Antineoplastic drug contamination of surfaces throughout the hospital medication system in Canadian hospitals

Perception, knowledge, practices and training regarding the risk of exposure to antineoplastic drugs in three French compounding units

INTRODUCTION

Healthcare workers are exposed to hazardous drugs such as antineoplastic drugs, which have potential carcinogenic, mutagenic and teratogenic effects. Protective measures must be taken after appropriate staff training to handle antineoplastic drugs in a safe way. The objective was to assess perception, knowledge, practices and training regarding the risk of exposure of healthcare workers in three French compounding units.

METHODS

This descriptive study was based on a questionnaire made of 33 questions divided into five sections related to the handling of antineoplastic drugs: perception of the risks, knowledge of the risks, protection practices, specific training and general questions.

RESULTS

Among the 39 participants, over half considered their overall risk of exposure to antineoplastic drugs not being very low. Inhalation was known to 69.2% of them as possible route of contamination. The breakroom was identified by 28.9% of them as a place of contamination. The procedure in case of accidental exposure to antineoplastic drugs was known by 69.2%, but only half could explain it. Only 38.5% said they changed their gloves every 30 min as recommended. Barely half said that they had been trained specifically for the handling of antineoplastic drugs during an initial training. Over half wished to be informed, trained and aware of the proper handling of antineoplastic drugs.

CONCLUSION

Although some of these results are encouraging, specifically when compared to the other settings where antineoplastic drugs are handled, there is still room for improvement. Efforts to build an adapted and impactful training program must pursue.

CLINICAL TRIAL REGISTRATION

Study CONTACT, ref. 19-504.

Evaluation of long-term data on surface contamination by antineoplastic drugs in pharmacies

PURPOSE

The handling of antineoplastic drugs represents an occupational health risk for employees in pharmacies. To minimize exposure and to evaluate cleaning efficacy, wipe sampling was used to analyze antineoplastic drugs on surfaces. In 2009, guidance values were suggested to facilitate the interpretation of results, leading to a decrease in surface contamination. The goal of this follow-up was to evaluate the time trend of surface contamination, to identify critical antineoplastic drugs and sampling locations and to reassess guidance values.

METHODS

Platinum, 5-fluorouracil, cyclophosphamide, ifosfamide, gemcitabine, methotrexate, docetaxel and paclitaxel were analyzed in more than 17,000 wipe samples from 2000 to 2021. Statistical analysis was performed to describe and interpret the data.

RESULTS

Surface contaminations were generally relatively low. The median concentration for most antineoplastic drugs was below the limit of detection except for platinum (0.3 pg/cm²). Only platinum and 5-fluorouracil showed decreasing levels over time. Most exceedances of guidance values were observed for platinum (26.9%), cyclophosphamide (18.5%) and gemcitabine (16.6%). The most affected wipe sampling locations were isolators (24.4%), storage areas (17.6%) and laminar flow hoods (16.6%). However, areas with no direct contact to antineoplastic drugs were also frequently contaminated (8.9%).

CONCLUSION

Overall, the surface contaminations with antineoplastic drugs continue to decrease or were generally at a low level. Therefore, we adjusted guidance values according to the available data. The identification of critical sampling locations may help pharmacies to further improve cleaning procedure and reduce the risk of occupational exposure to antineoplastic drugs.

LC-MS-MS Determination of Cytostatic Drugs on Surfaces and in Urine to Assess Occupational Exposure

The ever-increased usage of cytostatic drugs leads to high risk of exposure among healthcare workers. Moreover, workers are exposed to multiple compounds throughout their lives, leading to cumulative and chronic exposure. Therefore, multianalyte methods are the most suitable for exposure assessment, which minimizes the risks from handling cytostatic drugs and ensures adequate contamination containment. This study describes the development and full validation of two liquid chromatography-tandem mass spectrometry methods for the detection of gemcitabine, dacarbazine, methotrexate, irinotecan, cyclophosphamide, doxorubicinol, doxorubicin, epirubicin, etoposide, vinorelbine, docetaxel and paclitaxel in working surfaces and urine samples. The urine method is the first to measure vinorelbine and doxorubicinol. For surfaces, limits of detection (LOD) and limits of quantification (LOQ) were 5-100 pg/cm2, and linearity was achieved up to 500 pg/cm2. Inaccuracy was between -11.0 and 8.4%. Intra-day, inter-day and total imprecision were <20%, except for etoposide and irinotecan (<22.1%). In urine, LOD and LOQ were 5-250 pg/mL, with a linear range up to 1,000-5,000 pg/mL. Inaccuracy was between -3.8 and 14.9%. Imprecision was <12.4%. Matrix effect was from -58.3 to 1,268.9% and from -66.7 to 1,636% in surface and urine samples, respectively, and extraction efficiency from 10.8 to 75% and 47.1 to 130.4%, respectively. All the analytes showed autosampler (6°C/72 h), freezer (-22°C/2 months) and freeze/thaw (three cycles) stability. The feasibility of the methods was demonstrated by analyzing real working surfaces and patients' urine samples. Contamination with gemcitabine, irinotecan, cyclophosphamide, epirubicin and paclitaxel (5-4,641.9 pg/cm2) was found on biological safety cabinets and outpatients' bathrooms. Analysis of urine from patients under chemotherapy identified the infused drugs at concentrations higher than the upper LOQ. These validated methods will allow a comprehensive evaluation of both environmental and biological contamination in hospital settings and healthcare workers.

Barriers and facilitators for the safe handling of antineoplastic drugs

INTRODUCTION

Antineoplastic drugs are widely used in the treatment of cancer. However, some are known carcinogens and reproductive toxins, and incidental low-level exposure to workers is a health concern. CAREX Canada estimated that approximately 75,000 Canadians are exposed to antineoplastic drugs in workplace settings. While policies and guidelines on safe handling of antineoplastic drugs are available, evidence suggests that compliance is low. In this paper, we identify barriers and facilitators for safe handling of antineoplastic drugs in workplace settings.

METHODS

We utilized a unique method to study public policy which involved compiling policy levers, developing a logic model, conducting a literature review, and contextualizing data through a deliberative process with stakeholders to explore in-depth contextual factors and experiences for the safe handling of antineoplastic drugs.

RESULTS

The most common barriers identified in the literature were: poor training (46%), poor safety culture (41%), and inconsistent policies (36%). The most common facilitators were: adequate safety training (41%), leadership support (23%), and consistent policies (21%). Several of these factors are intertwined and while this means one barrier can cause other barriers, it also allows healthcare employers to mitigate these barriers by implementing small but meaningful changes in the workplace.

CONCLUSION

The combination of barriers and facilitators identified in our review highlight the importance of creating work environments where safety is a priority for the safe handling of antineoplastic drugs. The results of this study will assist policy makers and managers in identifying gaps and enhancing strategies that reduce occupational exposure to antineoplastic drugs.

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.

Prepregnancy handling of antineoplastic drugs and risk of miscarriage in female nurses

PURPOSE

To examine the association betweenantineoplastic drug (AD) handling and risk of miscarriage.

METHODS

Nurses' Health Study-3 participants self-reported AD administration and engineering controls (ECs) and personal protective equipment (PPE) use at baseline. We estimated the hazard ratio (HR) of miscarriage in relation to baseline AD handling using multivariable Cox proportional regression.

RESULTS

Overall, 2440 nurses reported 3327 pregnancies, with 550 (17%) ended in miscarriages. Twelve percent of nurses self-reported currently handling AD and 28% previously handling AD. Compared with nurses who never handled AD, nurses who handled AD at baseline had an adjusted HR of miscarriage of 1.26 (95% confidence interval [CI], 0.97-1.64). This association was stronger after 12-weeks gestation (HR=2.39 [95% CI, 1.13-5.07]). Nurses who did not always use gloves had HR of 1.51 (95% CI, 0.91-2.51) compared with 1.19 (95% CI, 0.89-1.60) for those always using gloves; nurses who did not always use gowns had HR of 1.32 (95% CI, 0.95-1.83) compared with 1.19 (95% CI, 0.81-1.75) for nurses always using gowns.

CONCLUSIONS

We observed a suggestive association between AD handling and miscarriage, particularly among nurses who did not consistently use PPE and EC with stronger associations for second trimester losses.

Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH's 2015 Draft Vapor Protocol

Purpose: In 2015, the National Institute for Occupational Safety and Health (NIOSH) published a draft vapor containment protocol to quantitatively evaluate combined liquid, aerosol, and vapor containment performance of commercially available closed-system drug-transfer devices (CSTDs) that claim to be effective for gas/vapor containment within a controlled test environment. Until the release of this proposed protocol, no standard method for evaluating airtightness of CSTDs existed. The aim of this study was to evaluate six commercially available CSTDs utilizing NIOSH draft protocol methodology to evaluate vapor containment under a robust vapor challenge. Methods: In this study, six commercially available CSTDs were tested utilizing draft NIOSH vapor containment protocol methodology to simulate drug compounding and administration using 70% isopropyl alcohol (IPA) as the challenge agent. All device manipulations were carried out in an enclosed test chamber. A Miran sapphIRe gas analyzer was used to detect IPA vapor levels that escaped the device. Study test included the two tasks designated by the NIOSH protocol, with additional steps added to the evaluation. Tasks were repeated 10 times for each device. Results: Only three of the six tested CSTDs (Equashield®, HALO®, and PhaSealTM) had an average IPA vapor release below the quantifiable performance threshold (1.0 ppm) for all tasks performed. This value was selected by NIOSH to represent the performance threshold for successful containment. The remaining three CSTDs had vapor release above 1 ppm at various times during the IPA manipulation process. Conclusion: Equashield®, HALO®, and PhaSealTM devices tested met the 2015 NIOSH protocol quantifiable performance threshold, functioning as a truly closed system. Quantifiable effective data may be useful in product selection.

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.

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

OBJECTIVES

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

DATA SOURCES

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

CONCLUSION

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

IMPLICATIONS FOR NURSING PRACTICE

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

Cross-sectional evaluation of surface contamination with 9 antineoplastic drugs in 93 Canadian healthcare centers: 2019 results

Introduction

The primary objective was to describe environmental contamination with National Institute for Occupational Safety and Health Group 1 hazardous drugs in oncology pharmacies and outpatient clinics in Canada in 2019, as part of an annual surveillance project.

Methods

In each participating center, 12 standardized sites (6 in the oncology pharmacy and 6 in outpatient clinic) were sampled. Each sample was prepared to allow quantification of six antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) by ultra-performance liquid chromatography-tandem mass spectrometry. Samples were also tested for three additional antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine) without quantification. The impact of certain characteristics of the sampling sites was evaluated with a Kolmogorov–Smirnov test for independent samples.

Results

Ninety-three Canadian centers participated in 2019, with a total of 1045 surfaces sampled. Cyclophosphamide was the drug most often found in the surface samples (32.4% of samples with positive result), followed by gemcitabine (20.3%). The front grille inside the biological safety cabinet (81.5% of samples positive for at least one antineoplastic drug) and the armrest of a treatment chair (75.8%) were the most frequently contaminated surfaces. Centers with more oncology inpatient and outpatient beds, those that prepared more antineoplastic drugs each year, and those that used more cyclophosphamide each year had higher concentrations of cyclophosphamide contamination on the surfaces tested ( p <  0.0001).

Conclusion

Traces of dangerous drugs were found in oncology pharmacies and oncology outpatient clinics in 93 Canadian hospitals in 2019. However, the quantities measured were very small. Every healthcare worker should consider these work areas to be contaminated and should wear appropriate protective equipment.

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

PURPOSE

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

PARTICIPANTS & SETTING

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

METHODOLOGIC APPROACH

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

FINDINGS

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

IMPLICATIONS FOR NURSING

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The assessment of environmental and external cross-contamination in preparing ready-to-administer cytotoxic drugs: a comparison between a robotic system and conventional manual production

Objectives

The primary aim of the study was to compare environmental and external (cross‐) contamination of traces of cytostatics, during preparation of 5‐fluorouracil and cyclophosphamide using a robotic system (APOTECAchemo) or the conventional manual compounding procedure. The secondary aim was to validate the cleaning procedure of the robot.

Methods

Eighty ready‐to‐administer (RTA) infusion bags with 5‐fluorouracil, cyclophosphamide or sodium chloride were compounded using both techniques on 3–5 days. Wipe samples were taken from several locations in the compounding room before and after cleaning, and also from the technician’s gloves. These samples were analysed for 5‐fluorouracil and cyclophosphamide concentrations using GC/MS/MS.

Key findings

A total of 284 wipe samples were collected during the study (113 from the manual and 171 from the robotic process). External contamination on the outside of infusion bags was 3.75% for both manual and robotic compounding. For manual compounding, external cross‐contamination occurred on 2.5% of the prepared infusion bags. External cross‐contamination occurred on 1.25% of the infusion bags for the robotic procedure. Inside the compounding room, 9% of the environmental wipe samples were contaminated in case of manual production and 24% for robotic compounding. Since 50% of the contaminated environmental samples for the robotic system were taken after cleaning, the cleaning procedure was extended and parameter setting for cyclophosphamide handling was performed. After this, residual environmental or external contamination was no longer detectable.

Conclusion

Comparison of both preparation methods showed that external (cross‐)contamination of infusion bags was lower using the robotic system. An optimized cleaning procedure showed the best results in environmental contamination for the robot.

Cross-Sectional Evaluation of Surface Contamination with Antineoplastic Drugs in Canadian Health Care Centres

BACKGROUND

Surfaces in health care centres are often contaminated with traces of antineoplastic drugs. Such contamination should be limited as much as possible, to reduce workers' exposure.

OBJECTIVES

The primary objective was to monitor environmental contamination with 9 antineoplastic drugs in oncology pharmacy and patient care areas of Canadian health care centres. The secondary objective was to explore the use of sodium hypochlorite as a cleaning agent for cyclophosphamide contamination.

METHODS

This cross-sectional evaluation was conducted from January to April 2018. Twelve standardized sites were sampled at each participating centre: 6 in the oncology pharmacy and 6 in patient care areas. Six of the antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) were quantified by ultra-performance liquid chromatography - tandem mass spectrometry. For the other 3 antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine), samples were screened for contamination but not quantified. The effect of using sodium hypochlorite as a cleaning agent was evaluated with a Kolmogorov-Smirnov test for independent samples.

RESULTS

Of 202 Canadian centres invited, 79 participated. A total of 887 surface samples were analyzed, 467 from pharmacy areas and 420 from patient care areas. Cyclophosphamide was the drug most often found as a contaminant (32.2% [286/887] of samples positive, 75th percentile of measured contamination 0.0017 ng/cm², 90th percentile 0.021 ng/cm²). The front grille inside the hood (80.8% [63/78] of samples positive for at least one antineoplastic drug), treatment chair armrest (78.9% [60/76]), storage shelf in pharmacy (61.5% [48/78]), and floor in front of the hood (60.3% [47/78]) were the most frequently contaminated surfaces. Cleaning with a sodium hypochlorite solution was highly variable. Among centres that reported using sodium hypochlorite to clean armrests on patient chairs, the concentration of cyclophosphamide was lower (0.00866 versus 0.0300 ng/cm², p = 0.014).

CONCLUSIONS

Despite growing awareness and implementation of new safe-handling guidelines, surfaces in health care centres were contaminated with traces of many antineoplastic drugs. Providing centres with attainable goals (e.g., 75th to 90th percentile relative to other similar centres) would help in identifying the sampling sites where improvements are needed and in achieving lower surface contamination.

Administration of antineoplastic drugs and fecundity in female nurses

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Field evaluation of onsite near real-time monitors for surface contamination by 5-fluorouracil

OBJECTIVES

In order to produce near real-time onsite results to detect surface contamination by antineoplastic drugs, the National Institute for Occupational Safety and Health developed monitors for 5-fluorouracil, which use surface wiping and lateral flow immunoassay for measurement. The monitors were tested in the laboratory to assess the sensitivity of detection on laboratory-produced contaminated surfaces. A field evaluation to assess the capability of the monitors to make measurements in healthcare workplaces was carried out in collaboration with a medical device company and the results are presented in this report.

METHODS

The 5-fluorouracil monitor was evaluated in areas where oncology drugs were prepared and administered to patients at five different hospitals. The levels of contamination measured with the monitors were compared to levels measured with liquid chromatography-tandem mass spectrometry.

RESULTS

The 5-fluorouracil values measured with the liquid chromatography-tandem mass spectrometry ranged from 0 to over 200,000 ng/100 cm². Measurements by the 5-fluorouracil monitors in the range 10-100 ng/100 cm² correlated with the liquid chromatography-tandem mass spectrometry. Receiver operating characteristic curves developed for the data indicated that a positive limit of 22 ng/100 cm² would give an acceptable level of false-positives while retaining most true-positive samples. If the liquid chromatography-tandem mass spectrometry measured greater than 100 ng/100 cm², then the monitors also measured levels greater than 100 ng/100 cm² for the majority of samples.

CONCLUSION

The data indicate that there are many areas in hospitals that are contaminated with 5-fluorouracil and the monitors will be useful in identifying this contamination.

Self-reported environmental health risks of nurses working in hospital surgical units

AIM

This study investigated the occupational health risk factors among nurses who work in public hospital surgical units.

BACKGROUND

Nursing has a significant place in healthcare systems around the world. Surgical units are environments with certain risks, especially because of the possibility of exposure to various chemical, biologic or physical hazards.

METHODS

This study was conducted with 229 nurses who were working in the 11 surgery units of a big university hospital. In this cross-sectional study, a personal information form and an occupational risk factors scale were administered to respondents. We performed factor and reliability analyses for the scale; the overall reliability of the 41 items was α = 0.924, and the factor analysis found the scale was feasible.

RESULTS

Biologic and psychological risk factor levels were found to be high. Physical, chemical, ergonomic and radiation risk factor levels were moderate. The general occupational risk factor score was moderate. Nurses working night duty were confronted with physical and psychological risk factors at a higher rate compared with those working in the daytime.

CONCLUSION

Reported occupational health problems by nurses were correlated with the descriptive properties of the nurses including age, sex, marital status, education level, working hours, mode of working and status of occupational health and safety training.

IMPLICATIONS FOR NURSING

Nurses experience different occupational risks. If these risks are identified, healthier working environments can be provided to the nurses by taking necessary precautions.

IMPLICATIONS FOR SOCIAL POLICY

The health care provided by nurses who work in a healthy environment would be more efficient and of better quality, which will result in better economic and social outcomes for individual and communities.

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.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Carry-over of antineoplastic drug contamination in Dutch hospital pharmacies

Background

To prevent occupational exposure of hospital staff to cytostatics, a mandatory national guideline describing a set of safety measures was issued in the Netherlands in 2004. The guideline includes, among other directives, obligatory annual wipe testing to assess the efficacy of the local cleaning protocol. Full implementation of this guideline was executed in all Dutch hospital pharmacies over the next couple of years.

Objective

We aimed to investigate the effect of the national guideline on contamination levels, and specifically on the phenomenon of carry-over of traces of antineoplastic drugs through contact with surfaces, since this is a potential route of exposure.

Methods

From a database including wipe sample results of 9 hospitals over 10 years, we extracted all sampled locations in the compounding areas as well as in adjacent or bypass rooms and locks. We considered only the locations outside safety cabinets or isolators, to examine the containment of contamination and to address possible routes of how a contamination can migrate through the preparation and distribution areas. The dataset consisted of 2647 wipe samples.

Results

In adjacent rooms, 18 out of 275 wipe samples were contaminated (6%). Inside the compounding room, the extracted locations away from the safety workbench showed a positive percentage for contamination of 13% (39 out of 297). When stratifying the data to sample year, it was shown that contaminations outside the preparation room were no longer detectable after 2008.

Conclusion

With this study, we show that implementation of a set of guidelines on safety measures can prevent spreading of cytostatic traces from the compounding area in hospital pharmacies.

Handling of hazardous drugs - Effect of an innovative teaching session for nursing students

BACKGROUND

Imparting knowledge and practical skills in hazardous drug handling in nursing students' education is essential to prevent hazardous exposure and to preserve nurses' health.

OBJECTIVES

This study aimed at comparing routine nursing education with an additional innovative teaching session.

DESIGN

A prospective controlled study in nursing students was conducted in two study periods: (i) a status-quo period (routine education on handling hazardous drugs) followed by (ii) an intervention period (additional innovative teaching session on handling hazardous drugs).

SETTINGS/PARTICIPANTS

Nursing students at a vocational school were invited to participate voluntarily.

METHODS

In both study periods (i) and (ii), the following factors were analysed: (a) knowledge of hazardous drug handling by questionnaire, (b) practical skills in hazardous drug handling (e.g. cleaning) by a simulated handling scenario, (c) contamination with drug residuals on the work surface by fluorescent imaging.

RESULTS

Fifty-three nursing students were enrolled. (a) Median knowledge improved from status-quo (39% right answers) to intervention (65%, p<0.001), (b) practical skills improved from status-quo (53% of all participants cleaned the work surface) to intervention (92%, p<0.001). (c) Median number of particles/m² decreased from status-quo to intervention (932/97, p<0.001).

CONCLUSIONS

Compared with routine education, knowledge and practical skills in hazardous drug handling were significantly improved after an innovative teaching session. Additionally, the amount of residuals on the work surface decreased. This indicates a lower risk for hazardous drug exposure.

Chemotherapy Safe Handling: Limiting Nursing Exposure With a Hazardous Drug Control Program

BACKGROUND

Nurses and other healthcare workers are at risk for adverse health consequences from occupational exposure to hazardous drugs.

OBJECTIVES

An evidence-based program for nurses was implemented to improve safe handling practices and reduce exposure to hazardous drugs.

METHODS

A quasiexperimental design was used, with pre- and post-tests of knowledge about chemotherapy exposure and pre- and post-test observations of compliance with donning and doffing personal protective equipment (PPE). Surface wipe tests were conducted to determine hazardous drug contamination in care areas. A toolkit of interventions, including hazardous drug identification, standardization of PPE, and education, was used.

FINDINGS

Mean knowledge scores of chemotherapy improved after education. Correct donning of PPE was high before and after the intervention, and the correct doffing sequence improved postintervention. One sample was positive for 5-fluorouracil, affirming the difficulty of maintaining an environment free of contamination.

Causes of Health Care Workers' Exposure to Antineoplastic Drugs: An Exploratory Study

BACKGROUND

The exposure of health care workers to antineoplastic drugs is associated with several adverse health effects, including reproductive toxicities and mutagenic effects. Recent studies have confirmed that Canadian health care workers are at risk of exposure to these agents. However, the causes leading to occupational exposure to antineoplastic drugs are unknown.

OBJECTIVE

To perform an exploratory study to ascertain the immediate and contributing causes of health care workers' exposure to antineoplastic drugs.

METHODS

Participants were recruited from 6 acute care facilities in Vancouver, British Columbia. Those agreeing to participate were asked to complete a questionnaire about previous exposure to antineoplastic drugs while at work and to describe the circumstances of each exposure incident. Responses were qualitatively analyzed, and the causes of each incident were classified as immediate (unsafe work acts and/or unsafe working conditions) or contributing (related to the management of the organization, the environment, and/or the physical and mental status of the worker).

RESULTS

Completed questionnaires were received from 120 participants, 18 (15.0%) of whom reported having had previous occupational exposure to antineoplastic drugs. Qualitative analysis of the responses showed 4 categories of immediate causes (needlestick injury, spill, direct contact, and other unintended exposure) and 3 categories of contributing causes (poor communication, inadequate controls, and lack of training). Some incidents had multiple immediate and/or contributing causes.

CONCLUSIONS

According to a review of the immediate and contributing causes identified in this study, many of the exposure incidents were deemed preventable. A "hierarchy of controls" should be implemented, including (in the following order) engineering controls, administrative controls, and personal protective equipment. The findings of this study can be used to develop job safety analyses, which can in turn be adopted in guidelines for safe handling of hazardous drugs. Future similar studies are suggested to ensure the generalizability of results.

Benefits of Wipe Sampling: Evaluation of Long-Term 5-Fluorouracil and Platinum Monitoring Data

Objectives:

The aim of this study was to evaluate environmental contamination levels from a large dataset of long-term monitoring data of 5-fluorouracil and platinum-containing drugs in pharmacies, and to investigate the contaminations over 15 years.

Methods:

Wipe sampling for 5-fluorouracil and platinum (marker for cis-, carbo- and oxaliplatin) was performed on-site from various surfaces in hospital and retail pharmacies with a validated sampling procedure over a period of 15 years. The 5-fluorouracil concentrations were quantified by GCMSMS and platinum concentrations by voltammetry. Statistical evaluation was performed with respect to sampling locations and years, and over the course of time.

Results:

Overall, 3,584 wipe samples for 5-fluorouracil and 2,955 wipe samples for platinum were analysed and contamination was detected at all surface types in all 151 examined pharmacies with ranges from ND (not detectable) to 1,725,000 pg/cm² and ND to 23,068 pg/cm², respectively. Median concentrations from the different locations ranged between ND and 4.3 pg/cm² (5-fluorouracil) and 0.2 and 1.8 pg/cm² (platinum) with highest loads inside the biological safety cabinets/isolators and storage areas. Evaluation of contamination over the course of 15 years showed a substantial decrease, especially in the years after introduction of guidance values.

Conclusions:

Long-term evaluation of surface wipe samples for antineoplastic drug contamination with repeated monitoring seems to be a beneficial tool to characterize the actual exposure situation and to assess surface contamination over time. Wipe sampling is a suitable control means to evaluate the work practices and the effectiveness of applied safety and hygiene measures and to identify the potential exposure risk for health care workers.

Surface Contamination in a Teaching Hospital: A 6 Year Perspective

Objective:

The aim of this paper is to review the surface contamination of three hazardous drugs within a teaching hospital and comment the different strategies put in place over the years in the context of these multicenter studies.

Background:

Many cross-sectional studies have been published about surface contamination with hazardous drugs in healthcare settings.

Methods:

This is a descriptive retrospective and longitudinal study. The study was conducted in a 500-bed mother-child university health center in Quebec, Canada.

Results:

A total of 72 samples (e. g. 36 in the pharmacy and 36 in outpatient care area) were obtained between 2010 and 2016 for a total of 216 analyses (three drugs/samples tested). The proportion of positive samples was 50 % (36/72) for cyclophosphamide, 32 % (23/72) for ifosfamide and 19 % (14/72) for methotrexate. The cyclophosphamide concentrations measured varied from undetectable to 400 pg/cm

Conclusion:

This study shows a longitudinal perspective of the surface contamination of hazardous drugs in a teaching mother-child hospital. Every hospital should review its annual scorecard of contamination with a longitudinal perspective to minimize drug contamination. It is possible to contain surface contamination with hazardous drugs with different strategies.

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

OBJECTIVES

Antineoplastic drugs are known reproductive and developmental toxicants. Our objective was to review the existing literature of reproductive health risks to workers who handle antineoplastic drugs.

METHODS

A structured literature review of 18 peer-reviewed, English language publications of occupational exposure and reproductive outcomes was performed.

RESULTS

Although effect sizes varied with study size and population, occupational exposure to antineoplastic drugs seems to raise the risk of both congenital malformations and miscarriage. Studies of infertility and time to pregnancy also suggested an increased risk for subfertility.

CONCLUSIONS

Antineoplastic drugs are highly toxic in patients receiving treatment, and adverse reproductive effects have been well documented in these patients. Health care workers with long-term, low-level occupational exposure to these drugs also seem to have an increased risk of adverse reproductive outcomes. Additional precautions to prevent exposure should be considered.

Environmental Contamination with Cyclophosphamide, Ifosfamide, and Methotrexate: A Study of 51 Canadian Centres

BACKGROUND

Occupational exposure to hazardous drugs may lead to adverse reproductive effects. There is no safe exposure limit for health care professionals.

OBJECTIVES

To monitor levels of cyclophosphamide, ifosfamide, and methotrexate contamination in oncology pharmacy and patient care areas in Canadian health care institutions.

METHODS

The study was conducted in 2014. Hospitals with at least 50 acute care beds were invited to participate. At each participating centre, 12 standardized sites (6 in pharmacy areas and 6 in patient care areas) were sampled. The samples were analyzed for the presence of cyclophosphamide, ifosfamide, and methotrexate by ultra-performance liquid chromatography tandem mass spectrometry technology. The limits of detection were 0.36 pg/cm(2) for cyclophosphamide, 0.95 pg/cm(2) for ifosfamide, and 0.97 pg/cm(2) for methotrexate. Descriptive statistical analyses were performed to determine the median, 75th percentile, and maximum levels.

RESULTS

Fifty-one hospitals participated in this descriptive study, and a total of 584 samples were quantified. Overall, 294 (50%) of the samples were positive for cyclophosphamide, 125 (21%) for ifosfamide, and 54 (9%) for methotrexate. The most frequently contaminated sampling sites in pharmacy areas were the front grille inside the hood and the floor in front of the hood and, in patient care areas, the armrest and outpatient clinic counter. The 75th percentiles for surface concentration were 10.8 pg/cm(2) for cyclophosphamide, 1.59 pg/cm(2) for ifosfamide, and below the limit of detection for methotrexate.

CONCLUSIONS

Relative to 3 other multicentre studies conducted in Quebec over the past few years, the proportion of positive samples remained constant. Nonetheless, the 75th percentile surface concentration of antineoplastic drugs has been decreasing and seems to have reached a plateau. Local (country-specific or region-specific) and attainable goals for surface contamination with hazardous drugs should be set annually, so long as no health-based limit is known.

Health Care Workers' Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada

Although nurses are knowledgeable regarding the risk of exposure to antineoplastic drugs, they often do not adhere with safe work practices. However, the knowledge, perceptions, and behavior of other health care job categories at risk of exposure has yet to be determined. This study aimed to survey a range of health care workers from British Columbia, Canada about their knowledge, perceptions, and behaviors regarding antineoplastic drugs. A self-administered questionnaire was sent to participants querying the degree of contact with antineoplastics, knowledge of risks associated with antineoplastics, perceptions of personal risk, previous training with respect to antineoplastics, and safe work practices. Subjects were recruited from health care facilities in and around Vancouver. Fisher's exact tests were performed to ascertain whether there were differences in responses between job categories. We received responses from 120 participants representing seven different job categories. Pharmacists, pharmacy technicians, and nurses were more knowledgeable regarding risks than other job categories examined (statistically significant difference). Although 80% of respondents were not afraid of working with or near antineoplastics, there were concerns about the suitability of current control measures and practices employed by co-workers. Only half of respondents felt confident that they could handle all situations where there was a potential for exposure. Only one of the perception questions, self-perceived risk of exposure to antineoplastic drugs, differed significantly between job categories. Not all respondents always wore gloves when directly handling antineoplastic drugs. Further, hand hygiene was not regularly practiced after glove usage or after being in an area where antineoplastic drugs are handled. The majority of responses to questions related to safe work practices differed significantly between job categories. Our results suggest that knowledge regarding risks associated with antineoplastic drugs can be improved, especially among job categories that are not tasked with drug preparation or drug administration. There is also a gap between knowledge and compliance with glove usage and hand hygiene.Training is also recommended to improve health care workers' perceptions of the risks associated with antineoplastic drugs.

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.

Adherence to Precautionary Guidelines for Compounding Antineoplastic Drugs: A Survey of Nurses and Pharmacy Practitioners

Precautionary guidelines detailing standards of practice and equipment to eliminate or minimize exposure to antineoplastic drugs during handling activities have been available for nearly three decades. To evaluate practices for compounding antineoplastic drugs, the NIOSH Health and Safety Practices Survey of Healthcare Workers was conducted among members of professional practice organizations representing primarily oncology nurses, pharmacists, and pharmacy technicians. This national survey is the first in over 20 years to examine self-reported use of engineering, administrative, and work practice controls and PPE by pharmacy practitioners for minimizing exposure to antineoplastic drugs. The survey was completed by 241 nurses and 183 pharmacy practitioners who compounded antineoplastic drugs in the seven days prior to the survey. They reported: not always wearing two pairs of chemotherapy gloves (85%, 47%, respectively) or even a single pair (8%, 10%); not always using closed system drug-transfer devices (75%, 53%); not always wearing recommended gown (38%, 20%); I.V. lines sometimes/always primed with antineoplastic drug (19%, 30%); and not always using either a biological safety cabinet or isolator (9%, 15%). They also reported lack of: hazard awareness training (9%, 13%); safe handling procedures (20%, 11%); and medical surveillance programs (61%, 45%). Both employers and healthcare workers share responsibility for adhering to precautionary guidelines and other best practices. Employers can ensure that: workers are trained regularly; facility safe-handling procedures reflecting national guidelines are in place and support for their implementation is understood; engineering controls and PPE are available and workers know how to use them; and medical surveillance, exposure monitoring, and other administrative controls are in place. Workers can seek out training, understand and follow facility procedures, be role models for junior staff, ask questions, and report any safety concerns.

Antineoplastic drugs contamination of workplace surfaces in two Portuguese hospitals

Despite the classification as known or suspected human carcinogens, by the International Agency for Research on Cancer, the antineoplastic drugs are extensively used in cancer treatment due to their specificity and efficacy. As human carcinogens, these drugs represent a serious threat to the healthcare workers involved in their preparation and administration. This work aims to contribute to better characterize the occupational exposure of healthcare professionals to antineoplastic drugs, by assessing workplace surfaces contamination of pharmacy and administration units of two Portuguese hospitals. Surface contamination was assessed by the determination of cyclophosphamide, 5-fluorouracil, and paclitaxel. These three drugs were used as surrogate markers for surfaces contamination by cytotoxic drugs. Wipe samples were taken and analyzed by HPLC-DAD. From the total of 327 analyzed samples, in 121 (37 %) was possible to detect and quantify at least one drug. Additionally, 28 samples (8.6 %) indicate contamination by more than one antineoplastic drug, mainly in the administration unit, in both hospitals. Considering the findings in both hospitals, specific measures should be taken, particularly those related with the promotion of good practices and safety procedures and also routine monitoring of surfaces contamination in order to guarantee the appliance of safety measures.

A review of the evidence for occupational exposure risks to novel anticancer agents – A focus on monoclonal antibodies

Introduction

Evidence of occupational exposure risks to novel anticancer agents is limited and yet to be formally evaluated from the Australian healthcare perspective.

Methods

From March to September 2013 medical databases, organizational policies, drug monographs, and the World Wide Web were searched for evidence relating to occupational exposure to monoclonal antibodies, fusion proteins, gene therapies, and other unclassified novel anticancer agents.

Results

Australian legislation, national and international guidelines, and drug company information excluded novel agents or provided inconsistent risk assessments and safe handling recommendations. Monoclonal antibody guidelines reported conflicting information and were often divergent with available evidence and pharmacologic rationale demonstrating minimal internalisation ability and occupational exposure risk. Despite similar physiochemical, pharmacologic, and internalisation properties to monoclonal antibodies, fusion proteins were included in only a minority of guidelines. Clinical directives for the safe handling of gene therapies and live vaccines were limited, where available focusing on prevention against exposure and cross-contamination. Although mechanistically different, novel small molecule agents (proteasome inhibitors), possess similar physiochemical and internalisation properties to traditional cytotoxic agents warranting cytotoxic classification and handling.

Conclusion

Novel agents are rapidly emerging into clinical practice, and healthcare personnel have few resources to evaluate risk and provide safety recommendations. Novel agents possess differing physical, molecular and pharmacological profiles compared to traditional cytotoxic anticancer agents. Evaluation of occupational exposure risk should consider both toxicity and internalisation. Evidence-based guidance able to direct safe handling practices for novel anticancer agents across a variety of clinical settings is urgently required.

Identification of Knowledge Gaps Regarding Healthcare Workers' Exposure to Antineoplastic Drugs: Review of Literature, North America versus Europe

We have been examining the issue of healthcare workers' exposure to antineoplastic drugs for nearly a decade and have observed that there appears to be more publications on the subject matter originating from Europe than from North America. The concern is that findings from Europe may not be generalizable to North America because of differences in handling practices, regulatory requirements, and training. Our objective was to perform a literature review to confirm our observation and, in turn, identify gaps in knowledge that warrants addressing in North America. Using select keywords, we searched for publications in PubMed and Web of Science. All papers were initially classified according to the originating continent and then categorized into one or more subject categories (analytical methods, biological monitoring, occupational exposure, surface contamination, and probability of risk/exposure). Our review identified 16 papers originating from North America and 55 papers from Europe with surface contamination being the subject matter most often studied overall. Based on our results, we are of the opinion that North American researchers need to further conduct dermal and/or urinary drug contamination studies as well as assess the exposure risk faced by healthcare workers who handle antineoplastic drugs. Trends in exposure levels should also be explored.

Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system

We previously reported that antineoplastic drug contamination is found on various work surfaces situated throughout the hospital medication system (process flow of drug within a facility from initial delivery to waste disposal). The presence of drug residual on surfaces suggests that healthcare workers involved in some capacity with the system may be exposed through dermal contact. The purpose of this paper was to determine the dermal contamination levels of healthcare employees working throughout a hospital and to identify factors that may influence dermal contamination. We selected participants from six hospitals and wiped the front and back of workers' hands. Wipe samples were analyzed for cyclophosphamide (CP), a commonly used antineoplastic drug, using high-performance liquid chromatography-tandem mass spectrometry. Participants were asked about their frequency of handling antineoplastic drugs, known contact with CP on their work shift, gender, job title, and safe drug handling training. In addition, participants were surveyed regarding their glove usage and hand washing practices prior to wipe sample collection. We collected a total of 225 wipe samples. Only 20% (N = 44) were above the limit of detection (LOD) of 0.36ng per wipe. The average concentration was 0.36ng per wipe, the geometric mean < LOD, the geometric standard deviation 1.98, and the range < LOD to 22.8ng per wipe. Hospital employees were classified into eight different job categories and all categories had some dermal contamination levels in excess of the LOD. The job category with the highest proportion of samples greater than the LOD were those workers in the drug administration unit who were not responsible for drug administration (volunteer, oncologist, ward aide, dietician). Of note, the highest recorded concentration was from a worker who had no known contact with CP on their work shift. Our results suggest that a broader range of healthcare workers than previously believed, including those that do not directly handle or administer the drugs (e.g. unit clerks, ward aides, dieticians, and shipper/receivers), are at risk of exposure to antineoplastic drugs. A review of control measures to minimize antineoplastic drug exposure that encompasses a wide array of healthcare workers involved with the hospital medication system is recommended.