Biological and environmental monitoring of hospital personnel exposed to antineoplastic agents: a review of analytical methods

Electrochemistry as a Powerful Tool for Investigations of Antineoplastic Agents: A Comprehensive Review

Cancer is most frequently treated with antineoplastic agents (ANAs) that are hazardous to patients undergoing chemotherapy and the healthcare workers who handle ANAs in the course of their duties. All aspects related to hazardous oncological drugs illustrate that the monitoring of ANAs is essential to minimize the risks associated with these drugs. Among all analytical techniques used to test ANAs, electrochemistry holds an important position. This review, for the first time, comprehensively describes the progress done in electrochemistry of ANAs by means of a variety of bare or modified (bio)sensors over the last four decades (in the period of 1982-2021). Attention is paid not only to the development of electrochemical sensing protocols of ANAs in various biological, environmental, and pharmaceutical matrices but also to achievements of electrochemical techniques in the examination of the interactions of ANAs with deoxyribonucleic acid (DNA), carcinogenic cells, biomimetic membranes, peptides, and enzymes. Other aspects, including the enantiopurity studies, differentiation between single-stranded and double-stranded DNA without using any label or tag, studies on ANAs degradation, and their pharmacokinetics, by means of electrochemical techniques are also commented. Finally, concluding remarks that underline the existence of a significant niche for the basic electrochemical research that should be filled in the future are presented.

Airborne and surface contamination after rotational intraperitoneal pressurized aerosol chemotherapy using cisplatin

OBJECTIVE

We evaluated the occupational exposure levels of healthcare workers while conducting rotational pressurized intraperitoneal aerosol chemotherapy (RIPAC) using cisplatin in a large animal model.

METHODS

We performed RIPAC using cisplatin in 6 female pigs and collected surface and air samples during the procedure. Surface samples were obtained from RIPAC devices and personal protective equipment (PPE) by wiping, and air samples were collected around the operating table. All samples were analyzed by inductively coupled plasma-mass spectrometry to detect platinum.

RESULTS

Among all surface samples (n=44), platinum was detected in 41 samples (93.2%) but not in all air samples (n=16). Among samples collected from RIPAC devices (n=23), minimum and maximum cisplatin levels of 0.08 and 235.09 ng/cm² were detected, mainly because of direct aerosol exposure in the abdominal cavity. Among samples collected from healthcare workers' PPE (n=21), 18 samples (85.7%) showed contamination levels below the detection limit, with a maximum of 0.23 ng/cm². There was no significant contamination among samples collected from masks, shoes, or gloves.

CONCLUSION

During the RIPAC procedures, there is a potential risk of dermal exposure, as platinum, a surrogate material for cisplatin, was detected at low concentration levels in some surface samples. However, the respiratory exposure risk was not identified, as platinum was not detected in the airborne samples in this study.

Risk assessment of personnel exposure in a central cytotoxic preparation unit using the FMECA method

INTRODUCTION

Personnel involved in the preparation of cytotoxics are exposed to them and the resulting risks. To protect themselves, many means of protection are currently implemented. Nevertheless, the exposure of these manipulators remains a possibility to be considered.

MATERIALS AND METHODS

The study was conducted during the period (October-November 2022) in the pharmacy of the National Institute of Oncology (INO), a hospital structure specializing in cancer care. The Failure Mode, Effects and Criticality Analysis method was used to assess the risks of exposure of personnel in a central cytotoxic preparation unit and then calculate the criticality index (CI  =  severity  ×  frequency  ×  detectability). The risks were classified into toxic, traumatic, chemical, and environmental risks. We have cited 12 failure modes of which nine are minor and three are major. The three major modes cited are essentially related to the particulate environment, direct contact and daily passive inhalation of handling.

CONCLUSION

Our study shows that in our institution, the analysis of the risk of exposure of personnel to cytotoxics remains important, hence the interest of automaton in charge of preparations and which will gradually take charge of all the preparations. The existing procedures and the pharmacotechnical equipment used also contribute to protection and risk reduction.

Proposals of guidance values for surface contamination by antineoplastic drugs based on long term monitoring in Czech and Slovak hospitals and pharmacies

Introduction

The exposures to hazardous antineoplastic drugs (AD) represent serious risks for health care personnel but the exposure limits are not commonly established because of the no-threshold effects (genotoxic action, carcinogenicity) of many ADs. In this study, we discussed and derived practically applicable technical guidance values (TGV) suitable for management of AD risks.

Methods

The long-term monitoring of surface contamination by eight ADs was performed in pharmacies and hospitals in the Czech Republic and Slovak Republic in 2008-2021; in total 2,223 unique samples were collected repeatedly in 48 facilities. AD contamination was studied by LC-MS/MS for cyclophosphamide, ifosfamide, methotrexate, irinotecan, paclitaxel, 5-fluorouracil and gemcitabine and by ICP-MS for total Pt as a marker of platinum-based ADs.

Results

The study highlighted importance of exposure biomarkers like 5-fluorouracil and especially carcinogenic and persistent cyclophosphamide, which should be by default included in monitoring along with other ADs. Highly contaminated spots like interiors of laminar biological safety cabinets represent a specific issue, where monitoring of contamination does not bring much added value, and prevention of staff and separated cleaning procedures should be priority. Rooms and surfaces in health care facilities that should be virtually free of ADs (e.g., offices, kitchenettes, daily rooms) were contaminated with lower frequency and concentrations but any contamination in these areas should be carefully examined.

Discussion and conclusions

For all other working places, i.e., majority of areas in pharmacies and hospitals, where ADs are being prepared, packaged, stored, transported, or administered to patients, the study proposes a generic TGV of 100 pg/cm2. The analysis of long-term monitoring data of multiple ADs showed that the exceedance of one TGV can serve as an indicator and trigger for improvement of working practices contributing thus to minimizing of unintended exposures and creating a safe work environment.

Engineered tenorite structure of barium-enriched copper oxide for on-site monitoring of cytotoxic methotrexate in environmental samples

Emerging pharmaceutical pollutants pose a threat to both human and environmental health. The removal and monitoring of such pollutants necessitate the use of practical on-site monitoring devices; however, the designs of such devices are underdeveloped. This study involves the fabrication of a low-cost sensor based on barium-incorporated copper oxide (Ba-CuO) for the on-site monitoring of the cytotoxic drug methotrexate (MTRX) in water and sediment samples. The tenorite structure of CuO was slightly enriched with Ba ions at the td sites, distorting the tetrahedron and enhancing its electrochemical properties. Ba-CuO was obtained from Cu(NO₃)₂ and Ba(OH)₂ by a ligand exchange protocol and was characterized using X-ray diffraction, Raman spectroscopy, X-ray photoelectron spectroscopy, field-emission scanning electron microscopy, transmission electron microscopy, and energy dispersive X-ray analysis. In addition, the Ba-CuO sensor was tested under various conditions, and it could detect MTRX at concentrations as low as 0.4 nM, with a high sensitivity of 1.3567 µA µM^-1 cm^-2. On-site monitoring yielded recoveries of greater than 93 % from spiked samples, thus exhibiting excellent reproducibility and stability. Therefore, the developed method is practical and has no matrix effect on the MTRX sensor.

Occupational Exposure during Intraperitoneal Pressurized Aerosol Chemotherapy Using Doxorubicin in a Pig Model

Background

This study evaluated occupational exposure levels of doxorubicin in healthcare workers performing rotational intraperitoneal pressurized aerosol chemotherapy (PIPAC) procedures.

Methods

All samples were collected during PIPAC procedures applying doxorubicin to an experimental animal model (pigs). All procedures were applied to seven pigs, each for approximately 44 min. Surface samples (n = 51) were obtained from substances contaminating the PIPAC devices, surrounding objects, and protective equipment. Airborne samples were also collected around the operating table (n = 39). All samples were analyzed using ultra-high performance liquid chromatography-mass spectrometry.

Results

Among the surface samples, doxorubicin was detected in only five samples (9.8%) that were directly exposed to antineoplastic drug aerosols in the abdominal cavity originating from PIPAC devices. The telescopes showed concentrations of 0.48-5.44 ng/cm² and the trocar showed 0.98 ng/cm² in the region where the spraying nozzles were inserted. The syringe line connector showed a maximum concentration of 181.07 ng/cm², following a leakage. Contamination was not detected on the surgeons' gloves or shoes. Objects surrounding the operating table, including tables, operating lights, entrance doors, and trocar holders, were found to be uncontaminated. All air samples collected at locations where healthcare workers performed procedures were found to be uncontaminated.

Conclusions

Most air and surface samples were uncontaminated or showed very low doxorubicin concentrations during PIPAC procedures. However, there remains a potential for leakage, in which case dermal exposure may occur. Safety protocols related to leakage accidents, selection of appropriate protective equipment, and the use of disposable devices are necessary to prevent occupational exposure.

Occupational Cancers among Employed Women: A Narrative Review

The facts that occupational cancer in women is under-investigated, with few in-depth analyses are well known. In recent decades the workforce has changed, with an increasing number of women employed. Therefore, the inclusion of women in occupational cancer studies has become more urgent and feasible than in the past decades. The difficulties to evaluate occupational causes of female gynecologic tumors in most past cohorts and the potential variation in outcome responses between men and women must be taken into consideration. This narrative review discusses women's occupational cancer as a current area of research, focusing on three groups of workers characterized by peculiar exposure to occupational carcinogens and where women are often employed: beauticians and hairdressers; farmers; and healthcare workers. We discuss the most relevant cancers in each working category, with a particular focus on female breast cancer. In the three industries reviewed in detail, there are some risk factors which may affect primarily women, inducing breast cancer and cervical cancer, as well as risk factors that are carcinogenic in both genders, but whose effects are less well known in women.

Cyclophosphamide alters the behaviors of adult Zebrafish via neurotransmitters and gut microbiota

Cyclophosphamide, one of the earliest prescribed alkylating anticancer drugs, has been frequently detected in aquatic environments. However, its effects on fish behavior and associated mechanisms remain largely unknown. In this study, the behaviors, neurochemicals, and gut microbiota of adult zebrafish were investigated after 2 months of exposure to CP at 0.05, 0.5, 5, and 50 µg/L. Behavioral assays revealed that CP increased locomotion and anxiety, and decreased the cognition of zebrafish. The alteration of neurotransmitters and related gene expressions in the dopamine and gamma-aminobutyric acid pathways induced by CP may be responsible for the observed changes in locomotion and cognition of adult zebrafish. Meanwhile, CP increased the anxiety of adult zebrafish through the serotonin, acetylcholine, and histamine pathways in the brain. In addition, increased abundances of Fusobacteriales, Reyanellales, Staphylococcales, Rhodobacterals, and Patescibateria in the intestine at the CP-50 treatment were observed. The study has demonstrated that CP affects the locomotion, anxiety, and cognition in zebrafish, which might be linked with the dysfunction of neurochemicals in the brain. This study further suggests that the gut-brain axis might interact to modulate fish behaviors upon exposure to CP (maybe other organic pollutants). Further research is warranted to test this hypothesis.

Design of Analytical Method Validation Protocol Evaluating Environmental Monitoring of AND Contamination on Surfaces Based on Cleaning Validation Procedures: A Multi Component RP-UHPLC Method

Environmental monitoring of anti-neoplastic drug (AND) residues in workplaces is crucial to limit exposure to workers who handle with them. Although wipe sampling is the most appropriate methodology to evaluate the risk, conflicting results are also reported due to the lack of standardized and validated procedures. In this study, procedures for surface contamination of ANDs in workplaces are presented, with a focus on sampling, sample preparation and instrumentation. The analytical method validation parameters are designed to comply with requirements of The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) Q7 Good Manufacturing Practice (GMP) for active pharmaceutical ingredients. Additionally, the study provides a simple, specific, rapid and multi-component analytical method to evaluate seven ANDs that are Gefitinib, Imatinib, Dasatinib, Axitinib, Erlotinib, Nilotinib and Sorafenib at very low concentration levels, simultaneously. Quantitative, precise and reproducible results obtained from the study show that environmental monitoring procedure and analytical method validation protocol presented in the study can be used to reduce and monitor occupational exposure risk to ANDs in wokplaces.

Quantification of three antineoplastic agents in urine using the UniSpray ionisation source

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.

Exposure to Antineoplastic Drugs in Occupational Settings: A Systematic Review of Biological Monitoring Data

The high toxicity of antineoplastic drugs (ADs) makes them dangerous not only for patients, but also for exposed workers. Therefore, the aim of this review was to provide an updated overview of the biological monitoring of occupational AD exposure in order to extrapolate information useful to improve risk assessment and management strategies in workplaces. Several studies demonstrated that remarkable portions of healthcare workers may have traces of these substances or their metabolites in biological fluids, although with some conflicting results. Nurses, directly engaged in AD handling, were the occupational category at higher risk of contamination, although, in some cases, personnel not involved in AD-related tasks also showed quantifiable internal doses. Overall, further research carried out on greater sample sizes appears necessary to gain deeper insight into the variability retrieved in the reported results. This may be important to understand the impact of the extent of ADs use, different handling, procedures, and cleaning practices, spill occurrence, training of the workforce, as well as the adoption of adequate collective and personal protective equipment in affecting the occupational exposure levels. This may support the achievement of the greatest clinical efficiency of such therapies while assuring the health and safety of involved workers.

Photodegradation of methotrexate in aqueous solution: degradation kinetics and identification of transformation products

Methotrexate is an antineoplastic folate analog of high environmental concern, due to its low biodegradability and toxicological properties. This study focused on its photodegradation under two irradiation conditions, aiming to be representative of environment (300-450 nm) and drinking water treatment (254 nm). The photodegradation experiments were conducted at two pH, to vary the methotrexate ionization state and to produce a large variety of transformation products (TPs). The degradation kinetics determined through LC-UV monitoring were contrasted according to pH and irradiation wavelength. However, the quantum yields were independent of ionization state at 254 nm and the changes in kinetics at higher wavelengths were attributed to a change in the degradation mechanism. The TPs formed during the reactions were identified by UHPLC-MS/MS, using both the positive and negative modes. Among the eleven proposed structures, five were described as methotrexate TPs for the first time. The TPs result from N-demethylation, glutamic acid oxidation, and C-N cleavage, all of them leading to further degraded photoproducts presenting modified or lost glutamic acid part. This was made possible thanks to the negative mode, which allowed the exploration of the glutamic acid moiety modifications. Cytotoxicity assessment on A549 cancer cells demonstrated that all photoproducts formed at pH 7 were less toxic than the parent compound.

Multi-Matrix Approach for the Analysis of Bicalutamide Residues in Oncology Centers by HPLC-FLD

Cytostatics are toxic pharmaceuticals, whose presence in surfaces puts healthcare workers at risk. These drugs might also end up in hospital effluents (HWW), potentially damaging aquatic ecosystems. Bicalutamide is a cytostatic extensively consumed worldwide, but few analytical methods exist for its quantification and most of them require advanced techniques, such as liquid chromatography mass spectrometry (LC-MS), which are very complex and expensive for large monitoring studies. Therefore, a simple but reliable multi-matrix high performance liquid chromatographic method, with fluorescence detection, was developed and validated to rapidly screen abnormal concentrations of bicalutamide in HWW and relevant contamination levels of bicalutamide in indoor surfaces (>100 pg/cm2), prior to confirmation by LC-MS. The method presents good linearity and relatively low method detection limits (HWW: 0.14 ng/mL; surfaces: 0.28 pg/cm2). Global uncertainty was below 20% for concentrations higher than 25 ng/mL (HWW) and 50 pg/cm2 (surfaces); global uncertainty was little affected by the matrix. Therefore, a multi-matrix assessment could be achieved with this method, thus contributing to a holistic quantification of bicalutamide along the cytostatic circuit. Bicalutamide was not detected in any of the grab samples from a Portuguese hospital, but an enlarged sampling is required to conclude about its occurrence and exposure risks.

Anticancer drugs in the aquatic ecosystem: Environmental occurrence, ecotoxicological effect and risk assessment

Anticancer drugs are a group of therapeutic agents used to enhance cell death in targeted cell types of neoplasia. Because of frequent use and eventual discharge, they have been often detected in wastewater from pharmaceutical factories and hospitals, domestic wastewater, and surface waters. The occurrence of these drugs in aquatic ecosystems and their effects on aquatic organisms have been poorly characterized. This review focuses on the global occurrence of major classes of anticancer drugs in water and sediments of freshwater ecosystems and their ecotoxicological effects at different biological levels. While the availability of data is fairly limited, concentrations of most anticancer drugs range from < 2 ng/L to 762 µg/L in receiving water, while levels in sediments and sludge vary from 0.25 to 42.5 µg/kg. Their detection frequencies were 58%, 52% (78%) and 59% in hospital wastewater, wastewater treatment plant effluents (influents) and surface water, respectively. Predicted log K_ow values of vincristine, imatinib mesylate and tamoxifen are higher than 3 and have estimated half-lives>60 d in waters using quantitative structure-activity relationship models, indicating high potential for persistence and bioaccumulation. Based on a species sensitivity distribution evaluation of 9 compounds, crustaceans are most sensitive to anticancer drugs. The most hazardous compound is cisplatin which has a hazard concentration at the 5th percentile. For Daphnia magna, the acute toxicities of major classes of anticancer drugs are ranked as platinum complexes > endocrine therapy agents > antibiotics > antimetabolite agents > alkylating agents. Using hazard quotient analysis based primarily on the lowest observed effect concentrations (LOECs), cyclophosphamide, cisplatin, 5-fluorouracil, imatinib mesylate, bicalutamide, etoposide and paclitaxel have the highest hazard for aquatic organisms. Further research is needed to identify appropriate chronic endpoints for risk assessment thresholds as well as to better understand the mechanisms of action and the potential multigenerational toxicity, and trophic transfer in ecosystems.

An Improved LC-MS/MS Method for the Analysis of Thirteen Cytostatics on Workplace Surfaces

Cytostatics are drugs used in cancer treatment, which pose serious risks to healthcare workers. Dermal absorption via surface contamination is the key exposure route; thus, rapid, reliable, and validated analytical methods for multicomponent detection are crucial to identify the exposure risk. A surface-wipe-sampling technique compatible with hospitals' safety requirements (gauze, 1 mL isopropanol) and a fast and simple extraction method (1 mL acetonitrile, 20 min ultrasonic bath, evaporation, reconstitution in 200 µL acetonitrile), coupled with liquid chromatography-tandem mass spectrometry analysis, were developed. It allowed identification and quantification of 13 cytostatics on surfaces: cyclophosphamide, doxorubicin, etoposide, ifosfamide, paclitaxel, bicalutamide, capecitabine, cyproterone, flutamide, imatinib, megestrol, mycophenolate mofetil, prednisone. Good linearity, sensitivity, and precision were achieved (R² > 0.997, IDLs < 4.0 pg/cm², average CV 16%, respectively). Accuracy for four model surfaces (melamine-coated wood, phenolic compact, steel 304, steel 316) was acceptable (80 ± 12%), except for capecitabine and doxorubicin. Global uncertainty is below 35% for concentrations above 100 pg/cm² (except for capecitabine and doxorubicin)-a guidance value for relevant contamination. Method application in a Portuguese university hospital (28 samples) identified the presence of seven cytostatics, at concentrations below 100 pg/cm², except for three samples. The widespread presence of cyclophosphamide evinces the necessity to review implemented procedures.

Effectiveness of Closed System Drug Transfer Devices in Reducing Leakage during Antineoplastic Drugs Compounding

This study, conducted in a centralized cytotoxic drug preparation unit, analyzes the effectiveness of two closed system drug transfer devices (CSTDs) in reducing leakage during antineoplastic drug compounding. Wipe/pad samplings inside and outside the preparation area were taken during surveillance programs from 2016 to 2021. All samples were analyzed for gemcitabine (GEM) contamination. In 2016, the presence of GEM in some samples and the contamination of the operators’ gloves in the absence of apparent drug spilling suggested unsealed preparation systems. In subsequent monitoring, GEM was also evaluated in the vial access device and in the access port system to the intravenous therapy bag of Texium^TM/SmartSite^TM and Equashield^® II devices after the reconstitution and preparation steps of the drug. The next checks highlighted GEM dispersion after compounding using Texium^TM/SmartSite^TM, with positive samples ranging from 9 to 23%. In contrast, gemcitabine was not present at detectable levels in the Equashield^® II system in all of the evaluated samples. The Equashield^® II closed system seems effectively able to eliminate spills and leakage during gemcitabine compounding. Since drugs with different viscosities can have different effects on CSTDs, Equashield^® II needs to be considered with other antineoplastic drugs during a structured surveillance program.

Cytostatics in Indoor Environment: An Update of Analytical Methods

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.

Blood contamination of the pharmaceutical staff by irinotecan and its two major metabolites inside and outside a compounding unit

BACKGROUND

Caregivers in healthcare settings are exposed to a risk of antineoplastic drug contamination which can lead to adverse health effects. Biological monitoring is necessary to estimate the actual level of exposure of these workers. This study was conducted with the aim of assessing blood contamination levels by irinotecan and its metabolites of pharmaceutical staff operating inside and outside a compounding unit.

METHODS

The study took place within the pharmaceutical unit of a French comprehensive cancer centre. Blood samples were collected from the pharmacy workers operating inside and outside the compounding unit, and analysed by UHPLC-MS/MS. Plasma and red blood cell irinotecan and its metabolites (SN-38; APC) were determined with a validated analytical method detection test.

RESULTS

A total of 17/78 (21.8%) plasma and red blood cell-based assays were found to be contaminated among staff. Overall, the total number of positive assays was significantly higher for staff members working outside the compounding unit than for workers working inside it (P = 0.022), with respectively 5/42 (11.9%) and 12/36 (33.3%) positive assays. For plasma dosages, the "outside" group had a significantly higher number of positive assays (P = 0.014). For red blood cell-based assays, no significant difference was found (P = 0.309).

CONCLUSIONS

This study reveals that pharmaceutical staff serving in health care settings are exposed to a risk of antineoplastic drug contamination, not only inside the compounding room but also in adjacent rooms. The results would help to raise awareness and potentially establish protective measures for caregivers working in areas close to the compounding room as well.

Chemical risk in hospital settings: Overview on monitoring strategies and international regulatory aspects

Chemical risk in hospital settings is a growing concern that health professionals and supervisory authorities must deal with daily. Exposure to chemical risk is quite different depending on the hospital department involved and might origin from multiple sources, such as the use of sterilizing agents, disinfectants, detergents, solvents, heavy metals, dangerous drugs, and anesthetic gases. Improving prevention procedures and constantly monitoring the presence and level of potentially toxic substances, both in workers (biological monitoring) and in working environments (environmental monitoring), might significantly reduce the risk of exposure and contaminations. The purpose of this article is to present an overview on this subject, which includes the current international regulations, the chemical pollutants to which medical and paramedical personnel are mainly exposed, and the strategies developed to improve safety conditions for all healthcare workers.

The efficiency of antineoplastic drug contamination removal by widely used disinfectants-laboratory and hospital studies

OBJECTIVE

Antineoplastic drugs (ADs) pose risks to healthcare staff. Surface disinfectants are used in hospitals to prevent microbial contamination but the efficiency of disinfectants to degrade ADs is not known. We studied nine disinfectants on ten ADs in the standardized laboratory and realistic in situ hospital conditions.

METHODS

A survey in 43 hospitals prioritized nine most commonly used disinfections based on different ingredients. These were tested on inert stainless steel and in situ on contaminated hospital flooring. The effects against ten ADs were studied by LC-MS/MS (Cyclophosphamide CP; Ifosfamide IF; Capecitabine CAP; Sunitinib SUN; Methotrexate MET; Doxorubicin DOX; Irinotecan IRI; Paclitaxel PX; 5-Fluorouracil FU) and ICP-MS (Pt as a marker of platinum-based ADs).

RESULTS

Monitoring of the floor contamination in 26 hospitals showed that the most contaminated are the outpatient clinics that suffer from a large turnover of staff and patients and have limited preventive measures. The most frequent ADs were Pt, PX, FU and CP with maxima exceeding the recommended 1 ng/cm² limit by up to 140 times. IRI, FU, MET, DOX and SUN were efficiently removed by hydrolysis in clean water and present thus lower occupational risk. Disinfectants based on hydrogen peroxide were efficient against PX and FU (> 70% degradation) but less against other ADs, such as carcinogenic CP or IF, IRI and CAP. The most efficient were the active chlorine and peracetic acid-based products, which however release irritating toxic vapors. The innovative in situ testing of ADs previously accumulated in hospital flooring showed highly problematic removal of carcinogenic CP and showed that alcohol-based disinfectants may mobilize persistent ADs contamination from deeper floor layers.

CONCLUSION

Agents based on hydrogen peroxide, peracetic acid, quaternary ammonium salts, glutaraldehyde, glucoprotamine or detergents can be recommended for daily use for both disinfection and AD decontamination. However, they have variable efficiencies and should be supplemented by periodic use of strong chlorine-based disinfectants efficient also against the carcinogenic and persistent CP.

Evaluation of a safe infusion device on reducing occupational exposure of nurses to antineoplastic drugs: a comparative prospective study. Contamoins-1

PURPOSE

Despite the decreasing of environmental contamination throughout the anticancer drug circuit, the administration of chemotherapies remains at risk of occupational exposure for nurses. Many medical devices aim at securing administration, but none have been scientifically evaluated to verify the actual improvement.

METHODS

A monocentric comparative before/after study was carried out in an oncology day hospital to evaluate the efficacy of Safe Infusion Devices in reducing drug exposure compared to usual infusion practices. The rate of nurses' gloves contamination was estimated. To avoid false negatives and to ensure sampling reproducibility, each sample of gloves was contaminated with a drop of topotecan. Association between contamination and other variables was investigated using a multivariate logistic regression analysis.

RESULTS

The usual practice led to a rate of 58.3% of contaminated samples while Safe Infusion Devices to a rate of 15%: Safe Infusion Devices reduced the risk of gloves contamination by 85% in multivariate analysis (Odds ratio = 0.15; 95% confidence interval = 0.05-0.46; p < 0.001). Topotecan was identified in 100% of the samples. Only one case of cross-contamination has occurred.

CONCLUSION

Despite the current practice of using neutral solvent-purged infusers, the occupational exposure remains high for nurses and Safe Infusion Devices significantly reduced this risk of exposure. However, glove contamination is only a surrogate endpoint. The results confirmed that the disconnection of empty bags resulted in occupational exposure. Except a contamination due to the leakage of a bag, no cross-contamination was detected. Safe Infusion Devices were highly effective but did not completely eliminate exposure.

Is the blood of a surgeon performing HIPEC contaminated by irinotecan, its major metabolites and platinum compounds?

Objectives

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a beneficial surgical technique for patients, but the surgeons are being exposed to cytotoxic drugs. Few biomonitoring studies were led on blood samples in the context of HIPEC. This study aimed to evaluate the surgeon’s plasmatic and red blood cell (RBC) contamination by irinotecan, two of its major metabolites and platinum compounds.

Methods

HIPEC procedures performed using the coliseum techniques were observed between September 2015 and April 2018 in a French comprehensive cancer center. Irinotecan and its metabolites SN-38 and APC were dosed by UHPLC with a limit of quantification determined at 50 pg/mL. Platinum compounds were dosed by inductively coupled plasma mass spectrometry with a limit of quantification determined at 16 pg/mL.

Results

Despite collective and personal protective equipment, 80% of plasma samples were contaminated by irinotecan and 33% by platinum compounds out of 21. The results showed that the surgeon was contaminated after HIPEC and even after a period of HIPEC inactivity. Nineteen percent of plasmatic samples and 45% of RBC samples were contaminated by SN-38, the active metabolite of irinotecan. APC was only found in some RBC samples (33%).

Conclusions

Even if this study shows blood contamination by irinotecan, two of its major metabolites (including active SN-38) and platinum compounds both in the plasma and RBC of a surgeon performing the HIPEC procedures, further studies should be performed to confirm these results. Additional studies should be carried out to further investigate the contamination in the context of HIPEC and more broadly in the hospital.

Detection of anti-cancer drugs and metabolites in the effluents from a large Brazilian cancer hospital and an evaluation of ecotoxicology

The use of chemotherapy agents has been growing worldwide, due to the increase number of cancer cases. In several countries, mainly in Europe countries, these drugs have been detected in hospitals and municipal wastewaters. In Brazil this issue is poorly explored. The main goal of this study was to assess the presence of three anti-cancer drugs, 5-fluorouracil (5-FU), gemcitabine (GEM) and cyclophosphamide (CP), and two metabolites, alpha-fluoro-beta-alanine (3-NH₂-F) and 2'-deoxy-2',2'-difluorouridine (2-DOH-DiF), in effluents from a large cancer hospital, in the municipal wastewater treatment plant (WWTP) influent and effluent, and also to evaluate toxicity of the mixtures of these compounds by ecotoxicological testing in zebrafish. The sample collections were performed in Barretos Cancer Hospital of the large cancer center in Brazil. After each collection, the samples were filtered for subsequent Liquid Chromatography Mass Spectrometry analysis. The presence of CP, GEM, and both metabolites (3-NH₂-F and 2-DOH-DiF) were detected in the hospital wastewater and the WWTP influent. Three drugs, GEM, 2-DOH-DiF and CP, were detected in the WWTP effluent. Two drugs were detected below the limit of quantification, 2-DOH-DiF: <LOQ (above 1400 ng L^-1) and CP: <LOQ (above 300 ng L^-1), and GEM was quantified at 420 ng L^-1. Furthermore, 2-DOH-DiF (116,000 ng L^-1) was detected at the highest level in the hospital wastewater. There were no zebrafish deaths at any of the concentrations of the compounds used. However, we observed histological changes, including aneurysms and edema in the gills and areas of necrosis of the liver. In summary, we found higher concentrations of CP, GEM and both metabolites (3-NH₂-F and 2-DOH-DiF) were detected for the first time. There is currently no legislation regarding the discharge of anti-cancer drugs in effluents in Brazil. This study is first to focus on effluents from specific treatments from a large cancer hospital located in small city in Brazil.

The application of novel field measurement and field evaluation protocols for assessing health care workers' exposure risk to antineoplastic drugs

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.

Occupational exposure of pharmacy technicians and cleaning staff to cytotoxic drugs in Dutch hospitals

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.

Environmental assessment of cytotoxic drugs in the Oncology Center of Cyprus

Background

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

Methods

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

Results

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

Conclusions

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

A fully validated simple new method for environmental monitoring by surface sampling for cytotoxics

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.

Study protocol for the assessment of nurses internal contamination by antineoplastic drugs in hospital centres: a cross-sectional multicentre descriptive study

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.

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

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.

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

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

A case study to identify priority cytostatic contaminants in hospital effluents

This study analyses the presence of 17 cytostatic agents from seven different groups, based on their different mechanisms of action, in the effluent from a medium-sized hospital located in eastern Spain. Analysis of the compounds found in the effluents studied involved solidphase extraction (SPE) coupled on-line to a high performance liquid chromatograph tandem mass spectrometer (HPLC-MS/MS). The environmental risk of the compounds studied was then assessed by calculating the hazard quotient (HQ), combining the measured environmental concentrations (MECs) with dose-response data based on the predicted no effect concentrations (PNECs). In addition, the environmental hazard associated was evaluated in accordance with their intrinsic characteristics by calculating the PBT (Persistence Bioaccumulation Toxicity) index. The results of this study showed the presence of seven of the 17 compounds analysed in a range of between 25 and 4761 ng/L. The highest concentrations corresponded to ifosfamide (58-4761 ng/L), methotrexate (394-4756 ng/L) and cyclophosphamide (46-3000 ng/L). Assessment of the environmental hazard showed that the three hormonal agents (tamoxifen and its metabolites endoxifen and hydroxytamoxifen) exhibited a maximum PBT value of 9 due to their inherent harm to the environment resulting from their characteristics of persistence, bioaccumulation and toxicity. A combined evaluation of the risk and environmental hazard showed that three of the 17 compounds studied, namely, ifosfamide, imatinib and irinotecan, all of which exhibited HQ values higher than 10 and PBT indices of 6, indicative of a particularly high potential to harm the environment, deserve special attention.

Foreword

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).

A strategy for formulating regulation on CSTDs

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.

Measuring extent of surface contamination produced by the handling of antineoplastic drugs in low- to middle-income country oncology health care settings

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.

A review of high performance liquid chromatographic-mass spectrometric urinary methods for anticancer drug exposure of health care workers

This review describes published high performance liquid chromatography/mass spectrometry (HPLC-MS) methods for the determination of anticancer drugs in human urine as non-invasive tool for monitoring of health care worker exposure to antineoplastic and cytotoxic drugs. HPLC-MS is a sensitive and specific method for analysis of anticancer drugs and their metabolites in biological fluids. In this review, a tabular summary and overview of published HPLC-MS methods are presented, as well as future trends and limitations in this area of research.

New approaches to wipe sampling methods for antineoplastic and other hazardous drugs in healthcare settings

PURPOSE

At the present time, the method of choice to determine surface contamination of the workplace with antineoplastic and other hazardous drugs is surface wipe sampling and subsequent sample analysis with a variety of analytical techniques. The purpose of this article is to review current methodology for determining the level of surface contamination with hazardous drugs in healthcare settings and to discuss recent advances in this area. In addition it will provide some guidance for conducting surface wipe sampling and sample analysis for these drugs in healthcare settings.

METHODS

Published studies on the use of wipe sampling to measure hazardous drugs on surfaces in healthcare settings drugs were reviewed. These studies include the use of well-documented chromatographic techniques for sample analysis in addition to newly evolving technology that provides rapid analysis of specific antineoplastic.

RESULTS

Methodology for the analysis of surface wipe samples for hazardous drugs are reviewed, including the purposes, technical factors, sampling strategy, materials required, and limitations. The use of lateral flow immunoassay (LFIA) and fluorescence covalent microbead immunosorbent assay (FCMIA) for surface wipe sample evaluation is also discussed.

CONCLUSIONS

Current recommendations are that all healthcare settings where antineoplastic and other hazardous drugs are handled include surface wipe sampling as part of a comprehensive hazardous drug-safe handling program. Surface wipe sampling may be used as a method to characterize potential occupational dermal exposure risk and to evaluate the effectiveness of implemented controls and the overall safety program. New technology, although currently limited in scope, may make wipe sampling for hazardous drugs more routine, less costly, and provide a shorter response time than classical analytical techniques now in use.

Products of methotrexate during chlorination

Methotrexate (MTX) is a cytotoxic drug widely used in the treatment of tumors, autoimmune diseases and severe asthma. jen00883This drug has been frequently detected in the aquatic environment with concentrations up to μg/L levels. The MTX present in environmental water might be transformed and removed during chlorination disinfection treatment. In this work, the fate of MTX during aqueous chlorination was investigated in laboratory batch experiments, and the transformation products of MTX were identified. Aqueous solutions of MTX (1mg/L) were chlorinated by sodium hypochlorite solution at room temperature under neutral pH conditions. Chlorinated products were pre-concentrated with solid-phase extraction (SPE) cartridges and determined by liquid chromatography electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS). The reaction of MTX chlorination exhibited pseudo-first-order kinetics and the half-life time of MTX degradation was calculated to be 1.65min, when the initial chlorine concentration was 2mg/L. Two chlorinated MTX congeners, 4-amino-3-chlorinated-N10-methylpteroylglutamic (monochloro-MTX) and 4-amino-3,5-dichloro-N10-methylpteroylglutamic (dichloro-MTX) were found in the chlorinated solution. Monochloro-MTX was successfully fractionated by high performance liquid chromatography (HPLC) and its structure was further identified using ¹H nuclear magnetic resonance (NMR) analysis. The presence of the two products in real hospital wastewater was then examined and both compounds were detected. Finally, the effects of MTX and monochloro-MTX on the cell cycle progression in vitro were evaluated using zebrafish liver cell line. It was found that both compounds could inhibit the proliferation of zebrafish liver cells through S phase arrest and their effects on the cell cycle profile had no significant difference.

A review of surface wipe sampling compared to biologic monitoring for occupational exposure to antineoplastic drugs

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.

Testing an Intervention to Decrease Healthcare Workers' Exposure to Antineoplastic Agents

PURPOSE/OBJECTIVES

To develop and test a worksite intervention that protects healthcare workers who handle antineoplastic drugs from work-related exposures. 
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DESIGN

Intervention study. 
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SETTING

A university hospital in a large midwestern metropolitan area and its outpatient chemotherapy infusion clinic.
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SAMPLE

163 staff (nurses, pharmacists, and pharmacy technicians) who work with antineoplastic agents.
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METHODS

A self-report survey measured workplace and individual factors to assess use of personal protective equipment (PPE). Wipe samples were tested for surface contamination. An intervention incorporating study findings and worker input was developed.
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MAIN RESEARCH VARIABLES

PPE use was the dependent variable, and the independent variables included knowledge of the hazard, perceived risk, perceived barriers, interpersonal influence, self-efficacy, conflict of interest, and workplace safety climate. 
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FINDINGS

PPE use was lower than recommended and improved slightly postintervention. Self-efficacy and perceived risk increased on the post-test survey. Chemical residue was found in several areas. Awareness of safe-handling precautions improved postintervention. The unit where nurses worked was an important predictor of safety climate and PPE use on the pretest but less so following the intervention. 
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CONCLUSIONS

Involving staff in developing an intervention for safety ensures that changes made will be feasible. Units that implemented workflow changes had decreased contamination. 
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IMPLICATIONS FOR NURSING

Worksite analysis identifies specific targets for interventions to improve antineoplastic drug handling safety.

Effectiveness of activated carbon masks in preventing anticancer drug inhalation

Background

The exposure of healthcare workers to anticancer drugs such as cyclophosphamide (CPA) is a serious health concern. Anticancer drug pollution may spread outside biological safety cabinets even when a closed system is used. The inhalation of vaporized anticancer drugs is thought to be the primary route of exposure. Therefore, it is important that healthcare workers wear masks to prevent inhalation of anticancer drugs. However, the permeability of medical masks to vaporized anticancer drugs has not been examined. Furthermore, the performance differences between masks including activated carbon with chemical adsorptivity and non-activated carbon masks are uncertain. We investigated activated carbon mask permeability to vaporized CPA, and assessed whether inhibition of vaporized CPA permeability was attributable to the masks’ adsorption abilities.

Methods

A CPA solution (4 mg) was vaporized in a chamber and passed through three types of masks: Pleated-type cotton mask (PCM), pleated-type activated carbon mask (PAM), and stereoscopic-type activated carbon mask (SAM); the flow rate was 1.0 L/min for 1 h. The air was then recovered in 50 % ethanol. CPA quantities in the solution were determined by liquid chromatography time-of-flight mass spectrometry. To determine CPA adsorption by the mask, 5 cm² of each mask was immersed in 10 mL of CPA solution (50–2500 μg/mL) for 1 h. CPA concentrations were measured by high-performance liquid chromatography with ultraviolet detection.

Results

For the control (no mask), 3.735 ± 0.543 μg of CPA was recovered from the aerated solution. Significantly lower quantities were recovered from PCM (0.538 ± 0.098 μg) and PAM (0.236 ± 0.193 μg) (p < 0.001 and p < 0.001 vs control, respectively). CPA quantities recovered from all of SAM samples were below the quantification limit. When a piece of the SAM was immersed in the CPA solution, a marked decrease to less than 3.1 % of the initial CPA concentration was observed.

Conclusion

The SAM exhibited good adsorption ability, and this characteristic may contribute to avoiding inhalation exposure to vaporized CPA. These results suggest that wearing activated carbon masks may prevent anticancer drug inhalation by healthcare workers.