S. A strategy for formulating regulation on CSTDs. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2017; 26:S15-S22. [PMID: 28981323 DOI: 10.12968/bjon.2017.26.sup16b.s15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article identifies what steps need to be taken to ensure the mandatory use of closed system transfer devices by all health professionals involved in the hazardous drug journey.
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Affiliation(s)
- Allison Field
- Lead Chemotherapy Nurse, Dudley Group NHS Foundation Trust
| | - Gemma Hughes
- Clinical Nurse Educator, Heart of England NHS Foundation Trust
| | - Sarah Rowland
- Chemotherapy and IV Access Clinical Nurse Specialist, Cardiff and Vale University Health Board
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Meade E, Simons A, Toland S. The need for national mandatory guidance on CSTDs. ACTA ACUST UNITED AC 2017; 26:S5-S14. [DOI: 10.12968/bjon.2017.26.sup16b.s5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth Meade
- Advanced Nurse Practitioner in Oncology, HSE Dublin Mid Leinster, Midland Regional Hospital Tullamore, Ireland
| | - Alison Simons
- Senior Lecturer, Pathway Leader Haematology and Cancer Care, Birmingham City University, UK
| | - Samantha Toland
- Lead Chemotherapy Nurse, Worcestershire Acute Hospitals NHS Trust, UK
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Müller-Ramírez C, Squibb K, McDiarmid M. Measuring extent of surface contamination produced by the handling of antineoplastic drugs in low- to middle-income country oncology health care settings. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2017; 72:289-298. [PMID: 27603111 DOI: 10.1080/19338244.2016.1222346] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Antineoplastic drugs are known to cause detrimental effects to health care workers who are exposed through work tasks. Environmental monitoring studies are an excellent approach to measure the extent of surface contamination produced by the handling of antineoplastic drugs in the workplace and to assess the potential for occupational exposures in oncology health care settings. The main aim of the study was to establish the extent of surface contamination produced by the handling of antineoplastic drugs in a limited-resource oncology health care facility in Colombia by conducting an environmental monitoring study using affordable analytical instrumentation. Contamination with antineoplastic drugs was widespread in the health care facility under evaluation, which could result in health care worker exposure to antineoplastic drugs. A comprehensive review of current safety guidelines and protocols including assessment of adherence in the health care facility should be done.
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Affiliation(s)
- Claudio Müller-Ramírez
- a Department of Pharmacy , School of Pharmacy, University of Concepción, Chile Barrio Universitario S/N , Concepción , Chile
| | - Katherine Squibb
- b Division of Occupational and Environmental Medicine, School of Medicine, University of Maryland , Baltimore , Maryland , USA
| | - Melissa McDiarmid
- b Division of Occupational and Environmental Medicine, School of Medicine, University of Maryland , Baltimore , Maryland , USA
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Colombo M, Jeronimo M, Astrakianakis G, Apte C, Hon CY. Wipe Sampling Method and Evaluation of Environmental Variables for Assessing Surface Contamination of 10 Antineoplastic Drugs by Liquid Chromatography/Tandem Mass Spectrometry. Ann Work Expo Health 2017; 61:1003-1014. [DOI: 10.1093/annweh/wxx070] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 07/31/2017] [Indexed: 11/13/2022] Open
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Crul M, Simons-Sanders K. Carry-over of antineoplastic drug contamination in Dutch hospital pharmacies. J Oncol Pharm Pract 2017; 24:483-489. [DOI: 10.1177/1078155217704990] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background To prevent occupational exposure of hospital staff to cytostatics, a mandatory national guideline describing a set of safety measures was issued in the Netherlands in 2004. The guideline includes, among other directives, obligatory annual wipe testing to assess the efficacy of the local cleaning protocol. Full implementation of this guideline was executed in all Dutch hospital pharmacies over the next couple of years. Objective We aimed to investigate the effect of the national guideline on contamination levels, and specifically on the phenomenon of carry-over of traces of antineoplastic drugs through contact with surfaces, since this is a potential route of exposure. Methods From a database including wipe sample results of 9 hospitals over 10 years, we extracted all sampled locations in the compounding areas as well as in adjacent or bypass rooms and locks. We considered only the locations outside safety cabinets or isolators, to examine the containment of contamination and to address possible routes of how a contamination can migrate through the preparation and distribution areas. The dataset consisted of 2647 wipe samples. Results In adjacent rooms, 18 out of 275 wipe samples were contaminated (6%). Inside the compounding room, the extracted locations away from the safety workbench showed a positive percentage for contamination of 13% (39 out of 297). When stratifying the data to sample year, it was shown that contaminations outside the preparation room were no longer detectable after 2008. Conclusion With this study, we show that implementation of a set of guidelines on safety measures can prevent spreading of cytostatic traces from the compounding area in hospital pharmacies.
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Affiliation(s)
- M Crul
- Department of Clinical Pharmacy, OLVG, Amsterdam, The Netherlands
| | - K Simons-Sanders
- Department of Hospital Pharmacy Midden Brabant, TweeSteden Hospital, Tilburg, The Netherlands
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Böhlandt A, Sverdel Y, Schierl R. Antineoplastic drug residues inside homes of chemotherapy patients. Int J Hyg Environ Health 2017; 220:757-765. [PMID: 28372941 DOI: 10.1016/j.ijheh.2017.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/07/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Abstract
Chemotherapy treatment of cancer patients has shifted from inpatient to outpatient administration. Thus, family members are potentially exposed to cytotoxic drug residues from patients' excretions inside their homes. The study's aim was to evaluate the surface contamination and the potential uptake of antineoplastic drug residues by family members at home of chemotherapy patients. Overall, 265 wipe samples from 13 homes were taken at two times after chemotherapy from different surfaces (toilet, bathroom, kitchen). 62 urine samples were collected from patients and family members on three days. Samples were analyzed for cyclophosphamide, 5-fluorouracil (urine: FBAL) and platinum (as marker for cis-, carbo- and oxaliplatin). Substantial contamination was found on every surface type (PT: 0.02-42.5pg/cm2, 5-FU: ND-98.3pg/cm2, CP: ND-283.3pg/cm2) with highest concentrations on toilet and bathroom surfaces. While patients' urinary drug concentrations often were elevated for more than 48h after administration, no drug residues were detectable in the family members' urine. This study provided an insight in the exposure situation against antineoplastic drug residues at home of chemotherapy patients. As contamination could be found on various surfaces adequate hygienic and protective measures are necessary to minimize the exposure risk for cohabitants.
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Affiliation(s)
- Antje Böhlandt
- Occupational, Social and Environmental Medicine, LMU Munich, Germany.
| | - Yulia Sverdel
- Occupational, Social and Environmental Medicine, LMU Munich, Germany.
| | - Rudolf Schierl
- Occupational, Social and Environmental Medicine, LMU Munich, Germany.
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Kibby T. A review of surface wipe sampling compared to biologic monitoring for occupational exposure to antineoplastic drugs. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2017; 14:159-174. [PMID: 27676216 DOI: 10.1080/15459624.2016.1237026] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The potential for adverse health effects from occupational exposure to antineoplastic drugs (AD) is well known. Control measures recommended by the NIOSH Alert [3] include medical and biologic monitoring, and environmental monitoring where available. At present no guidelines or published best practices exist to guide EHS managers on how to carry out this biologic or environmental monitoring. Studies investigating surface wipe sampling for AD have been numerous in the past decade, but very limited research exists to correlate surface contamination with actual absorption by pharmacists and nurses. This article reviews the studies with concurrent surface wipe sampling and urine monitoring for the same AD, and tests their correlation. Methodologic limitations are reviewed. Twenty-one studies were identified that concurrently measured surface contamination by AD by wipe sampling and AD absorption by urine monitoring. Two studies directly evaluated the AD by wipe sampling and urine levels and neither found a statistically significant correlation. Six studies reported a decrease in both surface and urine levels following interventions to reduce contamination or exposure. Only one study directly evaluated the personal protective equipment and handling techniques employed by the studied workers, which can be viewed as a major confounder of absorption. While no statistically significant correlation was found between wipe sampling and urine monitoring for AD, decreases in urine and wipe levels following interventions to reduce exposure were noted. Limitations in the data and recommendations for future research are reviewed.
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Affiliation(s)
- Thomas Kibby
- a Department of Emergency Medicine , Toxicology Section, Washington University School of Medicine , St. Louis , Missouri
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Fung V, Seneviratne M. Regulatory verification on safe use of cytotoxic drugs in veterinary clinics and animal hospitals. Aust Vet J 2016; 94:400-404. [PMID: 27785801 DOI: 10.1111/avj.12515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Veterinarians are increasingly being asked to provide chemotherapy for veterinary patients. However, chemotherapy agents have cytotoxic effects that can pose a health risk to workers from exposure. There are no published studies examining cytotoxic drug (CTD) contamination in veterinary practices in Australia. METHODS CTD use at 13 veterinary clinics and animal hospitals across New South Wales (NSW) was verified for compliance with Work, Health and Safety (WHS) legislation on the effectiveness of exposure control measures. Surface swab sampling was performed to detect the restricted carcinogen cyclophosphamide and seven other CTD. A total of 73 surface swab samples were collected from nine locations associated with CTD delivery, storage, treatment and waste disposal at four veterinary practices, with repeat sampling at two veterinary practices. RESULTS Compliance with WHS legislation for systematic chemical management, including procedures for safe use of carcinogens, in veterinary practices was high: 4 of the 10 key clauses in WHS chemical management were complied with at all 13 verified workplaces. Surface contamination was detected in three locations, with levels of CTD contaminants ranging from 3.54 to 89 ng per sample. DISCUSSION Results showed that, in general, there were safe systems in place to work with CTD in the veterinary practices that were verified in NSW. Areas for improvement were mainly in administrative measures related to hazardous chemical management. Particular attention should be given to raising awareness of the intrinsic hazards of CTD, through training and hazard information provision to staff.
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Affiliation(s)
- V Fung
- Hygiene & Toxicology Unit, Hazardous Chemical Services Team, SafeWork NSW, Level 1, 2 Burbank Place, Norwest, New South Wales, Australia.
| | - M Seneviratne
- Hygiene & Toxicology Unit, Hazardous Chemical Services Team, SafeWork NSW, Level 1, 2 Burbank Place, Norwest, New South Wales, Australia
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Zare Sakhvidi MJ, Hajaghazadeh M, Mostaghaci M, Mehrparvar AH, Zare Sakhvidi F, Naghshineh E. Applicability of the comet assay in evaluation of DNA damage in healthcare providers' working with antineoplastic drugs: a systematic review and meta-analysis. INTERNATIONAL JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH 2016; 22:52-67. [PMID: 27110842 DOI: 10.1080/10773525.2015.1123380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Unintended occupational exposure to antineoplastic drugs (ANDs) may occur in medical personnel. Some ANDs are known human carcinogens and exposure can be monitored by genotoxic biomarkers. OBJECTIVE To evaluate the obstacles to obtaining conclusive results from a comet assay test to determine DNA damage among AND exposed healthcare workers. METHODS We systematically reviewed studies that used alkaline comet assay to determine the magnitude and significance of DNA damage among health care workers with potential AND exposure. Fifteen studies were eligible for review and 14 studies were used in the meta-analysis. RESULTS Under random effect assumption, the estimated standardized mean difference (SMD) in the DNA damage of health care workers was 1.93 (95% CI: 1.15-2.71, p < 0.0001). The resulting SMD was reduced to 1.756 (95% CI: 0.992-2.52, p < 0.0001) when the analysis only included nurses. In subgroup analyses based on gender and smoking, heterogeneity was observed. Only for studies reporting comet moment, I2 test results, as a measure of heterogeneity, dropped to zero. Heterogeneity analysis showed that date of study publication was a possible source of heterogeneity (B = -0.14; p < 0.0001). CONCLUSIONS A mixture of personal parameters, comet assay methodological variables, and exposure characteristics may be responsible for heterogenic data from comet assay studies and interfere with obtaining conclusive results. Lack of quantitative environmental exposure measures and variation in comet assay protocols across studies are important obstacles in generalization of results.
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Affiliation(s)
- Mohammad Javad Zare Sakhvidi
- a Faculty of Health, Department of Occupational Health , Shahid Sadoughi University of Medical Sciences , Yazd , Iran
| | - Mohammad Hajaghazadeh
- b Faculty of Health, Department of Occupational Health , Urmia University of Medical Sciences , Urmia , Iran
| | - Mehrdad Mostaghaci
- c Faculty of Medicine, Department of Occupational Medicine , Shahid Sadoughi University of Medical Sciences , Yazd , Iran
| | - Amir Houshang Mehrparvar
- c Faculty of Medicine, Department of Occupational Medicine , Shahid Sadoughi University of Medical Sciences , Yazd , Iran
| | - Fariba Zare Sakhvidi
- d Faculty of Health, Department of Occupational Health , Shahid Sadoughi University of Medical Sciences , Yazd , Iran
| | - Elham Naghshineh
- e Faculty of Medicine, Department of Obstetrics/Gynecology, Isfahan University of Medical Sciences , Isfahan , Iran
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Hanada T, Takami Y, Moriyama K, Oro M, Ogawa T, Moriyasu H, Inoue Y, Kanemitsu A, Kawamoto E, Nagase A, Hamahara A, Yamamoto A, Shimada K, Takahashi M, Egawa T. Prevention of the exposure by cyclophosphamide oral tablet. J Pharm Health Care Sci 2016; 1:20. [PMID: 26819731 PMCID: PMC4728781 DOI: 10.1186/s40780-015-0020-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 06/08/2015] [Indexed: 11/23/2022] Open
Abstract
Background Unintended exposure to antitumor agents from an oral medicine may place healthcare workers and patients taking medicine at risk. In this study, the exposure to blister pack by CP (cyclophosphamide) and appropriate preventive procedures were examined. Findings CP detected inside the blister pack of the tested seven lots by LC-MS/MS ranged from 8.2 to 199.6 ng. Raman imaging clearly showed that CP ingredient was completely covered by the tablet coating layer and had not leached out of the tablet. In addition, the amount of CP detected inside the vials was suppressed under the lower detection limit until day 28, and only 6.0 ng was detected only at day 56. Conclusions Various amounts of CP were contaminated to not only the inside of the blister pack but also the outside. This contamination may be caused not only by the manufacturing environment but also by the CP oral tablets themselves through volatilization of CP. Refrigerated storage of CP oral tablets may protect healthcare workers and patients from contact with CP. Electronic supplementary material The online version of this article (doi:10.1186/s40780-015-0020-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takae Hanada
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan ; Department of Pediatrics, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | - Yoichiro Takami
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Kei Moriyama
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Masafumi Oro
- Muscat Pharmacy, 1290-1 Tamasu, Kita-ku, Okayama, 701-1154 Japan
| | - Takehiro Ogawa
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan ; Muscat Pharmacy, 1290-1 Tamasu, Kita-ku, Okayama, 701-1154 Japan
| | - Hiroko Moriyasu
- Muscat Pharmacy, 1290-1 Tamasu, Kita-ku, Okayama, 701-1154 Japan
| | - Yuka Inoue
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Asako Kanemitsu
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Eiko Kawamoto
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Ayaka Nagase
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Anna Hamahara
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Atsuko Yamamoto
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | - Kenichi Shimada
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
| | | | - Takashi Egawa
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama, 703-8516 Japan
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Böhlandt A, Schierl R. Benefits of Wipe Sampling: Evaluation of Long-Term 5-Fluorouracil and Platinum Monitoring Data. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2016. [DOI: 10.1515/pthp-2016-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractObjectives:The aim of this study was to evaluate environmental contamination levels from a large dataset of long-term monitoring data of 5-fluorouracil and platinum-containing drugs in pharmacies, and to investigate the contaminations over 15 years.Methods:Wipe sampling for 5-fluorouracil and platinum (marker for cis-, carbo- and oxaliplatin) was performed on-site from various surfaces in hospital and retail pharmacies with a validated sampling procedure over a period of 15 years. The 5-fluorouracil concentrations were quantified by GCMSMS and platinum concentrations by voltammetry. Statistical evaluation was performed with respect to sampling locations and years, and over the course of time.Results:Overall, 3,584 wipe samples for 5-fluorouracil and 2,955 wipe samples for platinum were analysed and contamination was detected at all surface types in all 151 examined pharmacies with ranges from ND (not detectable) to 1,725,000 pg/cm² and ND to 23,068 pg/cm², respectively. Median concentrations from the different locations ranged between ND and 4.3 pg/cm² (5-fluorouracil) and 0.2 and 1.8 pg/cm² (platinum) with highest loads inside the biological safety cabinets/isolators and storage areas. Evaluation of contamination over the course of 15 years showed a substantial decrease, especially in the years after introduction of guidance values.Conclusions:Long-term evaluation of surface wipe samples for antineoplastic drug contamination with repeated monitoring seems to be a beneficial tool to characterize the actual exposure situation and to assess surface contamination over time. Wipe sampling is a suitable control means to evaluate the work practices and the effectiveness of applied safety and hygiene measures and to identify the potential exposure risk for health care workers.
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Silver SR, Steege AL, Boiano JM. Predictors of adherence to safe handling practices for antineoplastic drugs: A survey of hospital nurses. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2016; 13:203-212. [PMID: 26556549 DOI: 10.1080/15459624.2015.1091963] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Despite growing awareness of the hazards of exposure to antineoplastic drugs (ADs), surveys continue to find incomplete adherence to recommended safe handling guidelines. A 2011 survey of healthcare workers presents an opportunity to examine factors associated with adherence among 1094 hospital nurses who administered ADs. Data for these hypothesis-generating analyses were taken from an anonymous, web-based survey of healthcare workers. Regression modeling was used to examine associations between a number of predictors (engineering controls, work practices, nurse perceptions, and nurse and hospital characteristics) and three outcomes reported by nurses: use of personal protective equipment (PPE); activities performed with gloves previously worn to administer ADs; and spills of ADs. Adherence to safe handling guidelines was not universal, and AD spills were reported by 9.5% of nurses during the week prior to the survey. Familiarity with safe handling guidelines and training in safe handling were associated with more reported PPE use. Nurse-perceived availability of PPE was associated with more reported PPE use and lower odds of reported spills. Use of closed system drug-transfer devices and luer-lock fittings also decreased the odds of self-reported AD spills, while more frequent AD administration increased the risk. AD administration frequency was also associated with performing more activities with gloves previously worn to administer ADs, and nurse perception of having adequate time for taking safety precautions with fewer such activities. The results suggest that training and familiarity with guidelines for safe handling of ADs, adequate time to adhere to guidelines, and availability of PPE and certain engineering controls are key to ensuring adherence to safe handling practices. Further assessment of training components and engineering controls would be useful for tailoring interventions targeting these areas.
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Affiliation(s)
- Sharon R Silver
- a Division of Surveillance, Hazard Evaluation and Field Studies, National Institute for Occupational Safety and Health , Cincinnati , Ohio
| | - Andrea L Steege
- a Division of Surveillance, Hazard Evaluation and Field Studies, National Institute for Occupational Safety and Health , Cincinnati , Ohio
| | - James M Boiano
- a Division of Surveillance, Hazard Evaluation and Field Studies, National Institute for Occupational Safety and Health , Cincinnati , Ohio
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Yuki M, Ishida T, Sekine S. Secondary Exposure of Family Members to Cyclophosphamide After Chemotherapy of Outpatients With Cancer: A Pilot Study. Oncol Nurs Forum 2015; 42:665-71. [DOI: 10.1188/15.onf.42-06ap] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Siderov J, Kirsa S, McLauchlan R. Surface Contamination of Cytotoxic Chemotherapy Preparation Areas in Australian Hospital Pharmacy Departments. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2009.tb00434.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Sue Kirsa
- Peter MacCallum Cancer Centre; East Melbourne
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Friese CR, McArdle C, Zhau T, Sun D, Spasojevic I, Polovich M, McCullagh MC. Antineoplastic drug exposure in an ambulatory setting: a pilot study. Cancer Nurs 2015; 38:111-7. [PMID: 24831047 PMCID: PMC4232489 DOI: 10.1097/ncc.0000000000000143] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Exposure to antineoplastic drugs confers health risks to workers, yet little is known about the exposure after a drug spill, nor has the relationship between exposure and organizational factors such as staffing and work environment been studied. OBJECTIVE The aim of this study was to evaluate drug spills prospectively using biological measures and correlate drug spills with organizational factors. METHODS Prospective questionnaires with 8-hour timed urine samples were collected from nursing and pharmacy personnel who reported drug spill events in 1 academic health center's infusion center. Urine was collected similarly from workers who did not report a spill. Liquid chromatography tandem mass spectrometry techniques identified detectable drug levels. After the prospective sampling period, workers were surveyed on workloads, practice environment, and safety behaviors. RESULTS From 81 eligible individuals, 40 participated in the prospective study and 19 completed retrospective questionnaires. Four spills were reported by 9 personnel, as multiple employees were exposed to drug spills. Four participants who reported a spill showed detectable levels of antineoplastic drugs. Four participants who did not report a spill had detectable levels of docetaxel. Compared with respondents who did not report a spill, collegial relations with physicians were significantly poorer for workers who reported spills. CONCLUSIONS The study protocol successfully captured drug spill reports and biological samples. Workers have detectable levels of antineoplastic drugs through both drug spills and environmental contamination. IMPLICATIONS FOR PRACTICE Multisite research studies and practice-based quality improvement approaches are needed to improve adherence to personal protective equipment use and safe handling procedures.
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Affiliation(s)
| | - Cristin McArdle
- Michigan State University College of Human Medicine, Department of Epidemiology and Biostatistics, East Lansing, MI
| | - Ting Zhau
- University of Michigan College of Pharmacy, Pharmacokinetics Core, Ann Arbor, MI
| | - Duxin Sun
- University of Michigan College of Pharmacy, Pharmacokinetics Core, Ann Arbor, MI
| | - Ivan Spasojevic
- Department of Medicine, Duke University Medical Center and Duke Cancer Institute Pharmacokinetics/Pharmacodynamics Bioanalytical Core Lab, Durham, NC
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Antineoplastic drug contamination in the urine of Canadian healthcare workers. Int Arch Occup Environ Health 2015; 88:933-41. [DOI: 10.1007/s00420-015-1026-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 01/20/2015] [Indexed: 11/27/2022]
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Hon CY, Teschke K, Shen H. Health Care Workers' Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2015; 12:669-677. [PMID: 25897641 DOI: 10.1080/15459624.2015.1029618] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Although nurses are knowledgeable regarding the risk of exposure to antineoplastic drugs, they often do not adhere with safe work practices. However, the knowledge, perceptions, and behavior of other health care job categories at risk of exposure has yet to be determined. This study aimed to survey a range of health care workers from British Columbia, Canada about their knowledge, perceptions, and behaviors regarding antineoplastic drugs. A self-administered questionnaire was sent to participants querying the degree of contact with antineoplastics, knowledge of risks associated with antineoplastics, perceptions of personal risk, previous training with respect to antineoplastics, and safe work practices. Subjects were recruited from health care facilities in and around Vancouver. Fisher's exact tests were performed to ascertain whether there were differences in responses between job categories. We received responses from 120 participants representing seven different job categories. Pharmacists, pharmacy technicians, and nurses were more knowledgeable regarding risks than other job categories examined (statistically significant difference). Although 80% of respondents were not afraid of working with or near antineoplastics, there were concerns about the suitability of current control measures and practices employed by co-workers. Only half of respondents felt confident that they could handle all situations where there was a potential for exposure. Only one of the perception questions, self-perceived risk of exposure to antineoplastic drugs, differed significantly between job categories. Not all respondents always wore gloves when directly handling antineoplastic drugs. Further, hand hygiene was not regularly practiced after glove usage or after being in an area where antineoplastic drugs are handled. The majority of responses to questions related to safe work practices differed significantly between job categories. Our results suggest that knowledge regarding risks associated with antineoplastic drugs can be improved, especially among job categories that are not tasked with drug preparation or drug administration. There is also a gap between knowledge and compliance with glove usage and hand hygiene.Training is also recommended to improve health care workers' perceptions of the risks associated with antineoplastic drugs.
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Affiliation(s)
- Chun-Yip Hon
- a School of Occupational and Public Health, Ryerson University , Toronto , Ontario , Canada
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Böhlandt A, Groeneveld S, Fischer E, Schierl R. Cleaning Efficiencies of Three Cleaning Agents on Four Different Surfaces after Contamination by Gemcitabine and 5-fluorouracile. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2015; 12:384-392. [PMID: 25751496 DOI: 10.1080/15459624.2015.1009985] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Occupational exposure to antineoplastic drugs has been documented for decades showing widespread contamination in preparation and administration areas. Apart from preventive measures, efficient cleaning of surfaces is indispensable to minimize the exposure risk. The aim of this study was to evaluate the efficiency of three cleaning agents after intentional contamination by gemcitabine (GEM) and 5-fluorouracile (5-FU) on four different surface types usually installed in healthcare settings. Glass, stainless steel, polyvinylchloride (PVC), and laminated wood plates were contaminated with 20 ng/μl GEM and 2 ng/μl 5-FU solutions. Wipe samples were analyzed for drug residues after cleaning with a) distilled water, b) aqueous solution containing sodium dodecyl sulfate (10 mM) and 2-propanol (SDS-2P), and c) Incides N (pre-soaked) alcoholic wipes. Quantification was performed by high-performance liquid chromatography (HPLC) for GEM and gas chromato-graphy-tandem mass spectrometry (GCMS/MS) for 5-FU. Recovery was determined and cleaning efficiency was calculated for each scenario. Mean recoveries were 77-89% for GEM and 24-77% for 5-FU and calculated cleaning efficiencies ranged between 95 and 100% and 89 and 100%, respectively. Residual drug amounts were detected in the range nd (not detected) - 84 ng GEM/sample and nd - 6.6 ng 5-FU/sample depending on surface type and cleaning agent. Distilled water and SDS-2P had better decontamination outcomes than Incides N wipes on nearly all surface types, especially for GEM. Regarding 5-FU, the overall cleaning efficiency was lower with highest residues on laminated wood surfaces. The tested cleaning procedures are shown to clean glass, stainless steel, PVC, and laminated wood with an efficiency of 89-100% after contamination with GEM and 5-FU. Nevertheless, drug residues could be verified by wipe samples. Pure distilled water and SDS in an alcoholic-aqueous solution expressed an efficient cleaning performance, especially with respect to GEM. The study results demonstrate the need to adapt cleaning procedures to the variety of drugs and surface types to develop effective decontamination strategies.
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Affiliation(s)
- Antje Böhlandt
- a Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Clinical Center , Ludwig Maximilians University , Munich , Germany
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