Exposure of pharmacy technicians to antineoplastic agents: reevaluation after additional protective measures

Occupational exposure to antineoplastic drugs: what about hospital sanitation personnel?

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.

Protection behaviors for cytotoxic drugs in oncology nurses of chemotherapy centers in Shiraz hospitals, South of Iran

CONTEXT

The use of antineoplastic agents for the treatment of cancer is an increasingly common practice in hospitals. As a result, workers involved with handling antineoplastic drugs may be accidentally exposed to these agents, placing them at potential risk for long-term adverse effects. This study aimed to determine the occupational protection status of clinical nursing staff exposed to cytotoxic drugs.

SUBJECTS AND METHODS

The study was designed as an analytic descriptive survey. The research settings took place in six centers of chemotherapy in Shiraz, Iran. The participants were 86 nurses who worked in oncology units and administered cytotoxic drugs. Data were collected using a questionnaire and a checklist which was developed by the investigators to determine occupational protection status of clinical nursing staff exposed to cytotoxic drugs. Percentage calculations and the independent samples t-test were used to see the general distribution and analysis of data. To statistically analyze of the data, SPSS software (version 16) was applied.

RESULTS

The mean age of participants was 30.52 ± 6.50 years and 66.27% of the nurses worked on inpatient oncology wards. The mean practice score was 21.1 ± 3.76 that ranged from 12.5 to 31. The independent samples t-test showed the outpatient nurses were weaker in practice (17.2 ± 2.52) in comparison with university hospitals (23.35 ± 3.02, P < 0.001). Occupational protection status of clinical nursing staff exposed to cytotoxic drugs especially during administration and disposal of medicines was poor and rarely trained with this subject and was observed under the standard conditions.

CONCLUSIONS

There is deficiency in the understanding and related protection practices of clinical nursing staff vocationally exposed to cytotoxic drugs. It is recommended that all clinical nursing staff should receive full occupational protection training about these matters and the authorities provide standard conditions of oncology wards.

Evaluation of external contamination on the vial surfaces of some hazardous drugs that commonly used in Chinese hospitals and comparison between environmental contamination generated during robotic compounding by IV: Dispensing robot vs. manual compounding in biological safety cabinet

Objectives

The aims of the study were to evaluate the external contamination of hazardous drug vials used in Chinese hospitals and to compare environmental contamination generated by a robotic intelligent dispensing system (WEINAS) and a manual compounding procedure using a biological safety cabinet (BSC).

Methods

Cyclophosphamide, fluorouracil, and gemcitabine were selected as the representative hazardous drugs to monitor surface contamination of vials. In the comparative analysis of environmental contamination from manual and robotic compounding, wipe samples were taken from infusion bags, gloves, and the different locations of the BSC and the WEINAS robotic system. In this study, high-performance liquid chromatography coupled with double mass spectrometer (HPLC-MS/MS) was employed for sample analysis.

Results

(1) External contamination was measured on vials of all three hazardous drugs. The contamination detected on fluorouracil vials was the highest with an average amount up to 904.33 ng/vial, followed by cyclophosphamide (43.51 ng/vial), and gemcitabine (unprotected vials of 5.92 ng/vial, protected vials of 0.66 ng/vial); (2) overall, the environmental contamination induced by WEINAS robotic compounding was significantly reduced compared to that by manual compounding inside the BSC. Particularly, compared with manual compounding, the surface contamination on the infusion bags during robotic compounding was nearly nine times lower for cyclophosphamide (10.62 ng/cm² vs 90.43 ng/cm²), two times lower for fluorouracil (3.47 vs 7.52 ng/cm²), and more than 23 times lower for gemcitabine (2.61 ng/cm² vs 62.28 ng/cm²).

Conclusions

The external contamination occurred extensively on some hazardous drug vials that commonly used in Chinese hospitals. Comparison analysis for both compounding procedures revealed that robotic compounding can remarkably reduce environmental contamination.

Report on 2020 Safe to Touch Consensus Conference on Hazardous Drug Surface Contamination

PURPOSE

The 2020 Safe to Touch Consensus Conference on Hazardous Drug Surface Contamination was convened in order to gather subject matter experts in the field of hazardous drug (HD) handling to develop consensus statements regarding surface contamination monitoring for adoption by stakeholders in the drug supply chain, policy, and healthcare arenas.

SUMMARY

The Safe to Touch conference convened virtually on September 22, 24, and 26, 2020. An expert panel of healthcare providers with experience in HD handling, monitoring, and research; pharmacy and nursing operations; and medication safety led the conference. An experienced audience of approximately 25 reaction panel members provided feedback to the panel via a preconference survey, during the conference, and at a postconference virtual town hall. Additionally, expert speakers presented on a range of issues, including the impact of HD surface contamination on health, current regulations and standards, surface contamination monitoring technologies, and variables impacting surface contamination testing.

CONCLUSION

At the end of the conference, the expert panel developed 11 consensus statements and corresponding recommendations that should be widely disseminated in order to educate individuals regarding the impact of HD surface contamination and increase the scope of HD surface contamination monitoring. Institutions involved in the handling of HDs should set short- and long-term goals for implementation of applicable consensus statements.

Clinical, economic and organizational impact of pharmacist interventions on injectable antineoplastic prescriptions: a prospective observational study

Background

Pharmacists play a key role in ensuring the safe use of injectable antineoplastics, which are considered as high-alert medications. Pharmaceutical analysis of injectable antineoplastic prescriptions aims to detect and prevent drug related problems by proposing pharmacist interventions (PI). The impact of this activity for patients, healthcare facilities and other health professionals is not completely known. This study aimed at describing the clinical, economic, and organizational impacts of PIs performed by pharmacists in a chemotherapy preparation unit.

Methods

A prospective 10-week study was conducted on PIs involving injectable antineoplastic prescriptions. Each PI was assessed by one of the four multidisciplinary expert committees using a multidimensional tool with three independent dimensions: clinical, economic and organizational. An ancillary quantitative evaluation of drug cost savings was conducted.

Results

Overall, 185 patients were included (mean age: 63.5 ± 13.7 years; 54.1% were male) and 237 PIs concerning 10.1% prescriptions were recorded. Twenty one PIs (8.9%) had major clinical impact (ie: prevented hospitalization or permanent disability), 49 PIs (20.7%) had moderate clinical impact (ie: prevented harm that would have required further monitoring/treatment), 62 PIs (26.2%) had minor clinical impact, 95 PIs (40.0%) had no clinical impact, and 9 PIs (3.8%) had a negative clinical impact. For one PI (0.4%) the clinical impact was not determined due to insufficient information. Regarding organizational impact, 67.5% PIs had a positive impact on patient management from the healthcare providers’ perspective. A positive economic impact was observed for 105 PIs (44.3%), leading to a saving in direct drug costs of 15,096 €; 38 PIs (16.0%) had a negative economic impact, increasing the direct drug cost by 11,878 €. Overall cost saving was 3218€.

Conclusions

PIs are associated with positive clinical, economic and organizational impacts. This study confirms the benefit of pharmacist analysis of injectable antineoplastic prescriptions for patient safety with an overall benefit to the healthcare system.

Important exposure controls for protection against antineoplastic agents: Highlights for oncology health care workers

BACKGROUND

A great number of antineoplastic drugs (ANPDs) are used globally in cancer treatment. Due to their adverse health effects, occupational exposure to ANPDs is considered a potential health risk to health care workers.

OBJECTIVE

The current study aimed to evaluate safe-handling practices of ANPDs, exposure controls, and adverse health implications for health care providers exposed to ANDPs.

METHODS

Prevention measures, including engineering, administrative, and work practice controls, as well as personal protective equipment (PPE), were recorded daily through a questionnaire for six weeks. Acute adverse health effects experienced by health care workers were also documented.

RESULTS

The implemented exposure controls for preparation, administration, cleaning, and waste disposal were not in accordance with the safe handling guidelines. Central nervous system disorders (26.33%) were the most frequent acute adverse effects reported by health care workers. A significant correlation was found between the number of experienced adverse effects and handling characteristics, including the number of preparations (r = 0.38, p < 0.05), dose, and the number of prepared drugs (r = 0.46, p < 0.01 and 0.39, p < 0.05), and working hours in different locations of oncology setting for six weeks (preparation room: r = 0.38, P < 0.05, treatment room: r = 0.46, P < 0.01, patient room: r = 0.63, P < 0.01, and station: r = 0.68, P < 0.01).

CONCLUSIONS

Due to inadequate control measures, oncology health care workers were in danger of exposure to ANPDs and experienced acute adverse health effects. Implementation of appropriate exposure controls is required to prevent occupational exposure to ANPDs.

Evaluation of the PhaSeal Hazardous Drug Containment System

PhaSeal is a containment system designed to ensure the safe preparation and administration of cytostatic drugs and thus reduce environmental contamination to work areas and to medical and support staff. The PhaSeal system was tested in an outpatient setting in Sweden for 1 year during the preparation and administration of cyclophosphamide, fluorouracil, and similar cytostatic drugs. The study was designed to determine the effectiveness of PhaSeal in preventing the leakage of cytostatic drugs frequently reported in a number of studies. Cytostatic drugs were prepared and administered using standard safety procedures, except that a biological safety cabinet was not used. At the conclusion of the study period, environmental contamination was determined from wiping samples of objects and surfaces in the drug preparation room. Neither cyclophosphamide nor fluorouracil was found in any of these samples. Results show that use of the PhaSeal system alone is sufficient to prevent environmental contamination during the preparation of cytostatic drugs.

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.

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.

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.

[Occupational exposures among nurses caring for chemotherapy patients -Quantitative analysis of cyclophosphamide and α-fluoro-β-alanine in urine]

OBJECTIVES

The aim of this study was to measure the antineoplastic drug content in urine and verify the situation of occupational exposure of the antineoplastic drug among nurses who care for patients undergoing chemotherapy.

METHODS

Ten female nurses who were caring for patients receiving chemotherapy were the subjects of this study. Urine samples were collected over 24-hour periods, and each sample was analyzed. The excretion of cyclophosphamide (CP) and α-fluoro-β-alanine (FBAL) were measured in the urine of the 10 nurses. CP and FBAL were detected separately using gas chromatography tandem mass spectrometry (GC-MSMS) methods (Exposure Control, the Netherlands).

RESULT

CP was detected in 24 urine samples of 9 nurses. The total amount of CP excreted ranged from 5.4 to 44.2 ng/24-hours. The mean amount of CP excreted per nurse was 16.8 ng/24-hours. No significant difference was observed between the hospital I and II. FBAL was not detected in any of the urine samples. CP was detected in the urine of the nurses prior to their work shift. Moreover, CP was detected in the urine of the nurses who were not caring for patients in the intravenous drip of CP. There was most what answered that there was hair loss in health condition.

CONCLUSION

The results reveal that almost all nurses were exposed to cyclophosphamide. Even when the patient in the intravenous drip of CP was not being cared for, it became clear that exposure by CP existed. As the route of the exposure to CP, the inhalation or dermal absorption can be considered. To ensure minimum exposed to antineoplastic drugs, suitable personal protective equipment needs to be equipped also of various scenes of caring for chemotherapy patients. Moreover, it is important to keep an eye on the monitoring of the antineoplastic drug in the environment and a nurse's health condition periodically going forward.

External contamination of vials containing cytotoxic agents supplied by pharmaceutical manufacturers

Objectives. The aim of this report was to study the external contamination of vials of 5-fluorour-acil, cyclophosphamide, ifosfamide, etoposide, doxorubicin and docetaxel. It also investigated the possible contamination of 5-fluorouracil outer packaging.

Methods. External contamination was measured on vials containing 5-fluorouracil, etoposide, cyclophosphamide, ifosfamide, doxorubicin and docetaxel. Samples from the outer wall of the vials were obtained by immersing and rotating the stoppered vials for 30 seconds in water for injections.

Results. All vials tested were contaminated with quantities varying from 0.5 ng to 2.4 g per vial, depending on the supplier. The outer packaging containing 25 vials of 5-fluorouracil was contaminated with 1.5 g, but no contamination was detected on the plastic packaging of etoposide.

Conclusion. These results demonstrate that the environment of operators may be contaminated, even in the absence of any handling error, and that contamination is present even before the cytotoxic reconstitution has begun. This source of exposure to cytotoxics may account for the contamination detected in the urine of operators. We demonstrate the necessity of protecting effectively all skin surfaces that are likely to come into contact with antineoplastic agents when unpacking the vials. Wearing long disposable gloves with adequate thickness (such as surgical gloves) is strongly recommended, from the very moment operators enter the preparation room. In general, the contamination of operators can only be controlled efficiently when all possible sources of contamination are considered, and suitable protection facilities are used (safety cabinet or isolator).

Surface wipe sampling for antineoplastic (chemotherapy) and other hazardous drug residue in healthcare settings: Methodology and recommendations

Surface wipe sampling for various hazardous agents has been employed in many occupational settings over the years for various reasons such as evaluation of potential dermal exposure and health risk, source determination, quality or cleanliness, compliance, and others. Wipe sampling for surface residue of antineoplastic and other hazardous drugs in healthcare settings is currently the method of choice to determine surface contamination of the workplace with these drugs. The purpose of this article is to review published studies of wipe sampling for antineoplastic and other hazardous drugs, to summarize the methods in use by various organizations and researchers, and to provide some basic guidance for conducting surface wipe sampling for these drugs in healthcare settings.  Recommendations on wipe sampling methodology from several government agencies and organizations were reviewed. Published reports on wipe sampling for hazardous drugs in numerous studies were also examined. The critical elements of a wipe sampling program and related limitations were reviewed and summarized.  Recommendations and guidance are presented concerning the purposes of wipe sampling for antineoplastic and other hazardous drugs in the healthcare setting, technical factors and variables, sampling strategy, materials required, and limitations. The reporting and interpretation of wipe sample results is also discussed.  It is recommended that all healthcare settings where antineoplastic and other hazardous drugs are handled consider wipe sampling as part of a comprehensive hazardous drug "safe handling" program. Although no standards exist for acceptable or allowable surface concentrations for these drugs in the healthcare setting, 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. A comprehensive safe-handling program for antineoplastic drugs may utilize wipe sampling as a screening tool to evaluate environmental contamination and strive to reduce contamination levels as much as possible, using the industrial hygiene hierarchy of controls.

How to protect environment and employees against cytotoxic agents, the UZ Ghent experience

Objective. To compare two different systems for the reconstitution and preparation of cytotoxic drug-containing infusion bags. The Classical System (open) uses Luer lock syringes and needles, and the PhaSealA System (closed) uses special devices.

Methods. Both wipe samples of the Biological Safety Cabinet (BSC) plus surroundings and urine analysis of technicians and pharmacists involved in the preparatory activities were used. Analyses were performed using gas chromatography in tandem with mass spectroscopy.

Results. An important difference has been found in the surface contamination rate and in the number, periods and values of contaminated urine samples in favour of the closed PhaSealA System. J Oncol Pharm Practice (2001) 6, 146-152.

DrugCam®-An intelligent video camera system to make safe cytotoxic drug preparations

DrugCam(®) is a new approach to control the chemotherapy preparations with an intelligent video system that enables automatic verification during the critical stages of preparations combined with an a posteriori control with partial or total visualization of the video recording of preparations. The assessment was about the recognizing of anticancer drug vials (qualitative analysis) and syringe volumes (quantitative analysis). The qualitative analysis was conducted for a total of 120 vials with sensitivity of 100% for 84.2% of the vials and at least 97% for all the vials tested. Accuracy was at least 98.5% for all vials. The quantitative analysis was assessed by detecting 10 measures of each graduation for syringes. The identification error rate was 2.1% (244/11,640) i.e. almost 94% to the next graduation. Only 3% (35/1164) of the graduations tested, i.e. 23/35 for volume <0.13 ml of 1 ml syringes, presented a volume error outside the admissible limit of ± 5% of a confidence band constructed for the estimated linear regression line for each syringe. In addition to the vial detection model, barcodes can also read when they are present on vials. DrugCam(®) offers an innovative approach for controlling chemotherapy preparations and constitutes an optimized application of telepharmacy.

Comparative analysis of methods for real-time analytical control of chemotherapies preparations

Control of chemotherapies preparations are now an obligation in France, though analytical control is compulsory. Several methods are available and none of them is presumed as ideal. We wanted to compare them so as to determine which one could be the best choice. We compared non analytical (visual and video-assisted, gravimetric) and analytical (HPLC/FIA, UV/FT-IR, UV/Raman, Raman) methods thanks to our experience and a SWOT analysis. The results of the analysis show great differences between the techniques, but as expected none us them is without defects. However they can probably be used in synergy. Overall for the pharmacist willing to get involved, the implementation of the control for chemotherapies preparations must be widely anticipated, with the listing of every parameter, and remains according to us an analyst's job.

Efficacy of Two Cleaning Solutions for the Decontamination of 10 Antineoplastic Agents in the Biosafety Cabinets of a Hospital Pharmacy

OBJECTIVE

This study aimed to evaluate two cleaning solutions for the chemical decontamination of antineoplastic agents on the surfaces of two biosafety cabinets routinely used for chemotherapy preparation in a hospital pharmacy.

METHODS

For almost 1 year (49 weeks), two different solutions were used for the weekly cleaning of two biosafety cabinets in a hospital pharmacy's centralized cytotoxic preparation unit. The solutions evaluated were a commercial solution of isopropyl alcohol (IPA) and water (70:30, vol:vol), and a detergent solution constituted by 10(-2)M of sodium dodecyl sulfate (SDS) with 20% IPA. Seven areas in each biosafety cabinet were wiped 14 times throughout the year, before and after the weekly cleaning process, according to a validated procedure. Samples were analyzed using a validated method of high-performance liquid chromatography coupled to mass spectrometry. The decontamination efficacy of these two solutions was tested for 10 antineoplastic agents: cytarabine, gemcitabine, methotrexate, etoposide phosphate, irinotecan, cyclophosphamide, ifosfamide, doxorubicin, epirubicin, and vincristine.

RESULTS

Overall decontamination efficacies observed were 82±6% and 49±11% for SDS solution and IPA, respectively. Higher contamination levels were distributed on areas frequently touched by the pharmacy technicians-such as sleeves and airlock handles-than on scale plates, gravimetric control hardware, and work benches. Detected contaminations of cyclophosphamide, ifosfamide, gemcitabine, and cytarabine were higher than those of the others agents. SDS solution was almost 20% more efficient than IPA on eight of the antineoplastic agents.

CONCLUSION

Both cleaning solutions were able to reduce contamination levels in the biosafety cabinets. The efficacy of the solution containing an anionic detergent agent (SDS) was shown to be generally higher than that of IPA and, after the SDS cleaning procedure, biosafety cabinets demonstrated acceptable contamination levels.

Cleaning Efficiencies of Three Cleaning Agents on Four Different Surfaces after Contamination by Gemcitabine and 5-fluorouracile

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.

Evaluation of a closed-system cytotoxic transfer device in a pharmaceutical isolator

PURPOSE

The occupational risk associated with handling of cytotoxic anticancer drugs is well documented and, in many countries, pharmaceutical isolators are used to contain cytotoxic residues during preparation of cytotoxic infusions. Isolators are difficult to clean leading to concerns that cytotoxic contamination from the work area could be transferred to surfaces of products leaving the isolator. This study investigated the surface contamination arising from the preparation of five anticancer drug infusions (Epirubicin, Fluorouracil, Cisplatin, Oxaliplatin and Carboplatin) in a pharmaceutical isolator and compared use of a conventional syringe and needle technique with a closed-system drug transfer device (CSDTD).

METHODS

Wipe samples were taken over 1 week from pre-defined areas in the isolator, gloves, preparation mats, and also from the surfaces of prepared cytotoxic infusion bags and pre-filled syringes to obtain baseline surface contamination data. Following operator familiarisation, the CSDTD was then introduced and sampling repeated for a further week (intervention period). The samples obtained were analysed using validated HPLC-UV, HPLC-FL and ICP-MS techniques, as appropriate.

RESULTS

All surfaces sampled during baseline, including external surfaces of infusions and syringes, were contaminated with each marker drug. During the intervention phase, isolator surfaces were free from detectable contamination and the contamination measured on gloves, preparation mats and surface of infusions was markedly reduced. The frequency of contamination on syringe and infusion surfaces was also lower.

CONCLUSION

Surface contamination from cytotoxic infusion preparation in a pharmaceutical isolator was significant and could transmit cytotoxic residues to patient and public areas via infusion surfaces. The frequency and amount of contamination were reduced by the CSDTD.

Environmental contamination, product contamination and workers exposure using a robotic system for antineoplastic drug preparation

Environmental contamination, product contamination and technicians exposure were measured following preparation of iv bags with cyclophosphamide using the robotic system CytoCare. Wipe samples were taken inside CytoCare, in the clean room environment, from vials, and prepared iv bags including ports and analysed for contamination with cyclophosphamide. Contamination with cyclophosphamide was also measured in environmental air and on the technicians hands and gloves used for handling the drugs. Exposure of the technicians to cyclophosphamide was measured by analysis of cyclophosphamide in urine. Contamination with cyclophosphamide was mainly observed inside CytoCare, before preparation, after preparation and after daily routine cleaning. Contamination outside CytoCare was incidentally found. All vials with reconstituted cyclophosphamide entering CytoCare were contaminated on the outside but vials with powdered cyclophosphamide were not contaminated on the outside. Contaminated bags entering CytoCare were also contaminated after preparation but non-contaminated bags were not contaminated after preparation. Cyclophosphamide was detected on the ports of all prepared bags. Almost all outer pairs of gloves used for preparation and daily routine cleaning were contaminated with cyclophosphamide. Cyclophosphamide was not found on the inner pairs of gloves and on the hands of the technicians. Cyclophosphamide was not detected in the stationary and personal air samples and in the urine samples of the technicians. CytoCare enables the preparation of cyclophosphamide with low levels of environmental contamination and product contamination and no measurable exposure of the technicians.

Reduction in Surface Contamination With Cyclophosphamide in 30 US Hospital Pharmacies Following Implementation of a Closed-System Drug Transfer Device

PURPOSE

In a follow-up to a previous study, surface contamination with the antineoplastic drug cyclophosphamide was compared in 30 US hospital pharmacies from 2004 to 2010 following preparation with standard drug preparation techniques or the PhaSeal closed system drug transfer device (CSTD).

METHODS

Wipe samples were taken from biological safety cabinet (BSC) surfaces, BSC airfoils (the front leading edge of the BSC), floors in front of BSCs, and countertops in the pharmacy, and they were analyzed for contamination with cyclophosphamide. Contamination was reassessed after a minimum of 6 months following the implementation of the CSTD. Surface contamination (ng/cm(2)) was compared between the 2 techniques and between the previous and current test periods and evaluated with the Kruskal-Wallis test.

RESULTS

With the use of CSTD compared to the standard preparation techniques, a significant reduction in levels of contamination with cyclophosphamide was observed (P < .0001). Median values for surface contamination with cyclophosphamide were reduced by 86% compared to 95% in the previous study.

CONCLUSIONS

The CSTD significantly reduced, but did not totally eliminate, surface contamination with cyclophosphamide. In addition to other protective measures, increased usage of CSTDs should be employed to help protect health care workers from exposure to hazardous drugs.

Pharmaceutical dust exposure at pharmacies using automatic dispensing machines: a preliminary study

Automatic dispensing machines (ADMs) used in pharmacies concentrate and dispense large volumes of pharmaceuticals, including uncoated tablets that can shed dust. We evaluated 43 employees' exposures to pharmaceutical dust at three pharmacies where ADMs were used. We used an optical particle counter to identify tasks that generated pharmaceutical dust. We collected 72 inhalable dust air samples in or near the employees' breathing zones. In addition to gravimetric analysis, our contract laboratory used internal methods involving liquid chromatography to analyze these samples for active pharmaceutical ingredients (APIs) and/or lactose, an inactive filler in tablets. We had to choose samples for these additional analyses because many methods used different extraction solvents. We selected 57 samples for analysis of lactose. We used real-time particle monitoring results, observations, and information from employees on the dustiness of pharmaceuticals to select 28 samples (including 13 samples that were analyzed for lactose) for analysis of specific APIs. Pharmaceutical dust was generated during a variety of tasks like emptying and refilling of ADM canisters. Using compressed air to clean canisters and manual count machines produced the overall highest peak number concentrations (19,000-580,000 particles/L) of smallest particles (count median aerodynamic diameter ≤ 2 μm). Employees who refilled, cleaned, or repaired ADM canisters, or hand filled prescriptions were exposed to higher median air concentrations of lactose (5.0-12 μg/m(3)) than employees who did other jobs (0.04-1.3 μg/m(3)), such as administrative/office work, labeling/packaging, and verifying prescriptions. We detected 10 APIs in air, including lisinopril, a drug prescribed for high blood pressure, levothyroxine, a drug prescribed for hypothyroidism, and methotrexate, a hazardous drug prescribed for cancer and other disorders. Three air concentrations of lisinopril (1.8-2.7 μg/m(3)) exceeded the lower bound of the manufacturer's hazard control band (1-10 μg/m(3)). All other API air concentrations were below applicable occupational exposure limits. Our findings indicate that some pharmacy employees are exposed to multiple APIs and that measures are needed to control those exposures.

Association of surface contamination by antineoplastic drugs with different working conditions in hospital pharmacies

This study investigates the surface contamination levels of cyclophosphamide and platinum (a marker of platinum-containing drugs) in storage and preparation areas of hospital pharmacies and their relationship to working conditions surveyed by questionnaire. In total, 259 wipe samples were collected in 13 hospital pharmacies over 4 sampling campaigns. After sample extraction with acetate buffer, cyclophosphamide and platinum were determined using high-performance liquid chromatography-tandem mass spectroscopy (HPLC-MS/MS) and inductively coupled plasma mass spectrometry (ICP-MS). Depending on the sampling spot and campaign, median concentrations ranged from <2 to 61 pg/cm(2) and from <0.2 to 6.9 pg/cm(2) for cyclophosphamide and platinum, respectively. Statistical evaluation of monitoring data revealed that the contamination level was significantly influenced by laboratory throughput (expressed as number of chemotherapies prepared per week), personnel expertise (ie, participation of pharmacists with academic education in drug admixture activities), and surface material.

Impact of closed-system drug transfer device on exposure of environment and healthcare provider to cyclophosphamide in Japanese hospital

In spite of current recommended safe handling procedures, the potential for the exposure of healthcare providers to hazardous drugs exists in the workplace. A reliance on biological safety cabinets to provide total protection against the exposure to hazardous drugs is insufficient. Preventing workplace contamination is the best strategy to minimize cytotoxic drug exposure in healthcare providers. This study was conducted to compare surface contamination and personnel exposure to cyclophosphamide before and after the implementation of a closed-system drug transfer device, PhaSeal, under the influence of cleaning according to the Japanese guidelines. Personnel exposure was evaluated by collecting 24 h urine samples from 4 pharmacists. Surface contamination was assessed by the wiping test. Four of 6 wipe samples collected before PhaSeal indicated a detectable level of cyclophosphamide. About 7 months after the initiation of PhaSeal, only one of 6 wipe samples indicated a detectable level of cyclophosphamide. Although all 4 employees who provided urine samples had positive results for the urinary excretion of cyclophosphamide before PhaSeal, these levels returned to minimal levels in 2 pharmacists after PhaSeal. In combination with the biological safety cabinet and cleaning according to the Japanese guidelines, PhaSeal further reduces surface contamination and healthcare providers exposure to cyclophosphamide to almost undetectable levels.

Non-invasive quantification of 5 fluorouracil and gemcitabine in aqueous matrix by direct measurement through glass vials using near-infrared spectroscopy

Fourier transform near infrared spectroscopy (NIRS) was used for quantitative analysis of two cytotoxic drugs used in pharmaceutical infusion, 5-fluorouracil (5FU) and gemcitabine (GEM), at therapeutic concentrations in aqueous matrix. Spectra were collected from 4000 cm(-1) to 13,000 cm(-1) by direct measurement through standard glass vials and calibration models were developed for 5FU and GEM using partial least-squares regression. NIR determination coefficient (R(2)) greater than 0.9992, root-mean-square-error of cross-validation (RMESCV) of 0.483 mg/ml for 5FU and 0.139 mg/ml for GEM and the root mean square error of prediction (RMSEP) of 0.519 for 5FU and 0.108 mg/ml for GEM show a good prediction ability of NIR spectroscopy to predict 5FU and GEM concentrations directly through a glass packaging. According to accuracy profile, the linearity was validated from 7 to 50mg/ml and 2 to 40 mg/ml for 5-fluorouracil and gemcitabine respectively. This new approach for cytotoxic drugs control at hospital has shown the feasibility of near infrared spectroscopy to quantify antineoplastic drugs in aqueous matrix by a direct measurement through glass vial in less than 1 min and by non-invasive measurement perfect to limit exposure of operator to cytotoxic drugs.

Occupational exposure to anti-cancer drugs: A review of effects of new technology

Because anti-cancer drugs are non-selective, they affect both cancerous and non-cancerous cells. Being carcinogenic and mutagenic, many anticancer drugs therefore present a major health risk to healthcare staff working with them. This paper reviews the means by which exposure to anti-cancer drugs in the workplace may be monitored, assessed and reduced. Both biological monitoring, using non-selective methods or compound-selective methods, and environmental monitoring have provided information on the nature and degree of exposure in the workplace. Pharmaceutical isolators, used for the compounding of cytotoxic IV infusions and the preparation of injectable drugs, provide a physical barrier between pharmacists and cytotoxic drugs and reduce direct exposure. However, the interior of isolators and the contents thereof (e.g. infusion bags and syringes) are readily contaminated by aerosols and spillages and afford a secondary source of exposure to pharmacists, nurses and cleaning staff. Closed system transfer devices (CSTDs), designed to prohibit the transfer of contaminants into the working environment during drug transfer between the vial and syringe, have been successful in further reducing, but not eliminating surface contamination. Given that the number of patients requiring treatment with chemotherapeutic agents is predicted to increase, further efforts to reduce occupational exposure to anti-cancer drugs, including the refinement and wider use of CTSDs, are recommended.

Evaluation of safe infusion devices for antineoplastic administration

Nurses endure daily low-level exposure to cytotoxic drugs, which can lead to significant absorption with potential harmful consequences. New sterile medical devices called cytotoxic safe infusion systems (CSISs), intended by their manufacturers to improve safety and quality of cytotoxic drug infusions, have been made commercially available. CSISs from 3 manufacturers were tested in 2 cancer units and compared with standard infusion sets. The aim of this study is to evaluate the devices regarding occupational exposure, quality of the infusion, and economic aspects.

Application and assessment of a regular environmental monitoring of the antineoplastic drug contamination level in pharmacies - the MEWIP project

A large-scale study was carried out in order to determine the contamination level of antineoplastic drugs in pharmacies and to investigate the suitability and effects of wipe sample monitoring at regular intervals. A specific study design was developed. The 130 participating pharmacies were divided into a study and a control group, carrying out five and two wipe sampling cycles, respectively. The work practice was analyzed using questionnaires to identify factors that influence the contamination level. From 1269 wipe samples, 774 (61%) were contaminated with at least one of the analyzed cytotoxic drugs: cyclophosphamide, docetaxel, etoposide, 5-fluorouracil, gemcitabine, ifosfamide, methotrexate, and paclitaxel. A significant decrease of the contamination with cyclophosphamide and 5-fluorouracil was observed in the study group. The Monitoring-Effect Study of Wipe Sampling in Pharmacies method has proven to be a reliable and affordable tool for contamination control. Based on the 90th percentile of the contamination values, a substance-independent performance-based guidance value of 0.1ng cm(-2) has been derived.

A quantitative and qualitative method to control chemotherapeutic preparations by Fourier transform infrared-ultraviolet spectrophotometry

Chemotherapy products in hospitals include a reconstitution step of manufactured drugs providing an adapted dosage to each patient. The administration of highly iatrogenic drugs raises the question of patients' safety and treatment efficiency. In order to reduce administration errors due to faulty preparations, we introduced a new qualitative and quantitative routine control based on Fourier Transform Infrared (FTIR) and UV-Visible spectrophotometry. This automated method enabled fast and specific control for 14 anticancer drugs. A 1.2 mL sample was used to assay and identify each preparation in less than 90 sec. Over a two-year period, 9370 controlled infusion bags showed a 1.49% nonconformity rate, under 15% tolerance from the theoretical concentration and 96% minimum identification matching factor. This study evaluated the reliability of the control process, as well as its accordance to chemotherapy deliverance requirements. Thus, corrective measures were defined to improve the control process.

Biomarkers of occupational exposure do anticancer agents: a minireview

The majority of anticancer agents has in common DNA-damaging properties and affects not only target-cells but also non-tumour cells. Its genotoxicity has been demonstrated in experimental models and in cancer patients treated with chemotherapy. Health care personnel involved in the preparation and administration of chemotherapy is therefore at risk for adverse health effects, since most environmental sampling studies demonstrated that there is widespread contamination of work surfaces and equipments with anticancer drugs. Adherence to safety guidelines and proper use of personal protective equipment are insufficient to prevent significant absorption, as evidenced by the presence of detectable amounts of drugs in urine samples and increased frequency of genotoxicity biomarkers. In this minireview, a critical appraisal of the most important biomarkers used for the evaluation of occupational exposure to anticancer agents as well as a summary of the key findings from several studies published in this field is performed.

Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers

OBJECTIVE

This study evaluated health care worker exposure to antineoplastic drugs.

METHODS

A cross-sectional study examined environmental samples from pharmacy and nursing areas. A 6-week diary documented tasks involving those drugs. Urine was analyzed for two specific drugs, and blood samples were analyzed by the comet assay.

RESULTS

Sixty-eight exposed and 53 nonexposed workers were studied. Exposed workers recorded 10,000 drug-handling events during the 6-week period. Sixty percent of wipe samples were positive for at least one of the five drugs measured. Cyclophosphamide was most commonly detected, followed by 5-fluorouracil. Three of the 68 urine samples were positive for one drug. No genetic damage was detected in exposed workers using the comet assay.

CONCLUSIONS

Despite following recommended safe-handling practices, workplace contamination with antineoplastic drugs in pharmacy and nursing areas continues at these locations.

Simultaneous detection of three antineoplastic drugs on gloves by liquid chromatography with diode array detector

The aim of this study was to develop a method for simultaneous detection of antineoplastic drugs on gloves since, in occupational exposure, the main contamination route is through dermal contact, which may occur via prolonged contact with contaminated surfaces or materials. The assay was performed by liquid chromatography using the following conditions for the detection of 5-fluorouracil (5-FU), methotrexate (MTX) and paclitaxel (TAX): diode array detection and UV quantification at 195 nm for TAX, at 265 nm for 5-FU and at 302 nm for MTX; ODS column (250 x 4 mm, 5 μm) with a similar guard column; mobile phase consisted of water (pH 4)-methanol-acetonitrile (35:15:50, v/v/v) with a flow rate of 1 mL min-1. The method presented a linear range from 0.25 to 20 μg mL-1 with r² higher than 0.99. Repeatability was <15% and satisfactory extraction efficiency was obtained when liquid-liquid extraction with ethyl acetate was used for 5-FU and TAX. Satisfactory solid phase extraction was also achieved with C18 cartridges and elution with methanol for MTX. The diode array detector allowed drug quantification at a concentration > 0.25 μg mL-1 in samples, although detection was possible in samples that presented values of around 0.1 μg mL-1. The results obtained suggest that the method developed can be applied for the simultaneous determination of the drugs studied and can be considered useful in exposure assessment for health care workers.

Multicenter study for environmental and biological monitoring of occupational exposure to cyclophosphamide in Japan

Purpose. A multicenter field survey of environmental contamination and exposure of healthcare professionals to anticancer drugs were performed.

Setting. Three university hospitals, one cancer specialty hospital and two corporate hospitals from across Japan.

Method. The environmental contamination with cyclophosphamide (CP) was investigated. A wipe examination was performed at six sites apiece in two divisions. The urinary excretion of the CP over 24 h was determined. The subjects of the survey included physicians, pharmacists, and nurses, for a total of seven at each facility irrespective of job title. The wipe samples were collected at 12 sites within two divisions at each facility. For the exposure survey, the total urine volume was determined, and a portion of the urine sample was then collected from each participants at each facility. Urine was collected for 24 h. The samples were determined by using the GC-MS method.

Results. Wipe examination: contamination with CP was identified at 50% of the sites. The concentration was high (CP > 1.00 ng/cm2) in the general environment in two hospitals and in the safety cabinet in one hospital. In the survey for the exposure of staff to anticancer drugs, 276 samples were obtained from 41 healthcare professionals. CP was detected in 90 samples obtained from 23 subjects. The amount of exposure was greatly different among the facilities. The urinary excretion of CP per subject was between 2.7 and 462.8 ng/24 h. The range of urinary excretion for each hospital was between 4.6 and 211.2 ng/24 h.

Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device

PURPOSE

Surface contamination with the antineoplastic drugs cyclophosphamide, ifosfamide, and 5-fluorouracil was compared in 22 US hospital pharmacies following preparation with standard drug preparation techniques or the PhaSeal® closed-system drug transfer device (CSTD).

METHODS

Wipe samples were taken from biological safety cabinet (BSC) surfaces, BSC airfoils, floors in front of BSCs, and counters and analyzed for contamination with cyclophosphamide, ifosfamide, and 5-fluorouracil. Contamination was reassessed several months after the implementation of the CSTD. Surface contamination (ng/cm(2)) was compared between the two techniques and evaluated with the Signed Rank Test.

RESULTS

Using the CSTD compared to the standard preparation techniques, a significant reduction in levels of contamination was observed for all drugs (cyclophosphamide: p < 0.0001; ifosfamide: p < 0.001; 5-fluorouracil: p < 0.01). Median values for surface contamination with cyclophosphamide, ifosfamide, and 5-fluorouracil were reduced by 95%, 90%, and 65%, respectively.

CONCLUSIONS

Use of the CSTD significantly reduces surface contamination when preparing cyclophosphamide, ifosfamide, and 5-fluorouracil as compared to standard drug preparation techniques.

The application of hazard analysis and critical control points and risk management in the preparation of anti-cancer drugs

OBJECTIVE

To apply the Hazard analysis and Critical Control Points method to the preparation of anti-cancer drugs. To identify critical control points in our cancer chemotherapy process and to propose control measures and corrective actions to manage these processes.

SETTING

The Hazard Analysis and Critical Control Points application began in January 2004 in our centralized chemotherapy compounding unit. From October 2004 to August 2005, monitoring of the process nonconformities was performed to assess the method.

METHODS

According to the Hazard Analysis and Critical Control Points method, a multidisciplinary team was formed to describe and assess the cancer chemotherapy process. This team listed all of the critical points and calculated their risk indexes according to their frequency of occurrence, their severity and their detectability. The team defined monitoring, control measures and corrective actions for each identified risk. Finally, over a 10-month period, pharmacists reported each non-conformity of the process in a follow-up document.

RESULTS

Our team described 11 steps in the cancer chemotherapy process. The team identified 39 critical control points, including 11 of higher importance with a high-risk index. Over 10 months, 16,647 preparations were performed; 1225 nonconformities were reported during this same period.

CONCLUSIONS

The Hazard Analysis and Critical Control Points method is relevant when it is used to target a specific process such as the preparation of anti-cancer drugs. This method helped us to focus on the production steps, which can have a critical influence on product quality, and led us to improve our process.

Evaluation of surface contamination in a hospital hematology—oncology pharmacy

Objective. To describe environmental contamination with hazardous drugs in a hospital pharmacy setting before and after reorganizing a hematology— oncology satellite pharmacy.

Methods. This is a descriptive study of surface contamination with cyclophosphamide, ifosfamide, and methotrexate in two hematology—oncology satellite pharmacies. In order to measure surface contamination with hazardous drugs, samples from four distinct measurement sites within the pharmacy were taken in each of the two phases (pre-and postphases) using a sampling procedure and an analytical method modified from Larson et al.

Results. A total of 133 samples from four measurement sites were taken and analyzed over the course of the study (specifically 60 prephase samples and 73 postphase samples). The study showed a significant increase in the number of positive samples (from 66.7% to 90.4%, p<0.001) from the pre- to the postphase. The increase, however, is only significant in terms of the location where completed preparations were placed after they had come out from under the hood (from 0/15 to 21/28, p<0.001) and the work surface (from 8/15 to 15/15, p = 0.006) and only in terms of ifosfamide. Furthermore, for the other sites studied, the number of positive samples remained unchanged between the pre- and postphase. A statistically significant difference between the pre- and postphase was observed in terms of ifosfamide for three of the four measurement sites studied and methotrexate for one of the four sites. Average concentrations were higher in the post phase in three of the four cases.

Conclusion. This study describes environmental contamination with hazardous drugs in a hospital pharmacy setting before and after reorganizing a hematology—oncology satellite pharmacy. The study showed that a refitting of the hemato-oncology pharmacy is not a sufficient strategy to reduce the environmental contamination by ifosfamide because a significant increase in the number of positive samples from the pre- to the postphase have been observed. Many factors can contribute to influence the contamination of hazardous drugs such as the workflow and the training of the personal. Continuous environmental surveillance of hazardous drugs is required to document traces and help reduce risks. J Oncol Pharm Practice (2009) 15: 53—61.

Assessment of DNA damage in Japanese nurses handling antineoplastic drugs by the comet assay

To clarify genotoxic effects of occupational exposure to antineoplastic drugs in Japan, we examined DNA damage, assessed by the comet assay, in 121 female nurses and 46 female clerks working at three hospitals in the northeast of Japan. The comet assay is considered to be a sensitive and rapid method for DNA strand break detection in individual cells, and tail length and tail moment are used as the comet parameters. Concerning the basal characteristics, the 46 control subjects had higher rates of smoking and coffee-drinking habits and lower hemoglobin than the 121 nurses (p<0.05). The log-transformed tail length in the nurses was significantly longer than that in the control subjects after adjusting for possible covariates such as age and smoking habit (p<0.05). Also, the log-transformed tail length was significantly longer, in the 57 nurses who had handled antineoplastic drugs in the last six months, than that in the 46 control subjects (p<0.05); but, no significant difference in tail length or tail moment was seen between the two nurse groups with and without experience of handling hazardous drugs (p>0.05). These results suggest that Japanese nurses who have worked at hospitals using antineoplastic drugs may have a potential risk of DNA damage. To minimize this risk in Japan, use of biological safety cabinet and appropriate protective equipment, in addition to staff education and training, should be implemented in the healthcare environment.

Program to monitor surface contamination by methotrexate in a hematology–oncology satellite pharmacy

PURPOSE

The results of contamination monitoring during a one-year pilot period are described.

SUMMARY

A hematology-oncology satellite pharmacy conducted contamination monitoring for one year, using methotrexate as the index marker. From January 12, 2005, to December 21, 2005, 40 sampling sessions occurred during which 238 wipe samples (excluding positive controls) were collected. Each week, seven wipe samples were prepared by pharmacy technicians. Samples were obtained from the blank reference (site 0), the external metallic window frame of the main biological safety cabinet (BSC) (site 1), the back of the phone receiver (site 2), the external surface of an i.v. solution bag that was inside the BSC the previous hour (site 3), a working surface used for the final packaging and labeling (site 4), and the floor of the preparation room (site 5). The sixth sample was a positive methotrexate control. The methotrexate was detected by a high-performance liquid chromatograph with a fluorometric detector. Five samples tested positive for methotrexate-two from site 1, one from site 2, one from site 4, and one from site 0 (the blank); the last finding was thought to have most likely been the result of an error or sample mix-up during the wipe-sampling procedures. Despite differences in the sampling methods used, the type of wetting solution used, and the volume of desorption solution, the results were consistent with the literature in terms of few positive results.

CONCLUSION

A program was developed to monitor surface contamination by methotrexate in a hematology-oncology satellite pharmacy.